GERONTOLOGY

Dementia

Nursing diagnosis : Disturbance of thought related to instability of mind state

Goals : The client can improve thought processing at least at baseline level.

No. Nursing Intervention Rationale

1. Assess cognitive function testing such To determine the severity of dementia

as MMSE (Mini Mental State which will influence the client’s behavior,
Examination). process of thinking and also care and
treatment.

2. Assess client’s ability thought To identify the client’s problem and to

processing every shift such as: observe the level of cognitive thinking.

-Memory changes

-Disoriented to time or place

-Difficulty in communication

-Changes in thinking pattern

3. Give one simple direction at a time and To prevent confusion of the patient.
repeat it as necessary

4. Begin each interaction with the client by Help the clients to identify his/her
identifying ourselves and encourage the identity and to enhance memory.
family members to call clients by his/her
name.
 5. Avoid high expectations more than High expectations may cause clients to
patient capability to do something. become frustrated and angry.

6. Provide a safety environment such as To reduce the risk of falls and injury
raising the side rail for the clients who
have the confusion.

7. Administer the medication as prescribed Donepezil medication can help to

by a doctor such as donepezil (atricept) improve mental function such as
memory, attention, speaking, and
thinking clearly.

8. Provide opportunities to the clients for Help to prevent isolation and forcing
social interaction without forcing them. interaction that might lead to confusion.

Evaluation: The client is able to improve thought processing.

Nursing diagnosis: self-care deficit related to impaired thinking

Goals: patient will be able to perform basic activity daily living at minimal aid and assistant

No. Nursing interventions rationales

1. Assess patient’s ability to perform to identify patient’s ability level to care

self-care such as toileting, grooming, for themselves and to plan for further
eating, bathing using Barthell chart intervention to improves patients
become independent
-unable to perform the task

-substantial help required

-moderate help required

-minimal help required

-fully independent

2. Assess the specific cause of each deficit to provide appropriate intervention

such as cognitive impairment causing the based on the causes or assistive
patient to become dependant device as necessary such as get the
patient used to the environment or
provide a crutch

3. Encourage patients to perform and to improves their ability, skills, and

manage themselves on their own by being independent little by little as
giving simple commands step by step as practices day by day
necessary

4. Instruct family members or caregivers to to boost self-esteem and

perform the self-care together with a self-confidence on patient to perform
patient such as eating, grooming self-care on a daily basis
 5. Demonstrate to patients how to care for to improve their quality of self-care and
themselves such as bathing, sleep and determine their ability to re-do it again
rest, eating and the other ADL’s and
return demonstration by patient

6. Provide assistant if necessary especially to help patient improves their fine and
for activities that required energy and gross motor also balancing themselves
may confuse the patient such as dressing alongside with the assistant
and grooming like button up the shirt

7. Instruct family members to keep patient’s To keep the patient tidy as they are
hair short as appropriate deficient in self-care and to facilitate the
patient to wash it on their own during
bathing to maintain hygiene

8. Give praise to the patient for any ADLs because it will make patients feel
that they did by themselves or even with appreciated and want to do better for
their caregiver such as “Mr. Lee, you did tomorrow
great today.”

Evaluation: patient able to perform basic activity daily living at a minimal aid and assistant
Nursing Diagnosis: Wandering related to instability of mind statue
Goal: Patient will be able to minimize wandering behavior
No. Nursing Interventions
1. Assess the presence of wandering
behavior such as noting time, place, or
room and staring outside the window
(intention to go outside)
2. Assess reason for wandering if patient
able to verbalize as an example tell to
visit someone, or just want to wander for
enjoy
3. Provide a bed near the counter staff
nurse full with the safety side rail, lowest
bed, and lock the bed. Ensure to switch
on the lamp during bedtime
4. Encourage patients to participate in
activities if able to do so. For example,
provide an interesting activity such as
cooking, or light exercise (based on their
ability too)
5 Avoid using restraints if at all possible to
control patient behavior
Rationale
Identify the problem and determine
patient if have any intention to wander
anywhere when show symptoms such
as escape boredom or walking
To detect any problems patients have
and cope by giving the right plan. For
example, a patient wants to meet his
friends. Company and help to avoid any
injury
To monitor patient behavior and
minimize the risk of fall or injury when
they have the intention to escape or
wandering
To decrease restlessness and promote
enjoyment for them from feeling bored
Restraints might increase the risk of
agitation, depression, and anxiety. It can
 lead to complications of immobility and
feeling of powerlessness

6 Apply an identification bracelet or install To identify the patient identity and detect
a chip inside a bracelet for the elderly at the location of a patient
his wrist as the safety and facilitate for
searching if occur the missing or lost
elderly location

7 Identify how the family handles the Helps to determine potential appropriate
patient’s wandering behavior methods of managing patient’s behavior
by using a consistent method

8 Instruct and remind about patient safety As prevention unsafe environment at

at the house with installing safety tools home and protection of patient
by ensuring lock the gates, lock on door
and windows. Also, deadbolt lock
(upgrade safety)

9 Advise family members to always Helps police or other people to find a

beware of possible patient escape by lost person
taking note of daily routine or latest
activity of the patient

10 Encourage family members to always be To reduce patient depression regarding

a good listener to every patient’s feelings be stress only stay at home or not doing
and words, take the patient to go outside any activity
with making a promise such as patient
promise to keep a good behavior or
adhere to instruction if bring his/her
wandering
 11 Reassess patient’s presence of For evaluating the effectiveness of
wandering behavior intervention

Evaluation: Patient wandering behavior can be control and able to minimize it

Nursing Diagnosis: Forgetfulness related to impaired thinking as evidenced
patient‘s condition was blurred and forget about themself

Goal: Patient’s memory will be improved and remember slowly about their life.

No. Nursing intervention Rationale

1 Assess the overall cognitive memory because MMSE is very useful as a first step
through screening tests such as evaluation for determining whether a patient
mini-mental state examination (MMSE) has cognitive impaired thinking that needs
from the perspective of orientation, to refer to get suitable treatment for the
registered and recall patient.

2 Monitor symptoms that are experienced as baseline data and to plan the next
by patients when forgetfulness such as intervention that is appropriate with the
they cannot remember their name and patient to minimize the level of forgetfulness
always ask the same question over and that occurs among patients.
again.

3 Offer assistive devices or supervision to promote patient safety during ADL and
when patients bathe by using a as protection from an injury that harms the
commode chair, during their cooking patient.
must be monitored by the caregiver,
and feeding patients if they cannot eat
by self.

4 Provide patients with a single instruction because the patient cannot easily
using simple language that they remember multi instructions at one time
understand when the necessary
instructions need to be followed
5 Encourage family members to
frequently ask about patient’s past
stories as example sweet memories at
a young age such as marriage, having
children, and share about popular
movies in the past like Bujang Lapok
to stimulate the patient's brain for more
function to recall back and decrease the
level of forgetfulness and patients become
more remembering.

6 Provide the patient with a medicine to prevent patients from forgetting to take
container that has days, encourage medication for their illness and helps to
patient to know the color and shape of minimize patients to forget the important
medicine and always remember patient things
to take medication on time for their
premorbid disease for example
hypertension, diabetes mellitus that
prescribed by a doctor

7 Encourage the family member to always to avoid the patient out of a sudden and
monitor and make sure their door and cannot remember the way back home
gates are always closed especially because they had a problem with impaired
when they are busy with work thinking and it was dangerous to the
patient.

