• Encourage child to increase the amount of walking done per day; if child is willing, ask him or her to wear a pedometer to measure number of steps. EB: A study demonstrated that the recommended number of steps per day to have a healthy body composition for the 6- to 12-year-old is 10,000 to 13,000 steps for a girl and 12,000 to 16,000 steps for a boy. Evidence shows that adolescents steadily decrease steps/day until approximately 8000 to 9000 steps/day are observed in 18-year-olds (Tudor-Locke et al, 2011).

• Recommend the child decrease television viewing, watching movies, and playing video games. Ask parents to limit television to 1 to 2 hours per day maximum. EB: A study demonstrated that watching television was not connected to an increased BMI, but watching television advertising, including food advertisements, was associated with obesity in children (Zimmerman & Bell, 2010).

• Use valid and reliable criterion-referenced standards for fitness testing (e.g., Senior Fitness Test) designed for older adults that can predict the level of capacity associated with maintaining physical independence into later years of life (e.g., get up and go test). Interventions can subsequently be designed to target weak areas and therefore help reduce the risk of immobility and dependence (Rikli & Jones, 2012).

• Recommend the client begin a regular exercise program, even if generally active. Walking is an effective exercise in the elderly (Resnick, 2009). EB: A meta-analysis to determine the effect sizes of exercise on physical function, activities of daily living (ADLs), and quality of life of frail older adults found exercise beneficial in increasing gait speed and improving balance and ADL performance (Chou, Hwang, & Wu, 2012).

 Refer the client to physical therapy for resistance exercise training as able involving all major muscle groups. EB: A Cochrane review found that progressive resistance-strength training for physical disability in older clients resulted in increased strength and positive improvements in some limitations (Liu & Latham, 2009).

• Use the Function-Focused Care (FFC) rehabilitative philosophy of care with older adults in residential nursing facilities to prevent avoidable functional decline. EBN: The primary goals of FFC are to alter how direct care workers (DCWs) provide care to residents to maintain and improve time spent in physical activity and improve or maintain function. Residents receiving FFC had less functional decline, and a greater percentage who were not ambulating returned to ambulatory status for short functional distances (Resnick et al, 2011).

• Recommend the client begin a tai chi practice. EB: Tai chi resulted in increased function and quality of life for clients with osteoarthritis of the knee (Lee et al, 2009). Another study demonstrated that clients performing tai chi had better balance (Wong et al, 2009).

• If client is scheduled for an elective surgery that will result in admission into the intensive care unit (ICU) and immobility, or recovery from a joint replacement, for example, initiate a prehabilitation program that includes a warm-up followed by aerobic, strength, flexibility, neuromotor, and functional task work. EBN: A study of FFC with hospitalized older adults found physical functional declines in both study groups, but less decline was associated with the group receiving FFC. The role of the gerontological rehabilitation nurse is essential throughout the hospital stay and during transitional care (Boltz et al, 2011).

• The preceding interventions may be adapted for home care use.

 Assess home environment for factors that create barriers to mobility. Refer to physical and occupational therapy services if needed to assist the client in restructuring home environment and daily living patterns. Use home safety assessment tool to prevent falls and improve mobility and function such as the tool found at http://agingresearch.buffalo.edu/hssat/index.htm. EBN: Assess person-environment fit (P-E fit) using a reliable and valid instrument such as the Housing Enabler (http://www.enabler.nu/) to evaluate the impact of the relationship between the person and his or her environment and subsequently how P-E fit affects physical activity and function (Pomeroy et al, 2011).

• Work with the client using theory-based interventions (e.g., social cognitive theoretical components such as self-efficacy; transtheoretical model). EBN: In a behavioral validity study that examined the evidence for physical activity stage of change across nine studies, physical activity stage of change was found to be behaviorally valid, evidenced by self-reported exercise, physical activity, pedometers, sedentary behaviors, and physical functioning. Physical fitness and weight indicators were not related to physical activity stage of change (Hellsten et al, 2008).

• Recommend the client use the Exercise Assessment and Screening for You (EASY) tool to help determine appropriate exercise for the older adult client. This tool is available online at http://www.easyforyou.info (Resnick, 2009). EBN: A study found an association between higher EASY cumulative scores with decreased days limited from usual activity and decreased unhealthy physical health outcomes (Smith et al, 2011).

• Consider using motivational interviewing techniques when working with both children and adult clients to increase their activity. EBN: A study found that use of motivational interviewing along with evidence-based nutritional guidelines and exercise prescriptions was effective in decreasing the BMI and size of waistline in children (Tripp et al, 2011). EB: Another study found that clients with low back pain who received motivational interviewing were more compliant with performing ordered exercises and had improved physical function (Vong et al, 2011). EB: A study that evaluated compliance of diabetic clients with prescribed exercise found that use of motivational interviewing resulted in increased oxygenation and improved muscle strength and lipid profile (Lohmann, Siersma, & Olivarius, 2010).

• Assess and evaluate a child’s level of self-care and adjust strategies as needed. EBN: Parents of children with asthma needed to be able to detect, interpret, and monitor meaningful symptoms to adequately control them. When barriers exist for enhanced self-care activities, treatment in an emergency room is the consequence even if the parents are well intended (Cox & Taylor, 2005). Interventions that incorporate cognitive-behavioral skills building may be a key factor for promoting physical activity as well as fruit and vegetable intake in adolescents (Kelly et al, 2012). Nurses must adopt, recognize, and assess a child’s readiness to learn diabetes care and bear responsibility for it. A balance between diabetes care requirements and a child’s maturity must be assessed (Kelo, Martikainen, & Eriksson, 2011).

