Client Will (Specify Time Frame)

• Standardize internal and external transport forms using SBAR format (situation, background, assessment, recommendation) to provide safe and efficient transport of a high-risk pregnant client. QSEN: Using a standardized form throughout the hospital system decreases the risk of errors, miscommunications, and omissions (Edwards & Woodward, 2008; Guise & Lowe, 2008).

 Arrange for psychotherapeutic support when woman expresses intense fear related to high-risk pregnancy and fetal outcomes. EB & EBN: Women with comorbid conditions, such as diabetes or epilepsy, may express intense fear that need to be addressed to ameliorate negative consequences to the woman and her family (DeBackere, Hill, & Kavanaugh, 2008; Hutti, Armstrong, & Myers, 2011; Turner et al, 2008).

• Screen all antepartum clients for depression using a tool that evaluates the biopsychosocial-spiritual dimensions in a culturally sensitive way. EBN: Assessing depression during the antepartum period identifies risks and resources that can be modified to further support the mental health of pregnant women, particularly in women of color (Baisch et al, 2010; Breedlove & Fryzelka, 2011).

• Offer flexible visiting hours; private space for families; and nursing support for management of family stressors, including music and recreation therapy, when a woman is hospitalized with a high-risk pregnancy. CEB & EBN: In qualitative studies of women hospitalized for complications of pregnancy, accommodating individual family needs was recommended, such as flexible visiting hours and private space for family visits, and nursing support for management of family stressors, including identifying family strengths, such as spirituality (Gilbert, 2010; Handley & Stanton, 2006; Price et al, 2007; Richter, Parkes, & Chaw-Kant, 2007).

• Focus on the abilities of a woman with disabilities by encouraging her to identify her support system, resources, and needs for modification of her environment. CEB, EB, & EBN: Concern for safety and limitations for self-care for a woman with physical disabilities can lead nurses to question her desire to bear children and her ability to safely parent. Nurses need to seek knowledge about the physical disabilities their clients have and to provide holistic care to them (Huff, 2010; Smeltzer, 2007; Walsh-Gallagher, Sinclair, & Conkey, 2011).

• Recognize patterns of physical abuse in all pregnant and postpartum women, regardless of age, race, and socioeconomic status. EB & EBN: Studies of women have shown a pattern of abuse despite level of socioeconomic status. The major site of physical abuse during pregnancy is the torso, rather than the head and neck, which are the major sites in nonpregnant women. Recognition of physical injury patterns for assault could aid in better detection of all women experiencing intimate partner violence (Certain, Mueller, & Jagodzinski, 2008; Nannini et al, 2008).

• Perform accurate blood pressure readings at each client’s clinic encounter. EB & EBN: Women who have a history of chronic hypertension and are at risk for preeclampsia (e.g., family history, over 40 years old, first pregnancy, multiple gestation) need to be identified to decrease risk for inadequate placental perfusion or a multisystem shutdown. Choose the correct equipment by measuring a high mid-arm circumference, prepare the client, and record the measurements accurately to identify women at risk for hypertension (Hogan et al, 2011; Peters, 2008).

• Provide educational materials and support for personal autonomy about genetic counseling and testing options prior to pregnancy, that is, preimplantation genetic testing, or during pregnancy, that is, fetal nuchal translucency ultrasound, quadruple screen, cystic fibrosis. EB & EBN: Ethical principles of autonomy, nonmaleficence, and justice must be considered when discussing genetic counseling and testing with a pregnant woman and her family (Lewis, 2011; McCormick, 2011).

• Identify adherence barriers and assist with meal selections to maintain optimal and safe pregnancy weight gain (25 to 35 pounds; 15 to 25 if overweight). EB & EBN: Obesity (body mass index [BMI] above 30) is a common high risk factor that affects 1 in 5 pregnant women. Women can have adequate caloric intake, yet have inadequate nutritional intake. Low protein intake can adversely affect fetal brain development. The sequelae of obesity include gestational diabetes, fetal macrosomia and childhood obesity, congenital anomalies, and increased use of health care services (Chu et al, 2008; Gennaro et al, 2011; Lamont et al, 2011; Walters & Taylor, 2009).

