A
Activity Intolerance
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Participate in prescribed physical activity with appropriate changes in heart rate, blood pressure, and breathing rate; maintain monitor patterns (rhythm and ST segment) within normal limits
• State symptoms of adverse effects of exercise and report onset of symptoms immediately
• Maintain normal skin color, and skin is warm and dry with activity
• Verbalize an understanding of the need to gradually increase activity based on testing, tolerance, and symptoms
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Determine cause of activity intolerance (see Related Factors) and determine whether cause is physical, psychological, or motivational. Determining the cause of a problem can help direct appropriate interventions.
• If mainly on bed rest, minimize cardiovascular deconditioning by positioning the client in an upright position several times daily if possible. Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, fluid loss, decreased cardiac output, decreased peak oxygen uptake, and increased resting heart rate (Fauci et al, 2008). EB: A study found that diabetic clients developed orthostatic hypotension after 48 hours of bed rest, possibly from altered cardiovascular reflexes (Schneider et al, 2009).
• Assess the client daily for appropriateness of activity and bed rest orders. Mobilize the client as soon as it is possible. With bed rest there is a shift of fluids from the extremities to the thoracic cavity from the loss of gravitational stress. Positioning in an upright position helps maintain optimal fluid distribution and maintain orthostatic tolerance (Perme & Chandrashekar, 2009). CEB: A study utilizing tomography demonstrated significant decreased strength in the hip, thigh, and calf muscles in elderly orthopedic clients, as well as bone mineral loss with immobility (Berg et al, 2007).
• If client is mostly immobile, consider use of a transfer chair: a chair that becomes a stretcher. Using a transfer chair where the client is pulled onto a flat surface and then seated upright in the chair can help previously immobile clients get out of bed (Perme & Chandrashekar, 2009).
• When appropriate, gradually increase activity, allowing the client to assist with positioning, transferring, and self-care as possible. Progress from sitting in bed to dangling, to standing, to ambulation. Always have the client dangle at the bedside before trying standing to evaluate for postural hypotension. Postural hypotension is very common in the elderly (Krecinic et al, 2009).
• When getting a client up, observe for symptoms of intolerance such as nausea, pallor, dizziness, visual dimming, and impaired consciousness, as well as changes in vital signs; manual blood pressure monitoring is best. When an adult rises to the standing position, blood pools in the lower extremities; symptoms of central nervous system hypoperfusion may occur, including feelings of weakness, nausea, headache, lightheadedness, dizziness, blurred vision, fatigue, tremulousness, palpitations, and impaired cognition. EBN: Automatic devices cannot reliably detect or rule out orthostatic hypotension, indicating that nurses need to use manual devices to take accurate postural blood pressures for optimal client care (Dind et al, 2011).
• If the client experiences symptoms of postural hypotension, take precautions when getting the client out of bed. Put graduated compression stockings on client or use lower limb compression bandaging, if ordered, to return blood to the heart and brain. Have the client dangle at the side of the bed with legs hanging over the edge of the bed, flex and extend feet several times after sitting up, then stand up slowly with someone holding the client. If client becomes lightheaded or dizzy, return him to bed immediately. Use of compression stockings or leg bandaging can help return fluid from the lower extremities back where it collects from immobility to the heart and brain (Gorelik et al, 2009; Platts et al, 2009).
• Perform range-of-motion (ROM) exercises if the client is unable to tolerate activity or is mostly immobile. See care plan for Risk for Disuse Syndrome.
• Monitor and record the client’s ability to tolerate activity: note pulse rate, blood pressure, monitor pattern, dyspnea, use of accessory muscles, and skin color before, during, and after the activity. If the following signs and symptoms of cardiac decompensation develop, activity should be stopped immediately:
The above are symptoms of intolerance to activity and continuation of activity may result in client harm ( Urden, Stacy, & Lough, 2010; Goldman, 2011).
Instruct the client to stop the activity immediately and report to the physician if the client is experiencing the following symptoms: new or worsened intensity or increased frequency of discomfort; tightness or pressure in chest, back, neck, jaw, shoulders, and/or arms; palpitations; dizziness; weakness; unusual and extreme fatigue; excessive air hunger. These are common symptoms of angina and are caused by a temporary insufficiency of coronary blood supply. Symptoms typically last for minutes as opposed to momentary twinges. If symptoms last longer than 5 to 10 minutes, the client should be evaluated by a physician. Pulse rate and arterial blood oxygenation indicate cardiac/exercise tolerance; pulse oximetry identifies hypoxia (Urden, Stacy, & Lough, 2010; Goldman, 2011).
• Observe and document skin integrity several times a day. Activity Intolerance, if resulting in immobility, may lead to pressure ulcers. Mechanical pressure, moisture, friction, and shearing forces all predispose to their development. Refer to the care plan Risk for impaired Skin Integrity.
