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self-esteem. � Checking ideas out with trusted others Provides control of auditory alterations.70 � Practicing thought stopping by singing to self, telling the voices to go away (this can be done quietly to self, or asking the voices to come back later, but not to talk now) � Telling the voices to go away, using headphones to listen to music, watching TV, wearing ear plug in one ear • When the client is not constantly experiencing alterations, Facilitates interaction, self-management, and monitoring of engage him or her in a group that addresses management of symptoms, and instills hope.70 these alterations. • When the client is responding to hallucinations, respond to the feelings expressed in the client’s communication. • Respond to the client with “I” statements (“I do not see or hear Provides indirect confrontation of their experience. Preserves that”) when they request validation of hallucinations. Do not self-esteem while indicating that nurse does not experience the argue with client’s experience. same stimuli.71 • Talk with the client about ways to distract himself or herself from the hallucinations, such as physical exercise, playing a game or a craft that takes a great deal of concentration. (Note those activities preferred by the client here.) • When signs of the client’s hallucinating are present, assist the Reinforces new coping behaviors, and increases the client’s client in initiating those activities or other control behaviors that perceived control. have been identified by the client as useful. • As the client’s condition improves, primary nurse will assist the Facilitates the development of alternative coping behaviors. client to identify onset of hallucinations and situations that facilitate their onset. • As difficult situations are identified, primary nurse can begin Promotes the client’s sense of control and self-esteem. working with the client on alternative ways of coping with these situations. (Note alternative coping behaviors selected by the client here.) • Refer the client and support system to appropriate support Establishes continuity of responses and support for the client after systems in the community, e.g., Compeer. (Contact local mental discharge. health association for programs in your community.) • Arrange time with significant others to provide education about sensory-perceptual alterations and appropriate responses to them. Copyright © 2002 F.A. Davis Company 438 COGNITIVE-PERCEPTUAL PATTERN Gerontic Health The nursing actions for the gerontic patient with this diagnosis are the same as those for the adult health patient. Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family measures to prevent sensory deficit: Family and client involvement in basic safety measures enhances � Use of protective gear, e.g., goggles, sunglasses, earplugs, or the effectiveness of preventive measures. special clothing in hazardous conditions to prevent radiation, sun, or chemical burns � Avoidance of sharp or projectile toys � Prevention of injuries to eyes, ears, skin, nose, and tongue � Prevention of nutritional deficiencies � Close monitoring of medications that may be toxic to the eighth cranial nerve � Correct usage of contact lenses � Prevention of fluid and electrolyte imbalances • Involve the client and family in planning, implementing, and Involvement improves motivation. Communication and mutual promoting correction or compensation for sensory deficit goals increase the probability of positive outcomes. [specify] by [date]: � Family conference � Mutual goal setting � Communication, e.g., use of memorabilia and audiotapes or videotapes provided by family members to stimulate in cases of impaired communication72 • Assist the patient and family in lifestyle adjustments that may be Lifestyle changes require change in behavior. Self-evaluation and required: support facilitate these changes. � Assistance with activities of daily living � Adjustment to and usage of assistive devices, e.g., hearing aid, corrective lenses, or magnifying glass � Providing safe environment, e.g., protect kinesthetically impaired individuals from burns � Stopping substance abuse � Changes in family and work role relationships � Techniques of communicating with the individual with auditory or visual impairment � Providing meaningful stimulation � Special transportation needs � Special education needs • Consult with or refer to appropriate assistive resources as Use of the network of existing community services provides for indicated. effective utilization of resources. Copyright © 2002 F.A. Davis Company SENSORY PERCEPTION, DISTURBED (SPECIFY: VISUAL, AUDITORY, KINESTHETIC, GUSTATORY, TACTILE, OLFACTORY) 439 Sensory Perception, Disturbed (Specify: Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory) FLOWCHART EVALUATION: EXPECTED OUTCOME Interview the patient and significant others. Have they identified at least two ways to compensate for specific sensory problem? Yes No Record data, e.g., use of large letters Reassess using initial assessment factors. for labeling at home and appointment made for new glasses; grandson is making labels; has appointment with ophthalmologist tomorrow. Record RESOLVED (may want to use CONTINUE until patient is discharged from your service). Delete nursing No Is diagnosis validated? diagnosis, expected outcome, target date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., made 10 comments in first 24 h of Did evaluation show another admission regarding problems problem had arisen? Yes with sensory deficit; still has some complaints and