• Use an analogy to explain the pathophysiology of gestational diabetes to teach a pregnant woman about management and treatment. EBN: Teaching using an analogy to explain gestational diabetes can help pregnant women better understand the disorder. Gestational diabetes risk increases with higher BMI. The unique pathophysiology of hyperinsulinemia and hyperglycemia put both mother and baby at higher risk for type 2 diabetes in the future (Irland, 2010).

• Utilize the 5As (tobacco cessation interventions) to treat tobacco use and dependence in pregnant women. EB: According to the USDHHS Clinical Practice Guidelines, health care professionals should at every contact (1) ask if a woman is a tobacco user, (2) advise her to quit, (3) assess her willingness to quit, (4) assist with the quit attempt (such as counseling, medication), and (5) arrange for follow-up (telephone Quitline support) (USDHHS, 2008).

• When questioning at-risk clients regarding recreational drug use, ask if they have used substances such as marijuana or cocaine within the last month, instead of questioning if have used within the last few days. EB: A study demonstrated that the use of these substances correlates best with the toxicology screens if women are asked it they have used these substances within the month (Yonkers et al, 2011).

 Refer clients who self-report drug abuse or have positive toxicology screens to a comprehensive addiction program designed for the pregnant woman. Children born to addicted mothers often have poor neonatal outcomes. EB: A study demonstrated that addicted pregnant women who attended a comprehensive program for addicted moms had better infant and maternal outcomes than addicted pregnant women who did not attend the program, especially if care began early in the pregnancy (Ordean & Kahan, 2011).

• Encourage pregnant women to utilize electronic resources, such as Text4Baby or whattoexpect.com, to track pregnancy progress and provide education and motivation to make healthy lifestyle choices (abstinence from poor nutrition, smoking, alcohol, etc.). EBN: Making education fun, interactive, and personal can encourage women to make behavior modifications for healthier outcomes (Jordan et al, 2011).

Client Will (Specify Time Frame)

• Assess overall cognitive function and memory. The emphasis of the assessment is everyday memory, the day-to-day operations of memory in real-world ordinary situations. Use an assessment tool such as the Mini-Mental State Examination (MMSE). The MMSE can help determine whether the client has cognitive impairment and/or memory loss, delirium and needs to be referred for further evaluation and treatment (Britton & Russel, 2007; Federman et al, 2009).

• Determine whether onset of memory loss is gradual or sudden. If memory loss is sudden, refer the client to a physician or neuropsychologist for evaluation. Acute onset of memory loss may be associated with neurological disease, medication effect, electrolyte disturbances, hypoxia, hypothyroidism, mental illness, or many other physiological factors (Mosconi, Pupi, & De Leon, 2008).

• Determine amount and pattern of alcohol intake. Alcohol intake has been associated with blackouts; clients may function but not remember their actions. Higher average weekly quantity and frequency of alcohol consumed in midlife were associated with lower speech fluency and may impair components of executive function (Gross et al, 2011).

• Note the client’s current medications and intake of any mind-altering substances such as benzodiazepines, ecstasy, marijuana, cocaine, or glucocorticoids. Benzodiazepines, oxybutynin, amitriptyline, fluoxetine, and diphenhydramine can produce memory loss for events that occur after taking the medication; information is not stored in long-term memory (Barton et al, 2008). EB: Glucocorticoid therapy may cause a decrease in memory function that is usually reversible once a person is off the medications (de Quervain & Margraf, 2008). By inhibiting memory retrieval, cortisol may weaken the traumatic memory trace and thus reduce symptoms even beyond the treatment period.

• Note the client’s current level of stress. Ask if there has been a recent traumatic event. Post-traumatic stress and anxiety-inducing general life factors may induce memory problems. Stress or elevated cortisol levels temporarily blocks memory retrieval (van Stegeren, 2009; Wolf, 2009).

• If stress was associated with memory loss, refer to a stress reduction clinic. If not available, suggest that the client meditate, receive massages, and participate in moderate physical activity, all of which may promote stress reduction and reduce anxiety and depression (Peavy et al, 2009).