8 Provide some time with patients as to minimize patient forgetting and help their
quality time to recall their memory such brain to more function to remember what
as ask their name, age and avoid from their routine is when they have leisure time.
force patients to remember what these
words that always use and what they
are routine
 9 Maintain a nice, quiet, and comfortable to avoid excessive sensory neurons and
neighborhood can increases interferences.

Evaluation: Patient’s memory improved and they remembered about their routine
Nursing diagnosis: Inappropriate behavior related to instability of the mind
state.

Goal: Patient will have appropriate maintenance of mental and psychological function as
long as possible, and reversal of behaviors when possible.

No. Nursing Intervention Rationale

1 Assess the patient’s changes in mood
and personality such as feeling happy,
disappointed, sadness by using cam
score
(confusion assessment method)
dementia patients always having this
difficulty which will make them feel the
burden and can trigger them to act in
inappropriate ways to express their
emotions

2 Assess why the patient is behaving in It may be easier to figure out ways to
that way such as they will isolate prevent the behavior from happening
themself from others if they feel again
disappointed, refuse to eat, or attract
more attention from other patients or
staff

3 Approach and talk with the patient by to comforting them and prevent them
using a soft voice and talk gently from acting violently due to restricted
activities

4 Provide patient a conducive, safe, and dementia patient tend to have trouble in
comfortable dim light room with good sleep which when they get not enough
ventilation, and warm milk before going sleep, it will make they have confusion
to sleep and fatigue
 5 Introduce patients with each other,
doctor and staff nurse because at this
stage patients tend to get confused with
people’s identity, they sometimes think
of strangers as their family
6 Advice and educate family members to
always giving attention and be close
with patients such as helping patients
to manage themself and feeding them
7 Assess the patient's ability to cope with
events, interests in surroundings and
activity, motivation, and changes in
memory pattern.
8 Eliminate or minimize sources of
hazards in the environment
Evaluation: patients' behavior maintained stable.
to prevent from people feel discomfort
to ensure patients get enough love and
don’t feel left out that can cause them to
isolate or experience emotional stress
and cause them to do things they
shouldn't
Patients may exhibit assertiveness or
aggressiveness to compensate for
feelings of insecurity, or develop more
narrowed interests and have difficulty
accepting lifestyle changes.
Maintain security by avoiding a
confrontation that could improve the
behavior or increase the risk for injury.
DEPRESSION

Self isolation related to withdrawal and reduced in interest in activities.

GOALS: Patient will report a willingness to socialize with others.

Assessment

1.Review history and note traumatic events that may have occurred.
Traumatic events can cause anxiety and lead to isolation from social situations.

2. Assess factors contributing to a sense of helplessness (e.g., loss of

spouse/parent).
Patients who feel helpless may withdraw and fail to seek out significant people in
their lives.

3. Assess feelings about self, ability to control the situation, and sense of
hope.
Gauging the level of hopelessness and powerlessness may help the nurse
understand the severity of the situation.

Interventions:

1. Establish a therapeutic nurse-client relationship.

When patients feel they are talking to someone they trust, they will feel free to
discuss sensitive matters.

2. Assist the patient in identifying activities that encourage socialization.

Early support in mobility and social participation will give a sense of well-being and
relief of feelings of social isolation. People with regular social connections present
with lesser mental decline than those who are lonely and isolated.
3. Coordinate with available resources, support behaviors to engage in social
interactions, and manage personal resources and self care.
Managing activities of daily living can increase self-confidence and promote comfort
in social settings.

4. Promote participation in recreational or special interest activities in a setting

that the patient views as safe.
Safe environments can make patients feel secure to socialize.

Assess the patient's interests, preferences, and reasons for withdrawal.

● Rationale: Understanding the specific reasons behind the patient's

self-isolation and lack of interest in activities can help tailor interventions to
meet their individual needs and preferences. This assessment provides a
baseline to create a personalized care plan.

Encourage participation in group activities that match the patient's interests.

● Rationale: Group activities can provide social interaction and mental

stimulation, which can help reduce feelings of isolation and withdrawal.
Matching activities to the patient's interests increases the likelihood of
participation and enjoyment.

Facilitate social interaction with family, friends, or other residents.

● Rationale: Social support is crucial for mental and emotional well-being.

Facilitating interaction with family and friends can help the patient feel
connected and valued, thereby reducing feelings of isolation.

Implement a regular schedule of activities that includes physical, cognitive,

and social elements.
 ● Rationale: A structured routine that includes a variety of activities can help
maintain the patient’s physical and mental health. Regular participation in
such activities can provide a sense of normalcy and purpose.

Provide emotional support and active listening.

● Rationale: Offering a supportive and non-judgmental environment can help

the patient express their feelings and concerns, which can alleviate feelings of
loneliness and withdrawal. Active listening shows the patient that their feelings
are valued and understood.

Involve the patient in decision-making about their care and activities.

● Rationale: Involving the patient in decision-making can increase their sense

of control and empowerment, which can enhance motivation and engagement
in activities. It promotes autonomy and respects the patient’s preferences.

Educate the patient and family about the importance of social interaction and
activity.

● Rationale: Education can help the patient and their family understand the
benefits of social engagement and activity for overall health and well-being.
This knowledge can motivate the patient to participate in activities and reduce
withdrawal.

Monitor and evaluate the patient’s response to interventions.

● Rationale: Regular evaluation of the patient’s response to interventions helps

determine their effectiveness and allows for adjustments to be made as
needed. Continuous monitoring ensures that the care plan remains relevant
and effective.

Collaborate with other healthcare professionals, such as social workers and

occupational therapists.
● Rationale: A multidisciplinary approach can provide comprehensive care and
support for the patient. Social workers and occupational therapists can offer
additional resources and interventions to address social isolation and promote
engagement in activities.
Hopelessness related to feeling of worthlessness towards chronic disease

Assess the patient's level of hopelessness and feelings of worthlessness.

● Rationale: Understanding the extent and specific nature of the patient's

hopelessness and feelings of worthlessness is crucial for developing an effective
care plan. Assessment helps identify underlying causes and the impact on the
patient's daily life.

Encourage the expression of feelings and provide a supportive listening environment.

● Rationale: Allowing the patient to verbalize their feelings can be therapeutic and help
them feel heard and understood. A supportive environment fosters trust and can help
alleviate feelings of isolation and hopelessness.

Collaborate with the patient to set realistic, achievable goals.

● Rationale: Setting small, attainable goals can help the patient regain a sense of
purpose and accomplishment. This process can improve self-esteem and provide a
sense of progress and hope.

Promote activities that the patient finds enjoyable and fulfilling.

● Rationale: Engaging in enjoyable activities can enhance the patient's mood and
provide positive reinforcement. Activities that align with the patient’s interests can
help counter feelings of worthlessness by highlighting their abilities and strengths.

Provide education about the chronic disease and its management.

● Rationale: Educating the patient about their condition and how to manage it can
empower them and reduce feelings of helplessness. Knowledge can provide a sense
of control and improve their outlook on their ability to cope with the disease.