• Assess for constipation. If present, refer to care plan for Constipation. Activity Intolerance is associated with increased risk of constipation.
Refer the client to physical therapy to help increase activity levels and strength.
• Recognize that malnutrition causes significant morbidity due to the loss of lean body mass. Providing nutrition early helps maintain muscle and immune system function, and reduce hospital length of stay (McClave et al, 2009; Racco, 2009).
• Provide emotional support and encouragement to the client to gradually increase activity. Work with the client to set mutual goals that increase activity levels. Fear of breathlessness, pain, or falling may decrease willingness to increase activity. EB: In clients with Parkinson’s disease motivations for exercising included hope that exercise would slow the disease or prevent a decline in function, feeling better with exercise, belief that exercise is beneficial, and encouragement from family members (Ene, McRae, & Schenkman, 2011).
Obtain any necessary assistive devices or equipment needed before ambulating the client (e.g., walkers, canes, crutches, portable oxygen). Assistive devices can help increase mobility (Yeom, Keller, & Fleury, 2009).
Use a gait walking belt when ambulating the client. Gait belts improve the caregiver’s grasp, reducing the incidence of injuries of clients and nurses (Nelson et al, 2003).
Activity Intolerance Due to Respiratory Disease
• If the client is able to walk and has chronic obstructive pulmonary disease (COPD), use the traditional 6-minute walk distance to evaluate ability to walk. EB: The 6-minute walk test predicted mortality in COPD clients (Celli, 2010).
Ensure that the chronic pulmonary client has oxygen saturation testing with exercise. Use supplemental oxygen to keep oxygen saturation 90% or above or as prescribed with activity. Oxygen therapy can improve exercise ability and long-term administration of oxygen can increase survival in COPD clients (Gold Report, 2011; Stoller et al, 2010).
• Monitor a respiratory client’s response to activity by observing for symptoms of respiratory intolerance such as increased dyspnea, loss of ability to control breathing rhythmically, use of accessory muscles, nasal flaring, appearance of facial distress, and skin tone changes such as pallor and cyanosis (Perme & Chandrashekar, 2009).
• Instruct and assist a COPD client in using conscious, controlled breathing techniques during exercise, including pursed-lip breathing, and inspiratory muscle use. EBN: A systematic review found pursed-lip breathing effective in decreasing dyspnea (Carrieri-Kohlman & Donesky-Cuenco, 2008). EB: A systematic review found that inspiratory muscle training was effective in increasing endurance of the client and decreasing dyspnea (Langer et al, 2009).
Evaluate the client’s nutritional status. Refer to a dietitian if needed. Use nutritional supplements to increase nutritional level if needed. Improved nutrition may help increase inspiratory muscle function and decrease dyspnea. EBN: A study found that almost half of a group of clients with COPD were malnourished, which can lead to an exacerbation of the disease (Odencrants, Ehnfors, & Ehrenbert, 2008).
For the client in the intensive care unit, consider mobilizing the client in a four-phase method if there is sufficient knowledgeable staff available to protect the client from harm. Even intensive care unit clients receiving mechanical ventilation can be mobilized safely if a multidisciplinary team is present to support, protect, and monitor the client for intolerance to activity (Perme & Chandrashekar, 2009).
Activity Intolerance Due to Cardiovascular Disease
• If the client is able to walk and has heart failure, consider use of the 6-minute walk test to determine physical ability. EB: The 6-minute walk test is a simple, safe, and inexpensive exercise test to predict functional capacity (Du et al, 2009).
• Allow for periods of rest before and after planned exertion periods such as meals, baths, treatments, and physical activity. Both physical and emotional rest help lower arterial pressure and reduce the workload of the myocardium (Fauci et al, 2008).
Refer to a heart failure program or cardiac rehabilitation program for education, evaluation, and guided support to increase activity and rebuild life. EB: Exercise-based cardiac rehabilitation is effective in reducing total and cardiovascular mortality and hospital admissions (Heran et al, 2011).
• See care plan for Decreased Cardiac Output for further interventions.
Geriatric:• Slow the pace of care. Allow the client extra time to carry out physical activities. Slow gait in the elderly may be related to fear of falling, decreased strength in muscles, reduced balance or visual acuity, knee flexion contractures, and foot pain.
• Encourage families to help/allow an elderly client to be independent in whatever activities possible. Sometimes families believe they are assisting by allowing clients to be sedentary. Encouraging activity not only enhances good functioning of the body’s systems but also promotes a sense of worth (Fauci et al, 2008). EB: Physical activity and cognitive exercise may improve memory and executive functions in older people with mild cognitive impairment (Teixeira et al, 2012).