• Assist families to engage in and maintain social support networks. EBN: Children with cancer are competent agents, performing many practices in the area of universal and developmental self-care requisites (Moore & Beckwitt, 2004). EBN: Improved caregiver-child relationship suggests participation in an Internet support group as soon as possible for primary caregivers of a child with special health care needs (Baum, 2004). EB: Social support was effective in promoting psychological well-being in this study of AIDS orphans (Okawa et al, 2011).

• Encourage activities that support or enhance spiritual care. CEB: Spiritual growth is significantly related to an adolescent’s initiation and responsibility for self-care (Callaghan, 2005). EBN: Children’s care will be enhanced when children are given the opportunity to express their spiritual and relational concerns (Kamper, Van Cleve, & Savedra, 2010).

• Identify cultural beliefs, values, lifestyle practices, and problem-solving strategies when assessing the client’s level of self-care. For common minor illnesses, many people use self-care with medicines, vitamins, herbs, exercise, or foods that they believe have healing powers. Many self-care practices are handed down from generation to generation (Andrews & Boyle, 2003). EB: The importance of cultural and religious traditions was identified for self-management in this study of Thai Buddhist people with type 2 diabetes (Lundberg & Thrakul, 2012).

• Enhance cultural knowledge by seeking out information regarding different cultural or ethnic groups. The transcultural nurse must be guided by acquired knowledge in the assessment, diagnosis, planning, implementation, and evaluation of the client’s needs, based on culturally relevant information (Giger & Davidhizar, 2004). Cultural self-assessment is the first step in providing culturally competent care (Andrews & Boyle, 2003).

• Recognize the impact of culture on self-care behaviors. EB: Self-care practices play a critical role in the management of chronic illness, yet little is known about the self-care practices of chronically ill African Americans or how lack of access to health care affects health. Self-care practices are culturally based (Becker, Gates, & Newsom, 2004). EB: In noting the factors that influence self-efficacy in HlV risk reduction among Asian and Pacific Islanders, variations in reported self-efficacy for female respondents are explained by acculturation and comfort in asking medical practitioners about HIV/AIDS (Takahashi et al, 2006). EBN: Cultural beliefs play an important role in attitudes toward diabetes among people of South Asian origin. Understanding these beliefs assists in promoting self-management (Osman & Curzio, 2012).

• Provide culturally competent care. Cultural competence is a continuous process of awareness, knowledge, skill, interaction, and sensitivity that is demonstrated among those who render care and the services they provide (Giger & Davidhizar, 2004). EB: In this study of Latino women, a culturally based adaptation of a program to promote physical activity significantly improved both self-reported readiness to engage in physical activity and vigorous physical activity (Coleman et al, 2012).

• Support independent self-care activities. EB: In a study of self-care practices of migrant and seasonal farm workers, a majority of self-care practices were judged as appropriate for the health problem (Anthony et al, 2010).

• The nursing interventions described previously may also be used in home care settings.

• Support the new sense of self that may occur with complex health problems. EBN: In this review it was shown that a new sense of self permeated clients’ attempts to deal with the day-to-day management (self-care) of the health problems associated with heart disease (Welstand, Carson, & Rutherford, 2009).

• Assist individuals and families to prevent exacerbations of chronic illness symptoms so rehospitalization is not necessary. EBN: In a database analysis of OASIS, of 145,191 people with heart failure in home care, 15% experienced rehospitalization (Madigan, 2008).

• In complex chronic illnesses such as heart failure, help individuals and families to accept continued functional disabilities and work toward maintenance of optimum functional status, considering the reality of illness status. EBN: In the database analysis of 145,191 cases in OASIS of people with heart failure at home, there was only a small improvement in functional status over an average of 44 home care visits (Madigan, 2008).

• Use educational guidelines for stroke survivors. EBN: Evidence-based educational guidelines were developed and tested in 1150 home visits (Ostwald et al, 2008).

• Ensure appropriate interdisciplinary communication to support client safety. EBN: Health care providers can best facilitate self-management by coordinating self-management activities, by recognizing that different self-management processes vary in importance to clients over time, and by having ongoing communication with clients and providers to create appropriate self-management plans (Schulman-Green et al, 2012).

• Enhance individual and family coping with chronic illnesses. EBN: In a study of 113 adults 3 weeks after hospital discharge, many difficulties with coping were identified (Fitzgerald Miller, Placentine, & Weiss, 2008).

• Implement a community care management program. EBN: For 12 years, a community care management program in Colorado with a focus on improving the quality of life and facilitating the self-efficacy of elderly chronically ill individuals and families has successively achieved its goals and demonstrated an 81% reduction in financial losses during 2006 for emergency and inpatient services (Luzinski et al, 2008). EB: This study demonstrated a significant increase in self-management goal setting in clients with diabetes after the addition of community health workers to the team (Hargraves et al, 2012)

• Teach clients how to regularly assess their level of self-care.

• Instruct clients that a variety of interventions may be needed to enhance self-care.

• Help clients to understand that enhanced self-care is an achievable goal.

• Empower clients.

• Teach clients about the decision-making process and self-care activities needed to manage their illness state and promote well-being.

• Continuously stress that all self-care activities must be regularly evaluated to ensure that enhanced levels of self-care can be maintained.