Facilitate social support and interaction with peers, family, and support groups.

● Rationale: Social support is essential for emotional well-being. Interaction with

others who understand or share similar experiences can provide comfort, reduce
feelings of isolation, and foster a sense of community and belonging.

Encourage participation in spiritual or religious practices if the patient finds them

meaningful.
 ● Rationale: Spiritual or religious practices can provide comfort, hope, and a sense of
purpose. For many individuals, these practices are a source of strength and can help
mitigate feelings of hopelessness.

Utilize cognitive-behavioral techniques to challenge negative thoughts and promote

positive thinking.

● Rationale: Cognitive-behavioral techniques can help the patient identify and reframe
negative thoughts, reducing feelings of worthlessness and hopelessness. Promoting
positive thinking can improve the patient's overall outlook and mental health.

Collaborate with mental health professionals for counseling or therapy if needed.

● Rationale: Professional counseling or therapy can provide specialized support and

strategies to address hopelessness and feelings of worthlessness. Mental health
professionals can offer additional resources and interventions tailored to the patient's
needs.

Monitor the patient's mental status and response to interventions regularly.

● Rationale: Regular monitoring helps evaluate the effectiveness of interventions and

allows for timely adjustments. Continuous assessment ensures that the care plan
remains relevant and responsive to the patient’s changing needs and condition.

Assessment:

1. Assess coping behaviors and defense mechanisms utilized in previous and

current situations and the patient’s perception of their effectiveness.
Focusing and utilizing these strengths may encourage the patient to deal with the
current situation.

2. Evaluate both useful and harmful defense mechanisms.

These include increased sleeping, substance abuse, illness behaviors, eating
disorders, denial, forgetfulness, daydreaming, ineffectual organizational efforts,
exploiting own goal setting, or regression. Helping the patient recognise maladaptive
behaviors that may cause harm to their health would help redirect them to safe
coping mechanisms.

3. Perform physical examination and review results of laboratory tests and

diagnostic studies.
The current situation may be due to a decline in physical well-being or the
progression of a chronic condition, or physical symptoms may be associated with the
effects of depression (e.g., loss of appetite, lack of sleep).

Interventions:

1. Discuss current options and provide a list of helpful actions to gain a sense
of control over the situation.
These options facilitate the use of own actions, validate reality, and promote a sense
of control of the situation.

2. Encourage or assist with the use of relaxation exercises and guided

imagery.
Relaxation may help the patient to look at possibilities of feeling more hopeful.

3. Make time to listen and offer support.

Patients with feelings of hopelessness may only need a person who could lend some
ears and make them feel that they are not alone with their battle against cancer.
Expressing support may boost their perceived self-worth.

4. Encourage to join a support group for cancer survivors.

Support groups help the patient to cope with feelings of hopelessness, improve
self-esteem, and feel that they are not alone.
Risk for suicide related to depression

Patient will remain safe from suicide or self-injury

Assessment
1. Assess for a suicide plan.
A patient should be directly asked if they want to kill themself and if they have a
specific plan to do so to determine intent.

2. Note the use of drugs or alcohol.

Assess if a patient is using drugs or alcohol or abusing prescribed medications. Easy
access to pain medication, benzodiazepines, and anti-depressants can be
dangerous for a suicidal patient.

Risk For Suicide Interventions

1. Present a positive attitude.

Structure statements and actions in a positive “can do” way instead of “do not.” An
example is “You can go for a walk today” or “You get to see your family tomorrow.”

2. Acknowledge suicide and consequences.

The nurse can acknowledge suicide as an option while also discussing the reality of
that option and its consequences. Inquire about how suicide will solve the patient’s
problems and offer alternatives.

3. Administer medications.
Medications such as anti-depressants, benzodiazepines, and antipsychotics should
be given in a controlled and monitored setting.

4. Promote safety.
If on an inpatient behavioral health unit, the patient may require 1:1 supervision to
ensure safety. Items that could be used to harm themselves such as clothing items,
cords, and sharp objects should be removed.
5. Continually re-evaluate suicide risk.
Especially after mood changes and at discharge as a patient who is feeling better is
at the highest risk for suicide because they may now have the energy to carry out
their suicide.

Conduct a thorough suicide risk assessment.

● Rationale: Identifying the level of suicide risk is crucial for implementing

appropriate interventions. Assessing factors such as suicidal thoughts, plans,
means, and previous attempts helps determine the immediate level of risk and
the necessary level of care.

Ensure a safe environment by removing potentially harmful objects.

● Rationale: Creating a safe environment reduces the risk of self-harm.

Removing items such as sharp objects, medications, and any other means
that could be used for suicide is essential in preventing potential attempts.

Establish a therapeutic relationship and provide emotional support.

● Rationale: Building a trusting relationship and offering consistent emotional

support can help the patient feel valued and understood. This support can
decrease feelings of isolation and hopelessness, which are often associated
with suicidal ideation.

Monitor the patient closely, especially during high-risk periods.

● Rationale: Close observation is necessary to ensure the patient's safety,

particularly during times of increased risk, such as during severe depressive
episodes or after receiving distressing news. Frequent checks and constant
supervision may be required in acute cases.

Collaborate with mental health professionals for comprehensive care.

● Rationale: Involving mental health professionals such as psychiatrists,

psychologists, or counselors ensures that the patient receives specialized
 care. These professionals can provide therapy, medication management, and
other interventions that are critical for addressing depression and suicidal
ideation.

Develop a safety plan with the patient.

● Rationale: A safety plan provides the patient with concrete steps to follow
during a crisis, including whom to contact and where to seek help. This plan
empowers the patient and provides a structured approach to managing
suicidal thoughts.

Engage the patient in activities that promote social interaction and support.

● Rationale: Social engagement can help reduce feelings of loneliness and

isolation, which are common in depression. Activities that involve social
interaction can provide emotional support and a sense of belonging, which are
protective factors against suicide.

Educate the patient and family about the signs of worsening depression and
suicidal ideation.

● Rationale: Education helps the patient and their family recognize early
warning signs and seek timely intervention. Knowledge of these signs can
facilitate prompt action and potentially prevent a suicide attempt.

Encourage the use of coping strategies and stress management techniques.

● Rationale: Teaching and encouraging the use of healthy coping strategies

can help the patient manage depressive symptoms and reduce suicidal
thoughts. Techniques such as relaxation exercises, journaling, and
mindfulness can be effective.

Regularly evaluate the patient’s mood, behavior, and adherence to the

treatment plan.

● Rationale: Ongoing evaluation allows for the timely identification of changes

in the patient’s condition and the effectiveness of interventions. Regular
 assessment ensures that the care plan remains appropriate and responsive to
the patient’s needs.