Assess for swaying, poor balance, weakness, and fear of falling while elders stand/walk. If present, refer to physical therapy. Fear of falling and repeat falling is common in the elderly population. Balance rehabilitation provides individualized treatment for persons with various deficits associated with balance (Studer, 2008). Refer to the care plan for Risk for Falls and Impaired Walking.
Evaluate medications the client is taking to see if they could be causing activity intolerance. Medications such as beta-blockers; lipid lowering agents, which can damage muscle; antipsychotics, which have a common side effect of orthostatic hypotension; some antihypertensives; and lowering the blood pressure to normal in the elderly can result in decreased functioning. Elderly may need a blood pressure of 140/80 or higher in order to walk without dizziness. It is important that medications be reviewed to ensure they are not resulting in less function of the elderly client. Many of the medications found on the Beers list of medications that are inappropriate to prescribe for elderly clients can result in decreased function from dizziness and delirium (American Geriatrics Society; Molony, 2009).
If the client has heart disease causing activity intolerance, refer for cardiac rehabilitation. EB: A study found that elderly clients with coronary heart disease who participate in cardiac rehabilitation programs had significantly lower mortality rates (Suaya et al, 2009).
Refer the disabled elderly client to physical therapy for functional training including gait training, stepping, and sit-to-stand exercises, or for strength training. EB: Functional decline from hospital-associated deconditioning is common in the elderly, and acute inpatient rehabilitation can be effective in preventing this condition (Kortebein, 2009). CEB: A study found that intensive functional training improved balance and coordination more than strength training (Krebs, Scarborough, & McGibbon, 2007). EB: A Cochrane review found that progressive resistance strength training is effective in elderly clients to improve function (Liu & Latham, 2009).
• When mobilizing the elderly client, watch for orthostatic hypotension accompanied by dizziness and fainting. Postural hypotension is common in elderly clients. Cerebral hypoperfusion is the usual cause of orthostatic intolerance and hypotension (Weimer & Zadeh, 2009). CEB: Insufficient oral fluid intake has been identified as a serious problem in skilled nursing facility residents and has been associated with postural hypotension, acute confusion, and cognitive decline (Zembrzuski, 2006).
Home Care:
Begin discharge planning as soon as possible with case manager or social worker to assess need for home support systems and the need for community or home health services. EB: Home-based exercise appears more effective in increasing daily ambulatory activity in the community setting than supervised exercise in clients with intermittent claudication (Gardner et al, 2011)
Refer to physical therapy for strength training and possible weight training, to regain strength, increase endurance, and improve balance. If the client is homebound, the physical therapist can also initiate cardiac rehabilitation.
• Encourage progress with positive feedback. The client’s experience should be validated as within expected norms. Recognition of progress enhances motivation.
• Teach the client/family the importance of and methods for setting priorities for activities, especially those having a high energy demand (e.g., home/family events). Instruct in realistic expectations.
• Encourage routine low-level exercise periods such as a daily short walk or chair exercises. EB: Older adults participating in low levels of regular exercise can establish and maintain a home-based exercise program that yields immediate and long-term physical and affective benefits (Teri et al, 2011).
• Provide the client/family with resources such as senior centers, exercise classes, educational and recreational programs, and volunteer opportunities that can aid in promoting socialization and appropriate activity. Social isolation can be an outcome of and contribute to activity intolerance. EB: Community-based resistance training and dietary modifications can improve body composition, muscle strength, and physical function in overweight and obese older adults (Straight et al, 2011).
• Instruct the client and family in the importance of maintaining proper nutrition.
• Instruct in use of dietary supplements as indicated. Illness may suppress appetite, leading to inadequate nutrition.
• Allow terminally ill clients and their families to guide care. Control by the client or family respects their autonomy and promotes effective coping.
• Provide increased attention to comfort and dignity of the terminally ill client in care planning. Interventions should be provided as much for psychological effect as for physiological support. For example, oxygen may be more valuable as a support to the client’s psychological comfort than as a booster of oxygen saturation.
Institute case management of frail elderly to support continued independent living.
Client/Family Teaching and Discharge Planning:
• Instruct the client on techniques to utilize for avoiding activity intolerance, such as controlled breathing techniques.
• Teach the client techniques to decrease dizziness from postural hypotension when standing up.
• Help client with energy conservation and work simplification techniques in ADLs.
• Describe to the client the symptoms of activity intolerance, including which symptoms to report to the physician.
• Explain to the client how to use assistive devices, oxygen, or medications before or during activity.
• Help client set up an activity log to record exercise and exercise tolerance.
References
American Geriatrics Society. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Available at http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf. [Accessed August 2, 2012].
Berg, H.E., et al. Hip, thigh and calf muscle atrophy and bone loss after 5-week bedrest inactivity. Eur J Appl Physiol. 2007;99(3):283–289.