says, “I just can’t do anything about this; someone will have to handle this for me.” Record CONTINUE and change target date. Modify nursing actions as necessary No Finished Copyright © 2002 F.A. Davis Company 440 COGNITIVE-PERCEPTUAL PATTERN Thought Process, Disturbed 7. Schizophrenic disorders 8. Dissociative disorders DEFINITION 9. Obsessive-compulsive disorders 10. Paranoid disorder A state in which an individual experiences a disruption in cognitive 11. Delirium operations and activities.2 12. Eating disorders NANDA TAXONOMY: DOMAIN 5—PERCEPTION/ COGNITION; CLASS 4—COGNITION HAVE YOU SELECTED NIC: DOMAIN 4—SAFETY; CLASS V—RISK THE CORRECT DIAGNOSIS? MANAGEMENT Disturbed Sensory Perception This NOC: DOMAIN II—PHYSIOLOGIC HEALTH; diagnosis refers to deficits or overloads in CLASS J—NEUROCOGNITIVE sensory input. If the patient is having difficulty with sight, hearing, or any of the DEFINING CHARACTERISTICS2 other senses, then a confused patient might well be the result. Double-check the pattern 1. Cognitive dissonance assessment to be sure sensory deficit is not 2. Memory deficit or problems the primary problem. 3. Inaccurate interpretation of environment Ineffective Health Maintenance The 4. Hypovigilence diagnosis of Disturbed Thought Process might 5. Hypervigilence well contribute to Ineffective Health 6. Distractibility Maintenance. In this case, Disturbed Thought 7. Egocentricity Process and Ineffective Health Maintenance 8. Inappropriate, nonreality-based thinking would be companion diagnoses. RELATED FACTORS2 To be developed. EXPECTED OUTCOME RELATED CLINICAL CONCERNS Will have at least a [number] percent decrease in signs and symp- toms of Disturbed Thought Process by [date]. 1. Dementia 2. Neurologic diseases affecting the brain TARGET DATES 3. Head injuries 4. Medication overdose, for example, digitalis, sedatives, or narcotics A target date of 5 days would be acceptable because this can be a 5. Major depression very long-range problem. 6. Bipolar disorder, manic or depressive or mixed NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Monitor at least every 4 h while awake: Assists in determining pathophysiologic causes for Disturbed � Vital signs Thought Process. � Neurologic status, particularly for signs and symptoms of ICP � Mental status � Laboratory values for metabolic alkalosis, hypokalemia, increased ammonia levels, or infection • Collaborate with psychiatric nurse clinician and rehabilitation Collaboration provides the best plan of care. nurse specialist. • Consistently provide a safe, calm environment: Basic safety measures and reinforcement of reality. � Provide siderails on bed. � Keep room uncluttered. � Reorient the client at each contact. � Reduce extraneous stimuli, e.g., limit noise and visitors, and reduce bright lighting. � Use touch judiciously. � Prepare for all procedures by explaining simply and concisely. (continued) Copyright © 2002 F.A. Davis Company THOUGHT PROCESS, DISTURBED 441 (continued) ACTIONS/INTERVENTIONS RATIONALES � Provide good, but not intensely bright lighting. � Have the family bring clock, calendar, and familiar objects from home. • Design communications according to the patient’s best means Enhances communication and quality of care. of communication, e.g., writing, visuals, or sound: � Give simple, concise directions. � Listen carefully. � Present reality consistently. � Do not challenge illogical thinking. • Encourage the patient to use prosthetic or assistive devices, e.g., Increases sensory input and reinforces reality. eyeglasses, dentures, hearing aid, or walker. • Provide frequent rest periods. Reduces environmental stimuli that could contribute to confusion, and helps to avoid sensory overload. • Provide consistent approach in nursing care and routine. Inspires trust, reinforces reality, decreases sensory stimuli, and provides memory cues. • Encourage self-care to the extent possible. Increases self-esteem, forces reality check, decreases powerlessness, and provides a means of evaluating the patient’s status. • Involve significant others in care, and include in teaching Provides social support and consistency in management. sessions. • Refer to and collaborate with appropriate assistive resources. Provides for long-term support and a more holistic approach to care. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor cognitive capacity according to age and developmental Basic data needed to plan individualized care. capacity. • Note discrepancies in chronologic age and mastery of developmental milestones. • Provide ongoing reality orientation by encouraging the family As the patient attempts to reorient, it is helpful that date, time, and to visit, and by emphasizing time, personal awareness, and specific concrete planning, hour by hour, are offered. The infant gradual resumption of daily routine to degree possible. should be reintroduced to data, in a calm manner, that will assist in regaining some control over the environment and in regaining the previous functioning level so that he or she can continue to progress. • Provide anticipatory safety to reflect greater range of potentials Disturbed Thought Process serves as a high-risk factor for all according to psychomotor capacity. involved. It would be a reasonable standard of care to increase all anticipatory safety efforts. • Encourage the family members to express concerns for the Promotes ventilation, which helps reduce anxiety and offers insight child’s condition by allowing 30 min each shift for discussion. into thoughts about the patient’s condition. • Provide for primary health needs, including