Definition: Assisting the patient to mediate impulsive behavior through application of problem-solving strategies to social and interpersonal situations

Activities:

• Select a problem-solving strategy that is appropriate to the patient’s developmental level and cognitive functioning

• Use a behavior modification plan, as appropriate, to reinforce the problem-solving strategy that is being taught

• Assist patient to identify the problem or situation that requires thoughtful action

• Teach patient to cue himself or herself to “stop and think” before acting impulsively

• Assist patient to identify courses of possible action and their costs/benefits

• Assist patient to choose the most beneficial course of action

• Assist patient to evaluate the outcome of the chosen course of action

• Provide positive reinforcement (e.g., praise and rewards) for successful outcomes

• Encourage patient to self-reward for successful outcomes

• Assist patient to evaluate how unsuccessful outcomes could have been avoided by different behavioral choices

• Provide opportunities for patient to practice problem solving (role-playing) within the therapeutic environment

• Provide models who demonstrate the steps of the problem-solving strategy in the context of situations that are meaningful to the patient

• Encourage patient to practice problem solving in social and interpersonal situations outside the therapeutic environment, followed by evaluation of outcome

2nd edition 1996

7980

Incident Reporting

Definition: Written and verbal reporting of any event in the process of patient care that is inconsistent with desired patient outcomes or routine operations of the health care facility

Activities:

• Identify events (e.g., patient falls, blood transfusion reactions, and equipment malfunction) that require reporting, as defined in agency policy

• Notify physician to evaluate patient, as appropriate

• Notify nursing supervisor, as appropriate

• Document in patient record that physician was notified

• Complete incident report form(s) to include factual information, patient hospital number, medical diagnosis, and date of admission

• Document factual information about the event in the patient record

• Document nursing assessments and interventions after the event

• Identify and report medical device failures leading to patient injury, as appropriate

• Maintain confidentiality of incident report, according to agency policy

• Initiate Medical Device Reporting System for deaths or serious injury resulting from medical devices

• Discuss event with involved staff to determine what, if any, corrective action is necessary

2nd edition 1996

3440

Incision Site Care

Definition: Cleansing, monitoring, and promotion of healing in a wound that is closed with sutures, clips, or staples

Activities:

• Explain the procedure to the patient, using sensory preparation

• Inspect the incision site for redness, swelling, or signs of dehiscence or evisceration

• Note characteristics of any drainage

• Monitor the healing process in the incision site

• Cleanse the area around the incision with an appropriate cleansing solution

• Swab from the clean area toward the less clean area

• Monitor incision for signs and symptoms of infection

• Use sterile, cotton-tipped applicators for efficient cleansing of tight-fitting wire sutures, deep and narrow wounds, or wounds with pockets

• Cleanse the area around any drain site or drainage tube last

• Maintain the position of any drainage tube

• Apply closure strips, as appropriate

• Apply antiseptic ointment, as ordered

• Remove sutures, staples, or clips, as indicated

• Change the dressing at appropriate intervals

• Apply an appropriate dressing to protect the incision

• Facilitate the patient’s viewing of the incision

• Instruct the patient on how to care for the incision during bathing or showering

• Teach the patient how to minimize stress on the incision site

• Teach the patient and/or the family how to care for the incision, including signs and symptoms of infection

1st edition 1992; revised 2000

6820

Infant Care

Definition: Provision of developmentally-appropriate, family-centered care to the child under 1 year of age

Activities:

• Encourage consistent assignment of professional caregivers

• Monitor infant’s height and weight

• Monitor intake and output

• Incorporate parent preferences for bathing, when possible

• Change diapers

• Feed infant foods that are developmentally appropriate

• Provide opportunities for nonnutritive sucking

• Keep side rails of crib up when not caring for infant

• Remove small items from crib (e.g., syringe covers and alcohol wipes)

• Monitor safety of infant’s environment

• Provide developmentally-appropriate safe toys and activities for infant

• Provide information to parent about child development and child rearing

• Provide visual, auditory, tactile, and kinetic stimulation during play

• Structure play and care around infant’s temperament

• Talk to infant while giving care

• Encourage parent to participate in care activities (e.g., bathing, feeding, medication administration, or dressing changes)

