Client Will (Specify Time Frame)

• Observe for factors causing or contributing to conflict (e.g., value conflicts, fear of outcome, poor problem-solving skills). EB: When studying client-provider dyads, it was found that the more unclear one member’s expressed values, the greater their interpretation that the other member has made an ineffective choice, and this also correlated with both members experiencing personal uncertainty (Leblanc et al, 2009).

• Provide emotional support. EBN: Clients with values-sensitive health decisions frequently experience decisional conflict and require support (Stacey et al, 2008b).

• Give the client time and permission to express feelings associated with decision-making. EB: Decision aids in practice influence client trust in the clinician, which may be mediated through improvements in knowledge, reductions in decisional conflict, values clarification, and increased client participation in clinical decision-making (Nannenga et al, 2009).

 Use decision aids or computer-based decision aid to assist clients in making decisions. EB: Learning assessment tools are beneficial in optimizing family outcomes when it is evident that decisions will need to be made for children with life-limiting illnesses (Knapp et al, 2010). Online tutorials, computerized decision-support tools, workshops, and educational outreach can help to reduce parental decisional conflict related to place of care, place of death, and treatment regimens (Knapp et al, 2010).

 Initiate health teaching and referrals when needed. EB: Male cancer clients who viewed a computerized education tool about sperm banking before their cancer treatment had significantly less decisional conflict about banking sperm than those who had not viewed it (Huyghe et al, 2008). EBN: Nurses may provide support via helplines. They can provide decision support that helps callers in understanding cancer information, as well as assisting in the clarification of their values that were associated with their options, and ultimately reduced decisional conflict (Stacey et al, 2008).

• Facilitate communication between the client and family members regarding the final decision; offer support to the person actually making the decision. EB: Family/HIV-positive adolescent-centered advance care planning demonstrated improved communication quality and congruence as well as decreased decisional conflict. Adolescents who received the intervention reported feeling significantly better informed about end-of-life decisions. Families were more willing to engage in end-of-life discussions (Lyon et al, 2009).

• Provide detailed information on benefits and risks using functional terms and probabilities tailored to clinical risk, plus steps for considering the issues and means for making a decision, including values clarification and decision aids, when clients are faced with difficult treatment choices. EBN: A study of 176 post-menopausal women who were exposed to either the tailored decision support booklet or the standard North American Menopause Society Menopause Guidebook significantly increased their knowledge and decreased their decisional conflict and uncertainty about hormone therapy use (Becker, Stuifbergen, & Dormire, 2009).

Client Will (Specify Time Frame)

• Support and encourage clients and their representatives to engage in health care decisions. EB: In order to support meaningful decision-making for palliative care patients and their families, perceived risks must be acknowledged as factors that shape and constrain end-of-life choices (Wilson, Gott, & Ingleton, 2011).

• Respect personal preferences, values, needs, and rights. EB: “Denial of this right of autonomy and self-determination may worsen the individual’s physical and existential suffering” (Soriano & Lagman, 2012).

• Determine the degree of participation desired by the client. EB: “Ultimately, a patient must be able to understand the information given to him, evaluate the consequences of the options presented, deliberate on these options based on his values, communicate this choice, and maintain consistency overtime” (Soriano & Lagman, 2012).

• Provide information that is appropriate, relevant, and timely. EB: Use of a “labor decision aid” demonstrated an improvement in women’s labor analgesia knowledge. The group using the decision aid was more informed of analgesia options and considered the opinions of providers in making analgesia decisions and demonstrated improved informed decision making (Raynes-Greenow et al, 2010).

• Determine the health literacy of clients and their representatives prior to helping with decision-making. EB: Communication skills are crucial in shared decision-making, especially for clients with low literacy. Tailoring information and communication to clients’ individual needs is beneficial (Shaw et al, 2009).

• Tailor information to the specific needs of individual clients, according to principles of health literacy. EB: Tailored decision support information was effective in supporting adults with low levels of education in making informed choices and increased involvement in decisions about treatment for presence of fecal occult blood (Smith et al, 2010).

• Motivate clients to be as independent as possible in decision-making. EB: According to Smith et al (2010), clarifying to the participants that they have a choice about screening, informing them of the limitations of screening, and discussing how they value each outcome encouraged some participants to share or prefer to share the decision with their provider.

• Identify the client’s level of choice in decision-making. EB: Women’s expectations of the duration and level of pain suffered, quality of her caregiver support, and involvement in labor decision-making are the most commonly reported factors in birthing satisfaction (Raynes-Greenow et al, 2010).

• Focus on the positive aspects of decision-making, rather than decisional conflicts. EBN: Numerous studies conducted during development of the health promotion model show that promotion differs from prevention and requires a positive rather than negative approach (Pender, Murdaugh, & Parsons, 2011).

• Design educational interventions for decision support. EBN: Using specific educational and institutional interventions decreased barriers for Helpline nurses in providing decision support (Stacey et al, 2008).

• Provide clients with the benefits of decisions at the same time as helping them to identify strategies to reduce the barriers for healthful decisions. EB: This study demonstrated that attrition in programs for the prevention of mother-to-child-transmission of HIV was partially due to the attitude of the male partner toward involvement and a low participation rate, suggesting that external barriers play a large role in this decision-making process and that partners’ needs should be addressed more specifically when providing services (Theuring et al, 2009).

• Acknowledge the complexity of everyday self-care decisions related to self-management of chronic illnesses. EB: The results of this study demonstrated that individuals’ participation in day-to-day life is influenced by personal characteristics as well as the environment, and these influence a person’s decision to return to walking in the community after stroke (Corrigan & McBurney, 2008).