administration of Attention to regular health needs must also be considered as the medications, comfort measures, and control of environment to whole person is considered. aid in the child’s adaptation. • Structure the room in a manner that befits the child’s needs. Keeping the environment adapted to personal needs will facilitate care, minimize the chance for accidents, and demonstrate the needed structure. • Allow for ample rest periods according to sleep patterns during Rest is a key and essential consideration to provide optimal health and within parameters for age-related sleep needs. potential for cognitive-perceptual functioning. • Monitor for existence of other patterns, especially altered coping All contributing factors must be explored to ensure meeting the and role performance. patient’s needs. • Assist the family in dismissal plans by utilization of appropriate Improves family adjustment and coping by assisting in preparing state and community resources. for home needs. Empowerment then permits them the opportunity for growth in coping skills and parenting. • If institutionalization is required, assist the family in learning Planning provides the means for coping and adjusting to the move about related issues, such as vitiation, medical records with an opportunity for clarification. Provides advocacy for the maintenance, prognosis, and risk factors. patient and family. • Maintain ethical and legal confidentiality on the patient’s behalf. Standard practice must include safeguarding the patient’s needs for confidentiality and legal rights. • Allow for culturally unique aspects in management of care, e.g., Increases individuation and satisfaction with care. Shows respect respect for visitation on religious holidays, family wishes for diet, for the family’s values. Enhances nurse-patient relationship. and bathing. (continued) Copyright © 2002 F.A. Davis Company 442 COGNITIVE-PERCEPTUAL PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide for appropriate follow-up by making appointments for Follow-up arrangements for clinic visits enhance the likelihood of next clinic visits. follow-up and demonstrate the importance of this follow-up care. • Allow the family members opportunities for learning necessary Anticipating learning needs serves to minimize crises related to the care and mastery of content for long-term needs, such as child’s condition. resolution of conflicts related to institutionalization or respite care and prognosis. Women’s Health This nursing diagnosis will pertain to the woman the same as any other adult, with the following excep- tion. For midlife women, the nursing actions and interventions are the same as those given in Deficient Knowledge, Sleep Deprivation, and Disturbed Sleep Pattern under the heading

of perimenopausal and menopausal life periods. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Monitor the client’s level of anxiety, and refer to Anxiety Too much information can increase the client’s confusion and (Chap. 8) for detailed interventions related to this diagnosis. disorganization. The amount of time devoted to interaction should be guided by the client’s attention span.73 • Speak to the client in brief, clear sentences. • Keep initial interactions short but frequent. Interact with client Facilitates the development of a trusting relationship. for [number] minutes every 30 min. Begin with 5-min interactions and gradually increase the times of interactions. • Assign the client a primary care nurse on each shift to assume Facilitates the development of a trusting relationship. responsibility for gaining a relationship of trust with the client. • Be consistent in all interactions with the client. Facilitates the development of a trusting relationship, and meets the client’s safety needs. • Set limits on inappropriate behavior that increase the risk of the Client and staff safety are of primary importance. client or others being harmed. Note the limits here as well as revisions to the limits. • Initially place the client in an area with little stimulation. Inappropriate levels of sensory stimuli can contribute to client’s sense of disorganization and confusion. • Orient the client to the environment, and assign someone to Promotes the client’s safety needs while facilitating the development provide one-to-one interaction while the client orients to unit. of a trusting relationship. • Do not make promises that cannot be kept. Facilitates the development of a trusting relationship. • Inform the client of your availability to talk with him or her; Communicates acceptance of the client, which facilitates the do not pry or ask many questions. development of trust and self-esteem. • Do not argue with the client about delusions; inform the client Argument may reinforce the client’s need to maintain the delusional in a matter-of-fact way that this is not your experience of the system and interferes with the development of a trusting situation, e.g., “I do not think I am angry with you.” relationship. • Recognize and support the client’s feelings, e.g., “You sound Focuses on the client’s real feelings and concerns. frightened.” • Respond to the feelings being expressed in delusions or hallucinations. • Initially have the client involved in one-to-one activities; as High levels of environmental stimuli may increase confusion and conditions improve, gradually increase the size of the disorganization. interaction group. Note current level of functioning here. • Have the client clarify those thoughts you do not understand. Facilitates the development of a trusting relationship, and prevents Do not