Nutrition imbalance less than body requirement related to loss of appetite

1. Assess the patient's nutritional status and dietary intake.

○ Rationale: A comprehensive assessment helps identify the extent of
the nutritional imbalance and any specific deficiencies. This information
is crucial for developing a personalized care plan to address the
patient's needs.
2. Monitor weight, body mass index (BMI), and laboratory values regularly.
○ Rationale: Regular monitoring of weight, BMI, and relevant lab values
(such as albumin, prealbumin, and electrolytes) provides objective data
to evaluate the patient’s nutritional status and the effectiveness of
interventions.
3. Provide small, frequent meals and snacks that are nutrient-dense.
○ Rationale: Small, frequent meals can be less overwhelming and more
manageable for patients with a poor appetite. Nutrient-dense foods
ensure that the patient receives adequate nutrition even with reduced
intake.
4. Enhance the appeal of meals by improving presentation and taste.
○ Rationale: Attractive presentation and palatable meals can stimulate
appetite and encourage the patient to eat more. This includes paying
attention to food texture, color, and aroma.
5. Encourage social dining experiences whenever possible.
○ Rationale: Eating with others can improve appetite and make
mealtimes more enjoyable. Social interaction during meals can distract
from negative feelings about eating and enhance the overall dining
experience.
6. Address any underlying factors contributing to loss of appetite, such as
pain, nausea, or depression.
○ Rationale: Identifying and managing underlying issues that affect
appetite can help improve food intake. For example, pain management,
 antiemetic medications for nausea, or addressing depression can
positively impact appetite.
7. Collaborate with a dietitian to develop a personalized nutrition plan.
○ Rationale: A dietitian can provide specialized knowledge and tailor a
nutrition plan to meet the patient’s specific needs, preferences, and
medical conditions. This ensures that the patient receives appropriate
nutritional support.
8. Educate the patient and family about the importance of adequate
nutrition and strategies to improve intake.
○ Rationale: Education helps the patient and their family understand the
critical role of nutrition in overall health and recovery. It also provides
practical strategies to enhance dietary intake and address barriers to
eating.
9. Offer high-calorie, high-protein supplements as needed.
○ Rationale: Nutritional supplements can help bridge the gap between
the patient’s intake and their nutritional needs. High-calorie,
high-protein options are particularly beneficial for patients with
significant nutritional deficits.
10. Create a pleasant and comfortable dining environment.
○ Rationale: A calm, pleasant dining environment can enhance the
eating experience and promote better intake. This includes minimizing
distractions, ensuring proper seating and comfort, and creating a
positive atmosphere.
11. Encourage light physical activity as tolerated.
○ Rationale: Physical activity can stimulate appetite and improve overall
well-being. Encouraging the patient to engage in light exercises, such
as walking, can help increase their desire to eat.
Disturbed thought related to imbalance of chemical in brain

Conduct a thorough assessment of the patient's cognitive function and mental

status.

● Rationale: Understanding the extent and nature of the cognitive disturbances

helps in developing an effective care plan. This assessment provides baseline
data to monitor changes and the effectiveness of interventions.

Monitor the patient's behavior and thought patterns regularly.

● Rationale: Regular monitoring helps identify changes in cognitive function

and thought processes. This enables timely intervention and adjustment of the
care plan as needed.

Ensure a safe environment by minimizing potential hazards.

● Rationale: Patients with disturbed thought processes may be at risk for injury
due to impaired judgment and confusion. Creating a safe environment
reduces the risk of accidents and enhances the patient's safety.

Provide a calm and structured environment.

● Rationale: A calm and structured environment can reduce confusion and

agitation, promoting a sense of security and stability. This can help improve
the patient’s cognitive function and thought clarity.

Use clear, simple communication and provide instructions one step at a time.

● Rationale: Simplified communication helps the patient understand and follow

instructions more easily, reducing frustration and confusion. This approach
supports better comprehension and compliance with care.

Orient the patient to time, place, and person regularly.

● Rationale: Regular orientation can help maintain the patient’s connection to

reality and reduce confusion. This is particularly important for patients with
cognitive impairments and memory issues.
Administer prescribed medications and monitor for side effects.

● Rationale: Medications may be prescribed to manage chemical imbalances in

the brain. Monitoring for side effects ensures that the patient tolerates the
medications well and that they are effective in managing symptoms.

Encourage participation in cognitive activities and mental exercises.

● Rationale: Cognitive activities and mental exercises can help stimulate brain
function and improve cognitive abilities. Engaging in these activities may slow
cognitive decline and enhance mental sharpness.

Collaborate with mental health professionals for comprehensive care.

● Rationale: Involving mental health professionals ensures that the patient

receives specialized care and support for their cognitive and psychological
needs. These professionals can provide therapy, counseling, and additional
interventions to manage disturbed thought processes.

Educate the patient and family about the condition and coping strategies.

● Rationale: Education helps the patient and their family understand the nature
of the cognitive disturbances and how to manage them effectively. Knowledge
of coping strategies can empower them to handle challenges and support the
patient’s well-being.

Promote regular physical activity and a healthy diet.

● Rationale: Physical activity and proper nutrition are important for overall brain
health. Exercise increases blood flow to the brain, and a balanced diet
provides essential nutrients that support cognitive function.

Encourage social interaction and participation in group activities.

● Rationale: Social interaction can stimulate cognitive function and improve

mood. Group activities provide opportunities for engagement and mental
stimulation, which can help reduce cognitive decline.
ORTHOSTATIC HYPOTENSION

Decreased cardiac output related to inadequate blood perfusion by

hypotension

1. Assess and monitor the patient's vital signs regularly, especially blood
pressure and heart rate in different positions (lying, sitting, standing).
○ Rationale: Regular monitoring helps identify changes in blood
pressure and heart rate, which are crucial for detecting orthostatic
hypotension and evaluating the effectiveness of interventions.
2. Educate the patient on how to change positions slowly (e.g., from lying
to sitting, and then to standing).
○ Rationale: Gradual position changes can help prevent sudden drops in
blood pressure, reducing the risk of dizziness, fainting, and falls
associated with orthostatic hypotension.
3. Encourage the patient to stay hydrated and consume adequate fluids.
○ Rationale: Proper hydration can help maintain blood volume and
prevent drops in blood pressure, thereby improving cardiac output and
reducing the risk of orthostatic hypotension.
4. Advise the patient to avoid prolonged bed rest and encourage regular
physical activity as tolerated.
○ Rationale: Regular physical activity can improve cardiovascular health
and enhance blood circulation, which can help mitigate the effects of
orthostatic hypotension and improve overall cardiac output.
5. Educate the patient about wearing compression stockings if
appropriate.
○ Rationale: Compression stockings can help improve venous return
and prevent blood pooling in the lower extremities, thereby reducing
the risk of orthostatic hypotension and enhancing cardiac output.
6. Administer prescribed medications and monitor for side effects.
○ Rationale: Medications may be prescribed to manage blood pressure
and improve cardiac output. Monitoring for side effects ensures patient
safety and the effectiveness of the medication regimen.
7. Teach the patient to avoid large meals and to eat smaller, more frequent
meals.
 ○ Rationale: Large meals can divert blood flow to the digestive system,
potentially exacerbating orthostatic hypotension. Smaller, more
frequent meals can help maintain more stable blood pressure levels.
8. Advise the patient to avoid alcohol and excessive caffeine consumption.
○ Rationale: Alcohol and excessive caffeine can cause vasodilation and
diuresis, leading to a drop in blood pressure and increasing the risk of
orthostatic hypotension.
9. Collaborate with a dietitian to ensure the patient’s diet supports
cardiovascular health.
○ Rationale: A dietitian can provide specialized dietary
recommendations to help maintain blood pressure and improve cardiac
output, ensuring the patient receives optimal nutritional support.
10. Educate the patient and family about the importance of recognizing and
reporting symptoms of orthostatic hypotension (e.g., dizziness,
lightheadedness, fainting).
○ Rationale: Early recognition and reporting of symptoms can lead to
timely intervention and prevent complications associated with
orthostatic hypotension, such as falls and decreased cardiac output.
11. Encourage the patient to elevate the head of the bed when sleeping.
○ Rationale: Elevating the head of the bed can help reduce the risk of
orthostatic hypotension upon waking by preventing sudden drops in
blood pressure when transitioning from a lying to a standing position.
Risk for fall related to lightheadedness or dizzines upon standing

Assess the patient's history of falls and incidents of dizziness or

lightheadedness.