Carrieri-Kohlman, V., Donesky-Cuenco, D. Dyspnea management. An EBP guideline. In: Ackley B., Ladwig G., Swann B.A., et al, eds. Evidence-based nursing care guidelines: medical-surgical interventions. Philadelphia: Mosby, 2008.
Celli, B.R. Predictors of mortality in COPD. Respir Med. 2010;104(6):773–779.
Dind, A. The inaccuracy of automatic devices taking postural measurements in the emergency department. Int J Nurs Pract. 2011;17(5):525–533.
Du, H., et al. A review of the six-minute walk test: its implication as a self-administered assessment tool. Eur J Cardiovasc Nurs. 2009;8(1):2–8.
Ene, H., McRae, C., Schenkman, M. Attitudes toward exercise following participation in an exercise intervention study. J Neurol Phys Ther. 2011;35(1):34–40.
Fauci, A., et al. Harrison’s principles of internal medicine, ed 17. New York: McGraw-Hill; 2008.
Gardner, A., et al. Efficacy of quantified home-based exercise and supervised exercise in patients with intermittent claudication: a randomized controlled trial. Circulation. 2011;123(5):491–498.
Global Initiative for Chronic Obstructive Lung Disease (GOLD Report). Available at http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html. [Accessed August 2, 2012, 2011].
Goldman, L. Goldman Cecil’s medicine, ed 24. St Louis: Saunders; 2011.
Gorelik, O., et al. Seating-induced postural hypotension is common in older patients with decompensated heart failure and may be prevented by lower limb compression bandaging. Gerontology. 2009;55(2):138–144.
Heran, B.S., et al, Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011;(7):CD001800.
Kortebein, P. Rehabilitation for hospital-associated deconditioning. Am J Phys Med Rehabil. 2009;88(1):66–77.
Krebs, D.E., Scarborough, D.M., McGibbon, C.A. Functional vs. strength training in disabled elderly outpatients. Am J Phys Med Rehabil. 2007;86(2):93–103.
Krecinic, T., et al. Orthostatic hypotension in older persons: a diagnostic algorithm. J Nutr Health Aging. 2009;13(6):572–575.
Langer, D., et al. A clinical practice guideline for physiotherapists treating patients with chronic obstructive pulmonary disease based on a systematic review of available evidence. Clin Rehabil. 2009;23(5):445–462.
Liu, C.J., Latham, N.K., Progressive resistance strength training for improving physical function in older adults. Cochrane Database Syst Rev 2009;(3):CD002759.
McClave, S., et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N). JPEN J Parenter Enteral Nutr. 2009;33(3):277–316.
Molony, S.L. Monitoring medication use in older adults. Am J Nurs. 2009;109(1):68–78.
Nelson, A., et al. Safe patient handling and movement. Am J Nurs. 2003;103(3):32.
Odencrants, S., Ehnfors, M., Ehrenbert, A. Nutritional status and patient characteristics for hospitalized older patients with chronic obstructive pulmonary disease. J Clin Nurs. 2008;17(13):1771–1778.
Perme, C., Chandrashekar, R. Early mobility and walking program for patients in intensive care units: creating a standard of care. Am J Crit Care. 2009;18(3):212–221.
Platts, S.H., et al. Compression garments as countermeasures to orthostatic intolerance. Aviat Spac Environ Med. 2009;80(5):437–442.
Puhan, M., et al, Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2009;(1):CD005305.
Racco, M. Nutrition in the ICU. RN. 2009;72(1):26–30.
Schneider, S.M., et al. Impaired orthostatic response in patients with type 2 diabetes mellitus after 48 hours of bedrest. Endocr Pract. 2009;15(2):104–110.
Stoller, J.K., et al. Oxygen therapy for patients with COPD: current evidence and the long-term oxygen treatment trial. Chest. 2010;138:179–187.
Straight, C.R., et al. Effects of resistance training and dietary changes on physical function and body composition in overweight and obese older adults. J Phys Act Health. 2011. [Aug 2, Epub ahead of print].
Studer, M. Keep it moving: advances in gait training techniques help clients reduce balance issues. Rehabil Manag. 2008;21(5):10–15.
Suaya, J.A., et al. Cardiac rehabilitation and survival in older coronary patients. J Am Coll Cardiol. 2009;54(1):25–33.
Teixeira, C.V., et al. Non-pharmacological interventions on cognitive functions in older people with mild cognitive impairment (MCI). Arch Gerontol Geriatr. 2012;54(1):175–180.
Teri, L., et al. A randomized controlled clinical trial of the Seattle Protocol for Activity in older adults. J Am Geriatr Soc. 2011;59(7):1188–1196.
Urden, L., Stacy, K., Lough, M. Critical care nursing: diagnosis and management, ed 6. St Louis: Mosby; 2010.
Weimer, L.H., Zadeh, P. Neurological aspects of syncope and orthostatic intolerance. Med Clin North Am. 2009;93(2):427–449.