• Encourage the client to develop an aerobic exercise program. EB: Reviews demonstrated that strength training and aerobic exercise had a positive effect on cognitive function (Ahlskog et al, 2011; Haaland et al, 2008).

• Determine the client’s sleep patterns. If insufficient, refer to care plan for Disturbed Sleep Pattern. EB: A review provided evidence of a range of cognitive deficits identified in untreated obstructive sleep apnea (OSA) clients, from attentional and vigilance to memory and executive functions, and more complex tasks such as simulated driving. Clients reported difficulty in concentrating, increased forgetfulness, an inability to make decisions, and falling asleep at the wheel of a motor vehicle (Jackson, Howard, & Barnes, 2011).

• Determine the client’s blood sugar levels. If they are elevated, refer to physician for treatment and encourage healthy diet and exercise. Baseline fasting glucose levels were NOT associated with memory or executive function (Euser et al, 2010). However, the need to rule out diabetes is a relevant concern for a differential diagnosis.

• If signs of depression such as weight loss, insomnia, or sad affect are evident, refer the client for psychotherapy. Depression can result in source memory errors, in which case the client is not sure if he or she did something or just thought about doing it (Gohier et al, 2008).

 Perform a nutritional assessment. If nutritional status is marginal, confer with a dietitian and primary care practitioner to evaluate whether the client needs supplementation with foods or vitamins. Teach the client the need to eat a healthy diet with adequate intake of whole grains, fruits, and vegetables to decrease cerebrovascular infarcts. Moderate, long-term deficiencies of nutrients may lead to loss of memory. This condition may be preventable or diminished through diet (Shukitt-Hale, Lau, & Joseph, 2008). EB: A study demonstrated that people who had high daily intake of raw fruits and vegetables may be protected from strokes (Griep et al, 2011).

• Question the client about cholesterol level. If it is high, refer to physician or dietitian for help in lowering. Encourage the client to eat a healthy diet, avoiding saturated fats and trans fatty acids. EB: Studies have shown that intake of increased saturated fats has been associated with increased cardiovascular disease including strokes (Hooper et al, 2012; Mahe et al, 2010). A systematic review of studies found that statins should NOT be recommended as a preventive treatment for dementia (Muangpaisan et al, 2010).

• Suggest clients use cues, including alarm watches, electronic organizers, calendars, lists, or pocket computers, to trigger certain actions at designated times. Cues and external cognitive strategies can help remind clients of certain actions, particularly for future intentions known as prospective memory (Kliegel, Jager, & Phillips, 2008).

• Encourage the client to participate in a multicomponent cognitive rehabilitation program that recommends stress and relaxation training, physical activity, external memory devices, such as a calendar for appointments and reminder lists. Using reminders can serve as cues for memory-impaired clients (McDougall et al, 2010b).

• Help the client set up a medication box that reminds the client to take medication at needed times; assist the client with refilling the box at intervals if necessary. Medication boxes are effective because clients will know whether medication has been taken when corresponding compartments are empty.

• If safety is an issue with certain activities (e.g., the client forgets to turn off stove after use or forgets emergency telephone numbers), suggest alternatives such as using a microwave or whistling teakettle for heating water and programming emergency numbers in telephone so that they are readily available.

• Refer the client to a memory clinic (if available), a neuropsychologist, or an occupational therapist. Memory clinics can help the client learn ways to improve memory. Clinics may be more effective for minority elders if work is done in groups because of increased support, reinforcement, and motivation (Harris et al, 2011).

• For clients with memory impairments associated with dementia, see care plan for Chronic Confusion.

Client Will (Specify Time Frame)

• Critically think/set priorities to use the most therapeutic bed positions based on client’s history, risk profile, preventive needs; realize positioning for one condition may negatively affect another. Conditions such as dyspnea, chest injury, pressure ulcer, pain, spinal cord or head injury, fractures, and amputation warrant certain bed positions to prevent complications, and head of bed (HOB) elevations may be contraindicated in certain cardiovascular or neurological conditions (Johnson & Meyenburg, 2009).

• Assess client’s risk for aspiration; if present, elevate HOB to 30 degrees and elevate HOB to 90 degrees during oral intake. Maintaining a sitting position with and after meals can help decrease aspiration pneumonia (Guy & Smith, 2009).