● Rationale: Understanding the patient's fall history and the frequency of

dizziness or lightheadedness helps in identifying risk factors and planning
targeted interventions to prevent falls.

Monitor vital signs, especially blood pressure, in different positions (lying,

sitting, standing).

● Rationale: Regular monitoring can help detect orthostatic hypotension and

assess the effectiveness of interventions. Early detection allows for timely
management to prevent dizziness and falls.

Educate the patient to change positions slowly and gradually (e.g., from lying
to sitting, then standing).

● Rationale: Gradual position changes can help prevent sudden drops in blood
pressure, reducing the risk of dizziness, lightheadedness, and subsequent
falls.

Ensure the patient uses assistive devices (e.g., canes, walkers) if needed.

● Rationale: Assistive devices provide stability and support, helping to prevent

falls, especially when the patient experiences dizziness or unsteadiness upon
standing.

Encourage the patient to stay hydrated and maintain adequate fluid intake.

● Rationale: Proper hydration helps maintain blood volume and pressure,

reducing the likelihood of orthostatic hypotension and associated dizziness or
lightheadedness.

Advise the patient to avoid standing for prolonged periods and to sit down if
feeling lightheaded.
 ● Rationale: Limiting prolonged standing and sitting down when feeling dizzy
can prevent falls by reducing the risk of sudden drops in blood pressure and
loss of balance.

Teach the patient and family about the importance of a safe home
environment, such as removing tripping hazards and ensuring good lighting.

● Rationale: A safe home environment reduces the risk of falls by eliminating

potential obstacles and improving visibility, making it easier for the patient to
navigate their surroundings safely.

Provide education on the side effects of medications that may contribute to

orthostatic hypotension and dizziness.

● Rationale: Awareness of medication side effects allows the patient and family
to take necessary precautions and report any adverse effects to the
healthcare provider for appropriate management.

Encourage the use of non-skid footwear and ensure proper fitting shoes.

● Rationale: Non-skid footwear provides better traction and reduces the risk of
slipping, while properly fitting shoes improve stability and support, decreasing
the likelihood of falls.

Implement a fall prevention program that includes regular exercise to improve

strength, balance, and coordination.

● Rationale: Exercise programs that focus on strength, balance, and

coordination can enhance physical stability and reduce the risk of falls by
improving the patient's overall physical condition.

Instruct the patient to avoid sudden or excessive bending or reaching

movements.

● Rationale: Sudden or excessive movements can cause dizziness and

increase the risk of losing balance and falling. Educating the patient on safe
movement techniques can prevent such incidents.
Collaborate with physical and occupational therapists to develop a
personalized fall prevention plan.

● Rationale: Physical and occupational therapists can provide specialized

interventions and exercises tailored to the patient's needs, improving their
physical function and reducing fall risk.
 CANCER

Pain related to cancer symptoms

Determine pain history (location of pain, frequency, duration, and intensity

using a numeric rating scale (0–10 scale), or verbal rating scale (“no pain” to
“excruciating pain”) and relief measures used.
The information provides baseline data to evaluate the effectiveness of interventions.
The pain of more than 6 mo duration constitutes chronic pain, which may affect
therapeutic choices. Recurrent episodes of acute pain can occur within chronic pain,
requiring an increased level of intervention. Note: The pain experience is an
individualized one composed of both physical and emotional responses.

Determine the timing or precipitants of “breakthrough” pain when using

around-the-clock agents, whether oral, IV, or patch medications.
Pain may occur near the end of the dosing interval, indicating the need for a higher
dose or shorter dose interval. Pain may be precipitated by identifiable triggers, or
occur spontaneously, requiring the use of short half-life agents for rescue or
supplemental doses.

Evaluate and be aware of the painful effects of particular therapies (surgery,

radiation, chemotherapy, biotherapy). Provide information to the patient and
SO about what to expect.
A wide range of discomforts is common (incisional pain, burning skin, low back pain,
headaches), depending on the procedure and agent being used. Pain is also
associated with invasive procedures to diagnose or treat cancer.

Provide non-pharmacological comfort measures (massage, repositioning,

backrub) and diversional activities (music, television)
Promotes relaxation and helps refocus attention.

Encourage the use of stress management skills or complementary therapies

(relaxation techniques, visualization, guided imagery, biofeedback, laughter,
music, aromatherapy, and therapeutic touch).
Enables patient to participate actively in the non-pharmacological treatment of pain
and enhances a sense of control. Pain produces stress and, in conjunction with
muscle tension and internal stressors, increases the patient’s focus on self, which in
turn increases the level of pain.

Provide cutaneous stimulation (heat or cold, massage).

May decrease inflammation, and muscle spasms, reducing associated pain. Note:
Heat may increase bleeding and edema following acute injury, whereas cold may
further reduce perfusion to ischemic tissues.

Be aware of barriers to cancer pain management related to patients, as well as

the healthcare system.
Patients may be reluctant to report pain for reasons such as fear that disease is
worse; worry about unmanageable side effects of pain medications; beliefs that pain
has meaning, such as “God wills it,” they should overcome it, or that pain is merited
or deserved for some reason. Healthcare system problems include factors such as
inadequate assessment of pain, concern about controlled substances or patient
addiction, inadequate reimbursement, or cost of treatment modalities.

Evaluate pain relief and control at regular intervals. Adjust medication regimen
as necessary.
The goal is maximum pain control with minimum interference with ADLs.

Inform the patient and SO of the expected therapeutic effects and discuss the
management of side effects
This information helps establish realistic expectations and confidence in own ability
to handle what happens.

Discuss the use of additional alternative or complementary therapies

(acupuncture and acupressure).
May provide reduction or relief of pain without drug-related side effects.

Administer analgesics as indicated.

See Pharmacologic Management
Imbalance nutrition related to loss of appetite

Monitor daily food intake; have the patient keep a food diary as indicated.
Identifies nutritional strengths and deficiencies.

Measure height, weight, and tricep skinfold thickness (or other anthropometric
measurements as appropriate). Ascertain the amount of recent weight loss.
Weigh daily or as indicated.
If these measurements fall below minimum standards, the patient’s chief source of
stored energy (fat tissue) is depleted.

Assess skin and mucous membranes for pallor, delayed wound healing, and
enlarged parotid glands.
Helps in the identification of protein-calorie malnutrition, especially when weight and
anthropometric measurements are less than normal.

Monitor I&O and specific gravity; include all output sources, (emesis, diarrhea,
draining wounds. Calculate 24-hr balance).
Continued negative fluid balance, decreasing renal output, and concentration of
urine suggest developing dehydration and the need for increased fluid replacement.