Yeom, H.A., Keller, C., Fleury, J. Interventions for promoting mobility in community-dwelling older adults. J Am Acad Nurse Pract. 2009;21(2):95–100.
Zembrzuski, C.D. Oral fluid intake and the effect on postural blood pressure and falls in skilled nursing facility residents. NYU doctoral dissertation. 2006:176.
Ineffective Activity Planning
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Establish a contract. EBN: This study of adolescents with Type I diabetes indicated that behavioral contracts may be an important adjunct to reduce nagging and improve outcomes with behavioral changes (Carroll et al, 2011).
Before the first conference/meeting with the client, begin by establishing an agenda and get the assurance that the client will participate. Record the information. Give precise information on the upcoming session. At each session identify precisely the tasks to be accomplished for each session and the upcoming tasks for subsequent session. It is important that the client use a sequential organizational model with the nurse/health care provider (Debray et al, 2005).
Ask the client how he perceives the situation in order to gather his personal vision of the problem and how they envisage their self-involvement. Specify the goals. Clients and caregivers may have different priorities on what is important (Junius-Walker et al, 2011).
Refer the client for cognitive-behavioral therapy. The work for the client begins with the understanding that his thoughts affect his emotions and reactions and therefore the success of meeting his objectives. Suggest that the client change their self-concept, for example, “Stop thinking of yourself as powerless.” The planning of the project (event) will depend in large part on the vision of the client with the problem and on their abilities (perception). Changing this perception may lead to self-confidence and a sense of accomplishment (emotions), which will translate into appropriate actions leading to successful behaviors (Rezvan et al, 2008).
Confront and restructure the following unrealistic idea: “Running away is a better reaction when confronted with a dangerous object.” The true syllogism is “running away is the reaction when confronted with an object that is ‘imagined’ to be dangerous.” Instruct the client to practice and repeat the following statement: “I have the power to change by changing my ideas.” Determine with accuracy the real nature of the danger and the probability that the danger will manifest itself. It is in experimentation that a person will be able to measure their abilities. This is the nature of the contract (Debray et al, 2005).
• Lower the anxiety level tied to the client’s fear of not succeeding. EB: This review of randomized placebo-controlled trials indicates that CBT is efficacious for adult anxiety disorders (Hofmann & Smits, 2008).
Research the client’s rising anxiety behaviors and show evidence of the client’s “catastrophic” thoughts by repeating what negative thoughts the client has expressed, for example, “It would be dreadful if I would not succeed,” “I can never do. . .” Work to change the dramatic interpretation of the situation by the client by using correct words, appropriate to the actual seriousness of the consequences. When assessing for anxiety, it is essential that social, emotional, physical, and cognitive factors are taken into account (McGrandles & McCaig, 2010).
Verify if the lack of success of the project would lower the client’s self-image. Reinforce the idea that making an effort is better than no action (Auger, 2006).
Determine as fairly as possible the success factors needed for the planning and success of the project: financial resources; the family situation; prior medical, psychiatric, and psychosocial conditions; material resources; and the ability to manage stress. EBN: Discussions identifying resources help to handle past resources, the functional solutions of everyday life, favorable changes, exceptions and differences in everyday life, the availability of support and the prospects of future. By noting and providing feedback to families, the nurse offers families a new perspective on themselves (Häggman-Laitila et al, 2010).
Identify the informational needs of the person: understanding of his state of health, supervision of his treatment if he is receiving treatment, diet, and important telephone numbers. EBN: This study of clients with stage 4 chronic kidney disease validated the need for an individual assessment to determine the unique informational needs of each person (Lewis et al, 2010).
Identify and reinforce the elements of the client’s personality that may help him to succeed with his plan. Have the client drill and repeat: “I can change my goals (dreams) with a plan.” Reviews have shown that goal consensus and collaboration between client and therapist are significant for treatment outcome (Mackrill, 2011).
• Assist the client to plan in a realistic way for work, studies, or the choice not to continue a project (determination des objectifs) (Auger, 2006).
Carry out the general objective by using secondary objectives in successive stages and in a logical progression. Remember that the attainment of these objectives may imply a modification of the schedule. Use a schedule, calendar, or agenda to write down the dates. For realistic planning: choose simple tasks, limit long hours of work, protect biopsychosocial well-being, improve techniques (of relaxation, of study, of concentration, of memory, aptitude of reading, writing, the way of taking notes).
• Anticipate the obstacles the client may encounter. This helps the client to increase their motivation and their responsibility to obtain their objectives and develop a plan of action (Auger, 2006).