• Instruct parent to perform special care for infant

• Reinforce parent skill in performing special care for infant

• Inform parent about infant’s status

• Involve parent in the decision-making process, providing support throughout process

• Explain rationale for treatments and procedures to parent

• Give parent the option of being present for procedure or returning upon its completion

• Apply restraints when indicated and monitor throughout use

• Comfort infant through rocking, holding, cuddling, swaddling

• Monitor infant for signs of pain, including kicking, legs drawn up, steady crying, and difficulty consoling

• Use pain management strategies (e.g., distraction, parent’s involvement, positioning, swaddling, or environmental manipulation)

• Explain to parent that regression is normal during times of stress, such as illness or hospitalization

• Encourage family to visit and stay overnight in hospital

• Provide emotional and spiritual support to parent (e.g., be available to listen, assist with maintaining or creating coping strategies or referral)

• Maintain infant’s daily routine during hospitalization, when possible

• Provide quiet, uninterrupted environment during nap time and nighttime

1st edition 1992; revised 2013

6824

Infant Care: Newborn

Definition: Provision of care to the infant during the transition from birth to extrauterine life and subsequent period of stabilization

Activities:

• Clear secretions from oral and nasal passages

• Perform Apgar evaluation at 1 and 5 minutes after birth

• Weigh and measure newborn

• Monitor newborn’s temperature

• Maintain adequate body temperature of newborn (i.e., dry infant immediately after birth, wrap newborn in blanket if not to be placed in warmer, apply stockinette cap and instruct parent to keep head covered, and place newborn in isolette or under warmer as needed)

• Monitor respiratory rate and breathing pattern

• Respond to signs of respiratory distress (e.g., tachypnea, nasal flaring, grunting, retractions, rhonchi, and rales)

• Monitor newborn’s heart rate

• Monitor newborn’s color

• Place newborn skin-to-skin with parent, as appropriate

• Measure head circumference

• Determine gestational age

• Compare newborn’s weight with estimated gestational age

• Put newborn to the breast immediately after birth

• Monitor newborn’s first feeding

• Monitor newborn’s suck reflex during feeding

• Burp newborn with the head elevated

• Monitor newborn’s weight

• Monitor intake and output

• Record newborn’s first voiding and bowel movement

• Assist parent in giving newborn initial bath after temperature has stabilized

• Regularly hold or touch newborn in isolette

• Provide prophylactic eye care

• Compare maternal and newborn blood groups and types

• Swaddle newborn to promote sleep and provide a sense of security

• Position newborn on back or side after feeding

• Elevate head of mattress of bassinet or isolette to promote respiratory function

• Use blanket roll at newborn’s back to position on side, placing dependent arm forward to decrease likelihood of rolling into prone position

• Reinforce or provide information about newborn’s nutritional needs

• Determine condition of newborn’s cord prior to transfusion using umbilical vein

• Cleanse umbilical cord with prescribed preparation

• Keep umbilical cord dry and exposed to air by diapering newborn below cord

• Monitor umbilical cord for redness and drainage

• Cleanse and apply petroleum jelly dressing to circumcision

• Apply diapers loosely after circumcision

• Apply restraints when indicated and appropriate monitoring throughout use

• Monitor newborn’s response to circumcision

• Monitor for hypoglycemia and anomalies if mother has diabetes

• Monitor for signs of hyperbilirubinemia, if appropriate

• Instruct parent to recognize symptoms of hyperbilirubinemia

• Protect newborn from sources of infection in hospital environment

• Determine newborn’s readiness state before providing care

• Make eye contact and talk to newborn while giving care

• Provide a quiet, soothing environment

• Respond to newborn’s cues for care to facilitate the development of trust

• Promote and facilitate family bonding and attachment with newborn

• Provide information and facilitate the screening of newborn for metabolic disorder(s)

• Instruct parent to recognize signs of breathing difficulty

• Instruct parent to place newborn on back when sleeping

6th edition 2013

6826

Infant Care: Preterm

Definition: Aligning caretaking practices with the preterm infant’s individual developmental and physiological needs to support growth and development