Weigh as indicated.
Sensitive measurement of fluctuations in fluid balance.

Monitor vital signs. Evaluate peripheral pulses and capillary refill.

Reflects adequacy of circulating volume.

Observe for bleeding tendencies (oozing from mucous membranes, puncture

sites); the presence of ecchymosis or petechiae.
Early identification of problems (which may occur as a result of cancer or therapies)
allows for prompt intervention.
Monitor laboratory studies (CBC, electrolytes, serum albumin).
Provides information about the level of hydration and corresponding deficits.

Hematest stools, and gastric secretions.

Certain therapies (antimetabolites) inhibit the renewal of epithelial cells lining the GI
tract, which may cause changes ranging from mild erythema to severe ulceration
with bleeding.

Review laboratory studies as indicated (total lymphocyte count, serum

transferrin, and albumin or prealbumin).
Helps identify the degree of biochemical imbalance, and malnutrition and influences
the choice of dietary interventions. Note: Anticancer treatments can also alter
nutrition studies, so all results must be correlated with the patient’s clinical status.

Encourage the patient to eat a high-calorie, nutrient-rich diet, with adequate

fluid intake. Encourage the use of supplements and frequent or smaller meals
spaced throughout the day.
Metabolic tissue needs are increased as well as fluids (to eliminate waste products).
Supplements can play an important role in maintaining adequate caloric and protein
intake.

Create a pleasant dining atmosphere; encourage the patient to share meals

with family and friends.
Makes mealtime more enjoyable, which may enhance intake.

Encourage open communication regarding anorexia.

Often a source of emotional distress, especially for SO who wants to feed patients
frequently. When the patient refuses, SO may feel rejected or frustrated.

Adjust diet before and immediately after treatment (clear, cool liquids, light or
bland foods, candied ginger, dry crackers, toast, and carbonated drinks). Give
liquids 1 hr before or 1 hr after meals.
The effectiveness of diet adjustment is very individualized in the relief of posttherapy
nausea. Patients must experiment to find the best solution or combination. Avoiding
fluids during meals minimizes becoming “full” too quickly.

Control environmental factors (strong or noxious odors or noise). Avoid overly

sweet, fatty, or spicy foods.
Can trigger nausea and vomiting response.

Encourage the use of relaxation techniques, visualization, guided imagery, and

moderate exercise before meals.
May prevent the onset or reduce the severity of nausea, decrease anorexia, and
enable the patient to increase oral intake.

Identify the patient who experiences anticipatory nausea and vomiting and
take appropriate measures.
Psychogenic nausea and vomiting occurring before chemotherapy generally do not
respond to antiemetic drugs. A change of treatment environment or patient routine
on treatment day may be effective.

Administer antiemetic on a regular schedule before or during and after

administration of antineoplastic agent as appropriate.
Nausea and vomiting are frequently the most disabling and psychologically stressful
side effects of chemotherapy.

Evaluate the effectiveness of antiemetics.

Individuals respond differently to all medications. First-line antiemetics may not work,
requiring alteration in or use of combination drug therapy.

Encourage increased fluid intake to 3000 mL per day as individually

appropriate or tolerated.
Assists in the maintenance of fluid requirements and reduces the risk of harmful side
effects such as hemorrhagic cystitis in patients receiving cyclophosphamide
(Cytoxan).
Minimize venipunctures (combine IV starts with blood draws). Encourage the
patient to consider central venous catheter placement.
Reduces potential for hemorrhage and infection associated with repeated venous
puncture.

Avoid trauma and apply pressure to puncture sites.

Reduces potential for bleeding and hematoma formation.

Provide IV fluids as indicated.

Given for general hydration and to dilute antineoplastic drugs and reduce adverse
side effects (nausea and vomiting, or nephrotoxicity).

Refer to a dietitian or nutritional support team.

Provides a specific dietary plan to meet individual needs and reduce problems
associated with protein, calorie malnutrition, and micronutrient deficiencies.

Insert and maintain NG or feeding tube for enteric feedings, or central line for
total parenteral nutrition (TPN) if indicated.
In the presence of severe malnutrition (loss of 25%–30% body weight in 2 mo) or if
the patient has been NPO for 5 days and is unlikely to be able to eat for another
week, tube feeding or TPN may be necessary to meet nutritional needs.

Fatigue related to disease process

Have the patient rate fatigue, using a numeric scale, if possible, and the time of
day when it is most severe.
Helps in developing a plan for managing fatigue.

Monitor physiological response to activity (changes in BP, heart, and

respiratory rate).
Tolerance varies greatly depending on the stage of the disease process, nutrition
state, fluid balance, and reaction to the therapeutic regimen.
Plan care to allow for rest periods. Schedule activities for periods when the
patient has the most energy. Involve patient and SO in schedule planning.
Frequent rest periods and naps are needed to restore and conserve energy.
Planning will allow the patient to be active during times when the energy level is
higher, which may restore a feeling of well-being and a sense of control.

Establish realistic activity goals with the patient.

Provides a sense of control and feelings of accomplishment.

Assist with self-care needs when indicated; keep the bed in a low position, and
pathways clear of furniture; assist with ambulation.
Weakness may make ADLs difficult to complete or place the patient at risk for injury
during activities.

Encourage the patient to do whatever is possible (self-bathing, sitting up in a

chair, walking). Increase activity level as the individual is able.
Enhances strength and stamina and enables the patient to become more active
without undue fatigue.

Perform pain assessment and provide pain management.

Poorly managed cancer pain can contribute to fatigue.

Provide supplemental oxygen as indicated.

The presence of anemia and hypoxemia reduces oxygen available for cellular uptake
and contributes to fatigue.

Refer to physical or occupational therapy.

Programmed daily exercises and activities help patients maintain and increase
strength and muscle tone, and enhance a sense of well-being. The use of adaptive
devices may help conserve energy.
Impaired skin integrity related to prolonged living

Assess skin frequently for side effects of cancer therapy; note breakdown and
delayed wound healing. Emphasize the importance of reporting open areas to
the health care providers.
A reddening or tanning effect (radiation reaction) may develop within the field of
radiation. Dry desquamation (dryness and pruritus), moist desquamation (blistering),
ulceration, hair loss, and loss of dermis and sweat glands may also be noted. In
addition, skin reactions (allergic rashes, hyperpigmentation, pruritus, and alopecia)
may occur with some chemotherapy agents.

Assess skin and IV site and vein for erythema, edema, tenderness; welt-like
patches, itching and burning; or swelling, burning, soreness; blisters
progressing to ulceration or tissue necrosis.
The presence of phlebitis, vein flare (localized reaction), or extravasation requires
immediate discontinuation of antineoplastic agents and medical intervention.

Bathe with lukewarm water and mild soap.

Maintains cleanliness without irritating the skin.

Encourage the patient to avoid vigorous rubbing and scratching and to pat the
skin dry instead of rubbing.
Helps prevent skin friction and trauma to sensitive tissues.

Turn or reposition frequently.

Promotes circulation and prevents undue pressure on skin and tissues.