Establish a safeguard that will be helpful in pursuing the goal. It should be nonpunitive, but help the client to remember the importance of the instrument’s use to attain the micro-objectives, the base of success. It could be written down like this: “I am going to take a 30-minute walk for 2 days. If I do it I will let myself watch TV for 1 hour, otherwise I will take a 1-hour walk for the next 2 days.” Drill and repeat: “I will realize my goals no matter what.”
Discuss the resources that the person has already used in order to verify if the changes assert themselves. Identify the potentially pivotal helping people. EBN: This study of families indicated that a resource-enhancing approach typically triggers favorable spontaneous processes of change and solutions (Häggman-Laitila et al, 2010).
If necessary, coordinate the orientation of the person towards other structures or treatments that have not been used, for example, individual or group therapy, an educational support person, a financial aid person.
Tackle the client’s fears and worries and encourage him to make a cognitive reconstruction. Use “desire thinking.” Drill and repeat: “I can change false ideas that make me believe that I am unable to carry out (achieve) my plan.” EBN: Desire thinking is a voluntary cognitive process involving verbal and imaginal elaboration of a desired target. Recent research has highlighted the role of desire thinking in the maintenance of addictive, eating, and impulse control disorders (Caselli & Spada, 2011).
• Refer to care plans Anxiety, Readiness for enhanced family Coping, Readiness for enhanced Decision-Making, Fear, Readiness for enhanced Hope, Readiness for enhanced Power, Readiness for enhanced Spiritual Well-Being, Readiness for enhanced Self-Health Management for additional interventions.
References
Auger, L. Vivre avec sa tête ou avec son cœur (Live with your head or with your heart). Quebec: Centre la Pensée Réaliste, republication par Pierre Bovo; 2006.
Carroll, A.E., et al. Contracting and monitoring relationships for adolescents with type 1 diabetes: a pilot study. Diabetes Tech Therapeut. 2011;13(5):543–549.
Caselli, G., Spada, M.M. The Desire Thinking Questionnaire: development and psychometric properties. Addict Behav. 2011;36(11):1061–1067.
Debray, Q., et al. The protocols of treatment of pathological personalities. Cognitive behavioral approach. Paris: Masson; 2005.
Häggman-Laitila, A., Tanninen, H., Pietilä, A. Effectiveness of resource-enhancing family-oriented intervention. J Clin Nurs. 2010;19(17/18):2500–2510.
Hofmann, S.G., Smits, J.A. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry. 2008;69(4):621–632.
Junius-Walker, U., et al. Health and treatment priorities of older patients and their general practitioners: a cross-sectional study. Qual Primary Care. 2011;19:67–76.
Lewis, A.L., Stabler, K.A., Welch, J.L. Perceived informational needs, problems, or concerns among patients with stage 4 chronic kidney disease. Nephrol Nurs J. 2010;37(2):143–149.
Mackrill, T. Differentiating life goals and therapeutic goals: expanding our understanding of the working alliance. Brit J Guid Couns. 2011;39(1):25–39.
McGrandles, A., McCaig, M. Diagnosis and management of anxiety in primary care. Nurse Prescribing. 2010;8(7):310. [312–318].
Rezvan, S., et al. A comparison of cognitive-behavior therapy with interpersonal and cognitive behavior therapy in the treatment of generalized anxiety disorder. Couns Psychol Q. 2008;21(4):309–321.
Risk for ineffective Activity Planning
Ineffective Airway Clearance
NANDA-I
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Demonstrate effective coughing and clear breath sounds
• Maintain a patent airway at all times
• Explain methods useful to enhance secretion removal
• Explain the significance of changes in sputum to include color, character, amount, and odor
• Identify and avoid specific factors that inhibit effective airway clearance
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Auscultate breath sounds q 1 to 4 hours. Breath sounds are normally clear or a few scattered fine crackles at bases, which clear with deep breathing. The presence of coarse crackles during inspiration indicates fluid in the airway; wheezing indicates an airway obstruction (Jarvis, 2012).
• Monitor respiratory patterns, including rate, depth, and effort. A normal respiratory rate for an adult without dyspnea is 10 to 20 (Jarvis, 2012). With secretions in the airway, the respiratory rate will increase.
• Monitor blood gas values and pulse oxygen saturation levels as available. An oxygen saturation of less than 90% (normal: 95% to 100%) or a partial pressure of oxygen of less than 80 (normal: 80 to 100) indicates significant oxygenation problems (Schultz, 2011).
Administer oxygen as ordered. Oxygen administration has been shown to correct hypoxemia (Wong & Elliott, 2009).
• Position the client to optimize respiration (e.g., head of bed elevated 30-45 degrees and repositioned at least every 2 hours). An upright position allows for maximal lung expansion; lying flat causes abdominal organs to shift toward the chest, which crowds the lungs and makes it more difficult to breathe. EB: In a mechanically ventilated client, there is a decreased incidence of ventilator-associated pneumonia if the client is positioned at a 30-to 45-degree semirecumbent position as opposed to a supine position (Siela, 2010; Vollman & Sole, 2011).