Client Will (Specify Time Frame)

• Assess the client’s and family’s understanding of the illness, the treatments, and expected outcomes. EBN: Effective communication between client and health care provider in relation to health promotion, disease prevention, and disease management is key to optimal health outcomes (Heinrich & Karner, 2011). EBN: It has been found that a significant number of older adults and/or their agents may not understand the client’s discharge instructions when released from the ED; this lack of information may have a negative effect on health outcomes (Hastings, Barrett, & Weinberger, 2011).

• Allow client time for adjustment to his/her situation. EBN: Health care providers could recognize and actively assist those clients who are unable to accept their disabilities by helping to develop effective modes of adjustment to their disease; especially in those recently diagnosed (Chao et al, 2010).

• Spend time with the client: listen and allow time for response. EB: Clinician-patient communication has been shown to be a determining factor in health outcomes (Street et al, 2009).

• Aid the client in making choices regarding treatment and actively involve him/her in the decision-making process. EB: A study of a current program that introduced nurse “care managers” into the primary health care system showed the program to be most effective in increasing patients’ cognition; self-management skills; and readiness to make changes in their health care decisions (Ciccone, Ambrogio, & Cortese, 2010).

• Explain the necessity of adherence to the prescribed treatment plan to promote feelings of wellness. EB: Health care professionals must be part of the solution to better adherence through communication and education (Scott & McClure, 2010).

• Allow the client to express and use denial as a coping mechanism if appropriate to treatment. EB: Denial in lung cancer patients may be an adaptive mechanism and must be respected by clinicians (Vos et al, 2010). EBN: To meet health requirements, assess the coping mechanism of denial of illness and support the client in examining/developing appropriate strategies in order to assist in their implementation of self-management (McGann, Sexton, & Chyun, 2008).

• Avoid confrontation and consider the client as an equal partner in health care. EBN: Current focus is on the person as the primary decision maker in his or her health care and is apropos in relation to the key concept of quality of life as defined by the person, or community and expressed in the nursing theory of Human Becoming (Marshall, Sahm, & McCarthy, 2012; Poirier, 2012).

• Support the client’s spiritual coping measures. EBN: The clinician should be aware of the religious methods of coping employed by terminally ill patients as they discuss prognosis and treatment (Phelps et al, 2009). It is suggested that unless clinicians recognize spirituality as an element of life, there is little chance that they will form an efficacious working relationship with their clients (Trevino & Pargament, 2008).

• Develop a trusting, therapeutic relationship with the client/family. EBN: Early interventions(i.e., routine family meetings) to address the ongoing needs of family members of—and patients with—chronic critical illnesses (CCI) is seen as instrumental in reducing the psychological impact of the patient’s ill health for the family and to incorporate their (patient’s and family’s) preferences into the plan of care (Hickman & Douglas, 2011).

 Assist the client in utilizing existing and additional sources of support. EBN: Health care providers should recognize the individual needs, including emotional, psychosocial, sexual, and relational, of those who suffer from chronic illness and provide suitable information and support—especially for those who are isolated from the mainstream (Spring et al, 2011). EBN: It is important for health care providers to identify and satisfy each patient’s unique situational needs; group education should be considered as an option (Ivarsson, Klefgard, & Nillsen, 2011).

• Refer to care plans Defensive Coping and Dysfunctional Family Processes.

Client Will (Specify Time Frame)

 Inspect oral cavity/teeth at least once daily and note any discoloration, presence of debris, amount of plaque buildup, presence of lesions such as white lesions or patches, edema, or bleeding, and intactness of teeth. Refer to a dentist or periodontist as appropriate. Systematic inspection can identify impending problems. White lesions are often leukoplakia, which is a precursor to squamous cell carcinoma. If the lesion is cancerous, prompt treatment is needed (Engelke & Pravikoff, 2010).

• If the client is free of bleeding disorders and is able to swallow, encourage the client to brush teeth with a soft toothbrush using fluoride-containing toothpaste at least two times per day. Do not use foam swabs or lemon glycerin swabs to clean the teeth. EB: Oral bacteria cause caries and periodontal disease. Plaque is a biofilm of bacteria, which often becomes contaminated with antibiotic-resistant bacteria in the hospitalized client (Roberts & Mullany, 2010). CEB: The toothbrush is the most important tool for oral care; toothbrushing is the most effective method of reducing plaque and controlling periodontal disease; a nursing study demonstrated that foam swabs are not effective in removing plaque (Pearson & Hutton, 2002). Lemon glycerin swabs dry the oral mucosa and can erode the tooth enamel (Foss-Durant & McAffee, 1997; Meurman et al, 1996; Poland, 1987). Inspect the gingiva for signs of gingivitis. Normally the gums should be pink and firm; gingivitis is likely when the gums are red and loose. Bleeding from the gums in an indication of gingivitis, and the client should see a dentist (Bissett, 2011).

• Encourage the client to floss the teeth at least once per day if free of a bleeding disorder, or if the client is unable, floss the teeth for the client. EB: A Cochrane review found that there is some evidence that flossing in addition to toothbrushing reduces gingivitis compared to toothbrushing alone. Also, there is some evidence that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 and 3 months (Sambunjak et al, 2011). Utilize a rotation-oscillation power toothbrush for removal of dental plaque. EB: Multiple studies have found a rotation-oscillation power toothbrush more effective than an ultrasonic toothbrush (Biesbrock, Walters, & Bartizek, 2008; He et al, 2008; Williams et al, 2008). A systematic review found that the powered toothbrush was safe to use on both hard and soft dental tissues (Robinson, 2011).

• Determine the client’s mental status and manual dexterity; if the client is unable to care for self, nursing personnel must provide dental hygiene. The nursing diagnosis Bathing/Hygiene Self-Care deficit is then applicable.

• If the client is unable to brush own teeth, follow this procedure:

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