Review skin care protocol for patients receiving radiation therapy: Avoid
rubbing or the use of soap, lotions, creams, ointments, powders, or
deodorants on the area.
Designed to minimize trauma to the area of radiation therapy. Can potentiate or
otherwise interfere with radiation delivery. May actually increase irritation and
reaction. Skin is very sensitive during and after treatment, and all irritation should be
avoided to prevent dermal injury.
Avoid applying heat or attempting to wash off marks or tattoos placed on the
skin to identify the area of irradiation.
Helps control dampness or pruritus. Maintenance care is required until skin and
tissues have regenerated and are back to normal.

Recommend wearing soft, loose cotton clothing; have female patients avoid
wearing bras if it creates pressure.
Protects skin from ultraviolet rays and reduces the risk of recall reactions.

Apply cornstarch, Aquaphor, Lubriderm, and Eucerin (or other recommended

water-soluble moisturizing gel) to the area twice daily as needed.
See Pharmacologic Management

Encourage liberal use of sunscreen or block and breathable, protective

clothing.
Development of irritation indicates the need for alteration of rate or dilution of
chemotherapy and change of IV site to prevent a more serious reaction.

Wash skin immediately with soap and water if antineoplastic agents are spilled
on unprotected skin (patient or caregiver).
Dilutes drug to reduce the risk of skin irritation and chemical burn.

Advise patients receiving 5-fluorouracil (5-FU) and methotrexate to avoid sun

exposure. Withhold methotrexate if the sunburn is present.
Sun can cause exacerbation of burn spotting (a side effect of 5-fluorouracil) or can
cause a red “flash” area with methotrexate, which can exacerbate the drug’s effect.

Review expected dermatologic side effects seen with chemotherapy (rash,

hyperpigmentation, and peeling of skin on palms).
Anticipatory guidance helps decrease concern if side effects do occur.

Inform the patient that if alopecia occurs, hair could grow back after
completion of chemotherapy, but may or may not grow back after radiation
therapy.
Anticipatory guidance may help in preparation for baldness. Men are often as
sensitive to hair loss as women. Radiation’s effect on hair follicles may be
permanent, depending on radiation dosage.

Apply an ice pack or warm compresses per protocol.

Controversial intervention depends on the type of agent used. Ice restricts blood
flow, keeping the drug localized, while heat enhances the dispersion of neoplastic
drug or antidote, minimizing tissue damage.

Fear and anxiety related to emotional responses towards cancer.

Review the patient’s and SO’s previous experience with cancer. Determine
what the doctor has told the patient and what conclusion the patient has
reached.
Clarifies patient’s perceptions; assists in the identification of fear(s) and
misconceptions based on diagnosis and experience with cancer.

Identify the stage and degree of grief the patient and SO are currently
experiencing.
The choice of interventions is dictated by the stage of grief, and coping behaviors
(anger, withdrawal, denial).

Note ineffective coping (poor social interactions, helplessness, giving up

everyday functions, and usual sources of gratification).
Identifies individual problems and provides support for the patient and SO in using
effective coping skills.

Be alert to signs of denial and depression (withdrawal, anger, inappropriate

remarks). Determine the presence of suicidal ideation and assess potential on
a scale of 1–10.
Patients may use the defense mechanism of denial and express hope that the
diagnosis is inaccurate. Feelings of guilt, spiritual distress, physical symptoms, or
lack of cure may cause the patient to become withdrawn and believe that suicide is a
viable alternative.

Encourage the patient to share thoughts and feelings.

Provides an opportunity to examine realistic fears and misconceptions about the
diagnosis.

Provide an open environment in which the patient feels safe to discuss

feelings or refrain from talking.
Helps patients feel accepted in their present conditions without feeling judged, and
promotes a sense of dignity and control.

Maintain frequent contact with the patient. Talk with and touch the patient as
appropriate.
Provides assurance that patient is not alone or rejected; conveys respect for and
acceptance of the person, fostering trust.

Be aware of the effects of isolation on the patient when required by

immunosuppression or radiation implant. Limit the use of isolation clothing
and masks as possible.
Sensory deprivation may result when sufficient stimulation is not available and may
intensify feelings of anxiety, fear, and alienation.

Assist the patient and SO in recognizing and clarifying fears to begin

developing coping strategies for dealing with these fears.
Coping skills are often stressed after diagnosis and during different phases of
treatment. Support and counseling are often necessary to enable individuals to
recognize and deal with fear and to realize that control and coping strategies are
available.

Provide accurate, consistent information regarding diagnosis and prognosis.

Avoid arguing about the patient’s perceptions of the situation.
Can reduce anxiety and enable patients to make decisions and choices based on
realities.
Permit expressions of anger, fear, and despair without confrontation. Give
information that feelings are normal and are to be appropriately expressed.
Acceptance of feelings allows the patient to begin to deal with the situation.

Explain the recommended treatment, its purpose, and potential side effects.
Help patients prepare for treatments.
The goal of cancer treatment is to destroy malignant cells while minimizing damage
to normal ones. Treatment may include surgery (curative, preventive, palliative), as
well as chemotherapy, radiation (internal, external), or organ-specific treatments
such as whole-body hyperthermia or biotherapy. Bone marrow or peripheral
progenitor cell (stem cell) transplant may be recommended for some types of cancer.

Explain procedures, providing opportunities for questions and honest

answers. Stay with patients during anxiety-producing procedures and
consultations.
Accurate information allows patients to deal more effectively with the reality of the
situation, thereby reducing anxiety and fear of the unknown.

Provide primary and consistent caregivers whenever possible.

May help reduce anxiety by fostering therapeutic relationships and facilitating
continuity of care.

Promote a calm, quiet environment.

Facilitates rest, conserves energy and may enhance coping abilities.

Encourage and foster patient interaction with support systems

Reduces feelings of isolation. If family support systems are not available, outside
sources may be needed immediately, (local cancer support groups).

Provide reliable and consistent information and support for SO.

Allows for better interpersonal interaction and reduction of anxiety and fear.

Include SO as indicated or patient desires when major decisions are to be

made.
Provides a support system for the patient and allows SO to be involved
appropriately.

Note components of family, presence of extended family, and others (friends

and neighbors).
Helps the patient and caregiver know who is available to assist with care or provide
respite and support.

Identify patterns of communication in the family and patterns of interaction

between family members.
Provides information about the effectiveness of communication and identifies
problems that may interfere with the family’s ability to assist the patient and adjust
positively to the diagnosis and treatment of cancer.

Assess role expectations of family members and encourage discussion about

them.
Each person may see the situation in own individual manner, and clear identification
and sharing of these expectations promote understanding.

Assess energy direction (are efforts at resolution and problem-solving

purposeful or scattered?).
Provides clues about interventions that may be appropriate to assist patient and
family in directing energies in a more effective manner.

Note cultural and religious beliefs.

Affects patient and SO reaction and adjustment to diagnosis, treatment, and
outcome of cancer.

Listen for expressions of helplessness.

Helpless feelings may contribute to difficulty adjusting to the diagnosis of cancer and
cooperating with the treatment regimen.

Deal with family members in a warm, caring, respectful way. Provide

information (verbal and written), and reinforce as necessary.
Provides feelings of empathy and promotes an individual’s sense of worth and
competence in the ability to handle the current situations.