• Raise HOB to 30 degrees for clients with acute increased intracranial pressure (ICP) and brain injury. Refer to care plan for Decreased Intracranial Adaptive Capacity.

 Consult physician for HOB elevation of clients with acute stroke and monitor their response. Refer to care plan for Decreased Intracranial Adaptive Capacity.

• Raise HOB as close to 45 degrees as possible for critically ill, ventilated clients to prevent pneumonia (this height may place clients at higher risk for pressure ulcers). Elevating the HOB decreases regurgitation and risk of aspiration of gastric contents. EB: Researchers reviewed random controlled trials/reviews of prevention of ventilator-associated pneumonia (VAP), and their recommendations included elevating HOB to 45 degrees (Muscedere et al, 2008).

• Assist client to sit as upright as possible during meals/ingestion of pills if dysphagic. Refer to care plan for Impaired Swallowing.

• Periodically sit client as upright as tolerated in bed and dangle client, if vital signs/oxygen saturation levels remain stable. Being vertical reduces the work of the heart, improves circulation/lung ventilation/strength, and stimulates reflexes and awareness of surroundings. EBN: Therapeutic positioning in stationary positions optimizes ventilation and perfusion and promotes effective pulmonary exchange (Johnson & Meyenburg, 2009).

• Maintain HOB at lowest elevation that is medically possible to prevent shear-related injury; check sacrum often. Sacral shearing risk is high when HOB is above 30 degrees; skin may stick to linen if clients slide down, causing skin to pull away from underlying muscle tissue/bone (WOCN, 2010). EBN: A study in surgical ICU clients with HOB elevation above 30 degrees had higher sacral tissue interface pressures than those placed in other positions, regardless of type of pressure redistribution surface used, and these results were confirmed in a study of healthy volunteers (Johnson & Meyenburg, 2009).

• Trial prone positioning for clients with acute respiratory distress syndrome (ARDS), acute lung injury (ALI), and amputation and monitor their tolerance/response. Prone positioning may improve oxygenation; it allows hip extension and thus prevents flexor contractions in amputated lower extremities. EBN: Research demonstrates that prone positioning in critically ill clients with acute lung injury and/or adult respiratory disease improves pulmonary gas exchange (Johnson & Meyenburg, 2009).

• Assess client’s risk for falls using a valid tool, establish individualized fall prevention strategies, and perform postfall assessment to further refine fall prevention interventions. EB: The fall prevention program should include fall prevention interventions as well as assessment of risk and assessment of a fall (Ruddick et al, 2009).

• Lock bed brakes, use low-rise beds at lowest position with floor mats next to them, avoid use of side rails, and apply personal exit alarms on confused clients. Such interventions help prevent falls and reduce injury if fall occurs. EB: Results of a 2008 study by Bowers, Lloyd, and Lee suggested a 25% chance of serious head injury with feet-first falls from about 3 feet onto a tiled floor surface, and that use of an appropriately sized mat (15 cm beyond head/foot boards) significantly reduced risk. Mats seemed to provide “a protective effect” for the pelvis during head-first falls and for the thorax during feet-first falls.

 Avoid use of bedrails and restraints unless ordered by physician.

• Place call light, bedside table, and telephone within reach of clients. Clients won’t fall out of bed reaching for needed items (Gray-Miceli, 2008).

• Use a formalized screening tool to identify persons at high risk for thromboembolism (DVT). Early detection of high risk prompts early initiation of prophylaxis (Kearon et al, 2008).

 Implement thromboembolism prophylaxis/treatment as ordered (e.g., anticoagulants, antiembolic stockings, elastic leg wraps, sequential compression devices, feet/ankle exercises, and hydration). Anticoagulants prevent blood clots; mechanical devices/exercises prevent venous stasis (Kearon et al, 2008). Refer to care plan for Ineffective peripheral Tissue Perfusion.

• Use a formal tool to assess for risk of pressure ulcers. Braden and Norton scales are valid tools along with nursing judgment to assess for risk of pressure ulcer (WOCN, 2010).

• Implement the following interventions to prevent pressure ulcers and complications of immobility:

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