• Help the client deep breathe and perform controlled coughing. Have the client inhale deeply, hold breath for several seconds, and cough two or three times with mouth open while tightening the upper abdominal muscles. Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective (Gosselink et al, 2008).
• If the client has obstructive lung disease, such as COPD, cystic fibrosis, or bronchiectasis, consider helping the client use the forced expiratory technique, the “huff cough.” The client does a series of coughs while saying the word “huff.” This technique prevents the glottis from closing during the cough and is effective in clearing secretions (Bhowmik et al, 2009; Gosselink et al, 2008).
Encourage the client to use an incentive spirometer if ordered. Recognize that controlled coughing and deep breathing may be just as effective (Gosselink et al, 2008). EBN: A study on care of clients in a medical unit found that use of respiratory bundle that included use of a spirometer and good oral care for ambulatory clients, and oral care, turning, and elevation of the head of the bed for dependent clients, was effective in decreasing the incidence of transfer to critical care for respiratory problems (pneumonia) (Lamar, 2012).
• Encourage activity and ambulation as tolerated. If unable to ambulate the client, turn the client from side to side at least every 2 hours. Body movement helps mobilize secretions. (See interventions for Impaired Gas Exchange for further information on positioning a respiratory client.)
• Encourage fluid intake of up to 2500 mL/day within cardiac or renal reserve. Fluids help minimize mucosal drying and maximize ciliary action to move secretions.
Administer medications such as bronchodilators or inhaled steroids as ordered. Watch for side effects such as tachycardia or anxiety with bronchodilators, or inflamed pharynx with inhaled steroids. Bronchodilators decrease airway resistance, improve the efficiency of respiratory movements, improve exercise tolerance, and can reduce symptoms of dyspnea on exertion (Barnett, 2008). Pharmacologic therapy in COPD is used to reduce symptoms, reduce the frequency and severity of exacerbation, and improve health strategies and exercise tolerance (GOLD, 2011).
Provide percussion, vibration, and oscillation as appropriate (Gosselink et al, 2008).
• Observe sputum, noting color, odor, and volume. Normal sputum is clear or gray and minimal; abnormal sputum is green, yellow, or bloody; malodorous; and often copious. The presence of purulent sputum during a COPD exacerbation can be sufficient indication for starting empirical antibiotic treatment. Notify physician of purulent sputum (GOLD, 2011).
Critical Care
If the client is intubated and is stable, consider getting the client up to sit at the edge of the bed, transfer to a chair, or walk as appropriate, if an effective interdisciplinary team is developed to keep the client safe. For every week of bed rest, muscle strength can decrease 20%; early ambulation also helped clients develop a positive outlook. An early mobility and walking program can promote weaning from ventilator support as a client’s overall strength and endurance improve (Gosselink et al, 2008; Perme & Chandrashekar, 2009).
If the client is intubated, consider use of kinetic therapy, using a kinetic bed that slowly moves the client with 40-degree turns. Rotational therapy may decrease the incidence of pulmonary complications in high risk clients with increasing ventilator support requirements, at risk for ventilator-associated pneumonia, and clinical indications for acute lung injury or acute respiratory distress syndrome (ARDS) with worsening PaO2:FIO2 ratio, presence of fluffy infiltrates via chest radiograph concomitant with pulmonary edema, and refractory hypoxemia (Johnson, 2011).
• Reposition the client as needed. Use rotational or kinetic bed therapy as above in clients for whom side-to-side turning is contraindicated or difficult. EBN: Changing position frequently decreases the incidence of atelectasis, pooling of secretions, and resultant pneumonia (Burns, 2011). EB & EBN: Continuous, lateral rotational therapy has been shown to improve oxygenation and decrease the incidence of VAP (Burns, 2011).
• When suctioning an endotracheal tube or tracheostomy tube for a client on a ventilator, do the following:
Explain the process of suctioning beforehand and ensure the client is not in pain or overly anxious. Suctioning can be a frightening experience; an explanation along with adequate pain relief or needed sedation can reduce stress, anxiety, and pain (Chulay & Seckel, 2011).
Hyperoxygenate before and between endotracheal suction sessions. Studies have demonstrated that hyperoxygenation may help prevent oxygen desaturation in a suctioned client (Chulay & Seckel, 2011; Pedersen et al, 2009; Siela, 2010).
Suction for less than 15 seconds. Studies demonstrated that because of a drop in the partial pressure of oxygen with suctioning, that preferably no more than 10 seconds be used actually suctioning, with the entire procedure taking 15 seconds (Chulay & Seckel, 2011; Pedersen et al, 2009).