Encourage appropriate expressions of anger without reacting negatively to

them.
Feelings of anger are to be expected when individuals are dealing with the difficult
and potentially fatal illness of cancer. Appropriate expression enables progress
toward the resolution of the stages of the grieving process.

Acknowledge the difficulties of the situation (diagnosis and treatment of

cancer, possibility of death).
Communicates acceptance of the reality the patient and family are facing.

Identify and encourage the use of previous successful coping behaviors.

Most people have developed effective coping skills that can be useful in dealing with
the current situation.

Stress the importance of continuous open dialogue between family members.

Promotes understanding and assists family members to maintain clear
communication and resolving problems effectively.

Refer to support groups, clergy, and family therapy as indicated.

May need additional assistance to resolve problems of disorganization that may
accompany a diagnosis of potentially terminal illness (cancer).
ARTHRITIS

Pain related to joint inflammation secondary to arthritis

Consider reports of pain, noting location and intensity (scale of 0–10). Note
precipitating factors and nonverbal pain cues.
Favorable in determining pain management needs and effectiveness of the program.

Monitor the duration, not the intensity, of morning stiffness.

Duration more accurately reflects the disease’s severity.

Recommend or provide a firm mattress or bedboard, and a small pillow.

Elevate linens with bed cradle as needed.
Soft and sagging mattresses and large pillows prevent the maintenance of proper
body alignment, placing stress on affected joints. Elevation of bed linens reduces
pressure on inflamed or painful joints.

Suggest patient assume a position of comfort while in bed or sitting in a chair.

Promote bedrest as indicated.
In severe disease or acute exacerbation, total bedrest may be necessary (until
objective and subjective improvements are noted) to limit pain or injury to the joint.

Place and monitor the use of pillows, sandbags, trochanter rolls, splints, and
braces.
Rests painful joints and maintains a neutral position. Note: The use of splints can
decrease pain and may reduce damage to joints; however, prolonged inactivity can
result in loss of joint mobility and function.

Encourage frequent changes of position. Assist the patient to move in bed,

supporting affected joints above and below, and avoiding jerky movements.
Prevents general fatigue and joint stiffness. Stabilizes joints, decreasing joint
movement and associated pain.
Recommend that the patient take a warm bath or shower upon arising or at
bedtime. Apply warm, moist compresses to affected joints several times a day.
Monitor water temperature of compress, baths, and so on.
Heat promotes muscle relaxation and mobility, decreases pain, and relieves morning
stiffness. Sensitivity to heat may be diminished and dermal injury may occur.

Provide gentle massage.

Promotes relaxation and reduces muscle tension.

Encourage the use of stress management techniques such as progressive

relaxation, biofeedback, visualization, guided imagery, self-hypnosis, and
controlled breathing. Provide Therapeutic Touch.
Promotes relaxation, provides a sense of control, and may enhance coping abilities.

Involve in diversional activities appropriate for the individual situation.

Refocuses attention, provides stimulation, and enhances self-esteem and feelings of
general well-being.

Medicate before planned activities and exercises as indicated.

Promotes relaxation, and reduces muscle tension and spasms, facilitating
participation in therapy.

Administer medications as indicated.

See Pharmacologic Management

Assist with physical therapies such as paraffin gloves, and whirlpool baths.
Provides sustained heat to reduce pain and improve ROM of affected joints.

Apply ice or cold packs when indicated.

Cold may relieve pain and swelling during acute episodes.

Instruct in use and monitor the effect of the transcutaneous electrical nerve
stimulator (TENS) unit if used.
Constant low-level electrical stimulus blocks the transmission of pain sensations.
Impaired physical imboloty related to intolerance ro activity; reduced muscle
strength

Assess and continuously monitor the degree of joint inflammation and pain.
The level of activity and exercise depends on the progression and resolution of the
inflammatory process.

Maintain bedrest or chair rest when indicated. Schedule activities providing

frequent rest periods and uninterrupted nighttime sleep.
Systemic rest is mandatory during acute exacerbations and important throughout all
phases of the disease to reduce fatigue, and improve strength.

Assist with active and passive ROM and resistive exercises and isometrics
when able.
Maintains and improves joint function, muscle strength, and general stamina. Note:
Inadequate exercise leads to joint stiffening, whereas excessive activity can damage
joints.

Encourage the patient to maintain an upright and erect posture when sitting,
standing, and walking.
Maximizes joint function, and maintains mobility.

Urge the patient to perform activities of daily living (ADLs), such as practicing
good hygiene, dressing, and feeding himself.
ADLs that can be done should be encouraged to maximize function.

Discuss and provide safety needs such as raised chairs and toilet seats, use
of handrails in the tub, shower, and toilet, proper use of mobility aids, and
wheelchair safety.
Helps prevent accidental injuries and falls.

Reposition frequently using adequate personnel. Demonstrate and assist with

transfer techniques and use of mobility aids such as a walker, cane, and
trapeze.
Relieves pressure on tissues and promotes circulation. Facilitates self-care and
patient independence. Proper transfer techniques prevent shearing abrasions of the
skin.

Position with pillows, sandbags, and trochanter roll. Provide joint support with
splints, and braces.
Promotes joint stability (reducing risk of injury) and maintains proper joint position
and body alignment, minimizing contractures.

Suggest using a small or thin pillow under the neck.

Prevents flexion of the neck.

Provide foam or alternating pressure mattresses.

Decreases pressure on fragile tissues to reduce risks of immobility and development
of decubitus.
Disturbed body image related to increased energy expenditure secondary to
arthritis

Note withdrawn behavior, use of denial, or over-concern with body changes.

May suggest emotional exhaustion or maladaptive coping methods, requiring more
in-depth intervention or psychological support.

Encourage verbalization about concerns about the disease process, and future
expectations.
Provides an opportunity to identify fears and misconceptions and deal with them
directly.

Encourage a balanced diet, but make sure the patient understands that special
diets won’t cure RA. Stress the need for weight control.
Obesity adds further stress to joints.

Ascertain how the patient views self in usual lifestyle functioning, including
sexual aspects.
Identifying how illness affects the perception of self and interactions with others will
determine the need for further intervention and counseling.

Discuss the patient’s perception of how SO perceives limitations.

Verbal and nonverbal cues from SO may have a major impact on how the patient
views self.

Acknowledge and accept feelings of grief, hostility, and dependency.

Constant pain is wearing, and feelings of anger and hostility are common.
Acceptance provides feedback that feelings are normal.

Set limits on maladaptive behavior. Assist the patient to identify positive

behaviors that will aid in coping.
Helps the patient maintain self-control, which enhances self-esteem.
Involve patients in planning care and scheduling activities.
Enhances feelings of competency and self-worth, and encourages independence
and participation in therapy.

Assist with grooming needs as necessary.

Maintaining appearance enhances self-image.

Give positive reinforcement for accomplishments.

Allows patient to feel good about self. Reinforces positive behavior. Enhances
self-confidence.

Administer medications as indicated (antianxiety and mood-elevating drugs).

May be needed in presence of severe depression until the patient develops more
effective coping skills.

Refer to psychiatric counseling like a psychiatric clinical nurse specialist,

psychiatrist or psychologist, or social worker.
Patient and SO may require ongoing support to deal with the long-term and
debilitating process.