Use a closed, in-line suction system. Closed in-line suctioning has minimal effects on heart rate, respiratory rate, tidal volume, and oxygen saturation (Chulay & Seckel, 2011; Seymour et al, 2009).
Avoid saline instillation before suctioning. EBN: Repeated studies have demonstrated that saline instillation before suctioning has an adverse effect on oxygen saturation in both adults and children (Chulay & Seckel, 2011; Pederson et al, 2009; Rauen et al, 2008; Siela, 2010).
With a subglottic suctioning drainage tube in place, be sure to irrigate per manufacturer’s instructions if it becomes clogged (Vollman & Sole, 2011).
Document results of coughing and suctioning, particularly client tolerance and secretion characteristics such as color, odor, and volume (Chulay & Seckel, 2011).
Pediatric:• Educate parents about the risk factors for ineffective airway clearance such as foreign body ingestion and passive smoke exposure.
• See the care plan Risk for Suffocation for more interventions on choking. EB: Passive smoke exposure significantly increases the risk of respiratory infections in children (Chatzimicael et al, 2008).
• Educate children and parents on the importance of adherence to peak expiratory flow (PEF) monitoring for asthma self-management.
• Educate parents and other caregivers that cough and cold medications bought over the counter are not safe for a child under 2 unless specifically ordered by a health care provider. Over-the-counter cold and cough medications are no longer recommended for children under the age of 2 unless recommended by a health care provider. Minimal data exist to support their effectiveness, and overuse can cause harm (Woo, 2008).
Geriatric:• Encourage ambulation as tolerated without causing exhaustion. Immobility is often harmful to the elderly because it decreases ventilation and increases stasis of secretions, leading to atelectasis or pneumonia.
• Actively encourage the elderly to deep breathe and cough. Cough reflexes are blunted, and coughing is decreased in the elderly.
• Ensure adequate hydration within cardiac and renal reserves. The elderly are prone to dehydration, and therefore more viscous secretions, because they frequently use diuretics or laxatives and forget to drink adequate amounts of water.
Home Care:• Some of the above interventions may be adapted for home care use.
• Assess home environment for factors that exacerbate airway clearance problems (e.g., presence of allergens, lack of adequate humidity in air, poor air flow, stressful family relationships).
• Assess affective climate within family and family support system. Problems with respiratory function and resulting anxiety can provoke anger and frustration in the client. Feelings may be displaced onto caregiver and require intervention to ensure continued caregiver support. Refer to care plan for Caregiver Role Strain.
• Refer to GOLD guidelines for management of home care and indications of hospital admission criteria (GOLD, 2011).
• When respiratory procedures are being implemented, explain equipment and procedures to family members, and provide needed emotional support. Family members assuming responsibility for respiratory monitoring often find this stressful. They may not have been able to assimilate fully any instructions provided by hospital staff.
• When electrically based equipment for respiratory support is being implemented, evaluate home environment for electrical safety, proper grounding, and so on. Ensure that notification is sent to the local utility company, the emergency medical team, and police and fire departments.
• Provide family with support for care of a client with chronic or terminal illness. Breathing difficulty can provoke extreme anxiety, which can interfere with the client’s ability or willingness to adhere to the treatment plan.
• Refer to care plan for Anxiety. Witnessing breathing difficulties and facing concerns of dealing with chronic or terminal illness can create fear in caregiver. Fear inhibits effective coping. Refer to care plan for Powerlessness.
• Instruct the client to avoid exposure to persons with upper respiratory infections, to avoid crowds of people, and wash hands after each exposure to groups of people, or public places.
• Teach the client when and how to use inhalant or nebulizer treatments at home.
• Teach the client/family importance of maintaining regimen and having PRN drugs easily accessible at all times. Success in avoiding emergency or institutional care may rest solely on medication compliance or availability.
• Instruct the client and family in the importance of maintaining proper nutrition, adequate fluids, rest, and behavioral pacing for energy conservation and rehabilitation.
• Instruct in use of dietary supplements as indicated. Illness may suppress appetite, leading to inadequate nutrition. Supplements will allow clients to eat with minimal energy consumption.
• Identify an emergency plan, including criteria for use. Ineffective airway clearance can be life-threatening.
For the client dying at home with a terminal illness, if the “ death rattle” is present with gurgling, rattling, or crackling sounds in the airway with each breath, recognize that anticholinergic medications can often help control symptoms, if given early in the process. Anticholinergic medications can help decrease the accumulation of secretions, but do not decrease existing secretions. This medication must be administered early in the process to be effective (Hipp & Letizia, 2009).
For the client with a “death rattle,” nursing care includes turning to mobilize secretions, keeping the head of the bed elevated for postural drainage of secretions, and avoiding suctioning. Suctioning is a distressing and painful event for clients and families, and is rarely effective in decreasing the “death rattle” (Hipp & Letizia, 2009).
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