pretend to understand that which you do not. inadvertent support of the delusional thinking. • Do not attempt to change delusional thinking with rational This may encourage the client to cling to these thoughts. explanations. • After listening to delusion once, do not engage in conversations Decreases the possibility of supporting or reinforcing the delusion. related to this material or focus conversations on this material. • Focus conversations on here-and-now content related to real Facilitates the client’s contact with reality.67 things in the environment or to activities on the unit. • Do not belittle or be judgmental about the client’s delusional beliefs. Protects the client’s self esteem. • Avoid nonverbal behavior that indicates agreeing with Decreases the possibility of supporting or reinforcing the delusion. delusional beliefs. • When the client’s behavior and anxiety level indicate readiness, Provides feedback about delusional beliefs from peers. place the client in small-group situations. The client will spend [number] minutes in group activities [number] times a day. (continued) Copyright © 2002 F.A. Davis Company THOUGHT PROCESS, DISTURBED 443 (continued) ACTIONS/INTERVENTIONS RATIONALES (Time and frequency will increase as the client’s ability to cope with these situations improves.) • Develop a daily schedule for the client that encourages focus on Facilitates the client’s contact with reality. Promotes positive “here and now” and is adapted to the client’s level of functioning self-image. so that success can be experienced. Note daily schedule here. • Assign the client meaningful roles in unit activities. Provide Facilitates the client’s contact with reality. Promotes positive roles that can be easily accomplished by the client to provide self-image. successful experiences. Note client responsibilities here. • Primary nurse will spend [number] minutes with the client Assists in the development of alternative coping behaviors. twice a day to discuss the client’s feelings and the effects of the delusions on the client’s life. (Number of minutes and the degree of exploration of the client’s feelings will increase as the client develops relationship with nurse.) • Provide rewards to the client for accomplishing task progress on Positive feedback encourages productive behavior. the daily schedule. These rewards should be ones the client finds rewarding. • Spend [number] minutes twice a day walking with the client. Facilitates the development of a trusting relationship. Social This should start at 10-min intervals and gradually increase. interaction provides positive reinforcement. Helps increase This can be replaced by any physical activity the client finds daytime wakefulness, promoting a normal sleep-wake cycle. enjoyable. A staff member should be with the client during this activity to provide social reinforcement to the client for accomplishing the activity. • Arrange a consultation with the occupational therapist to assist Increases daytime wakefulness, maintaining a normal sleep-rest the client in developing or continuing special interests. cycle. • Monitor delusional beliefs for potential of harming self or others. Patient and staff safety are of primary concern. • Note any change in behavior that would indicate a change in Patient and staff safety are of primary concern. the delusional beliefs that could indicate a potential for violence. • If the client is placed in seclusion, interact with the client at Provides reality orientation, and assists the client with controlling least every 15 min. hallucinations and delusions. • Maintain environment that does not stimulate the client’s Excessive environmental stimuli can increase confusion and delusions, e.g., if the client has delusions related to religion, disorganization. limit discussions of religion and religious activity on unit to very concrete terms. Limit interaction with persons who stimulate delusional thinking. • Primary nurse will assist the client in identifying signs and Promotes the client’s sense of control, and enhances self-esteem. symptoms of increasing thought disorganization and in developing a plan to cope with these situations before they get out of control. This will be done in the regular scheduled interaction times between the primary nurse and the client. • As the client’s condition improves, primary nurse will assist the Facilitates the client’s developing alternative coping behaviors. client to identify onset delusions with periods of increasing anxiety. • As connection is made between thought disorder and anxiety, Promotes the client’s sense of control, and enhances self-esteem. the client will be assisted to identify specific anxiety-producing situations and learn alternative coping behaviors. See Anxiety (Chap. 8) for specific interventions. • Refer the client to outpatient support systems, and assist with Facilitates the client’s reintegration into the community. making arrangements for the client to contact these before discharge. Gerontic Health NOTE: Problems related to Disturbed Thought Process with older adults may present themselves in various ways. Two conditions, dementia and delirium, are considered here. Irreversible dementia, such as Alzheimer’s or multi-infarct dementia, is usually progressive, gradual in onset, of long duration, and has a steady downward course. Delirium, or acute confusional state, presents with acute onset, is of short duration, and has a fluctuating course and is often reversible with treatment.74 Nursing inter- ventions vary depending on the course of the Disturbed Thought Process. ACTIONS/INTERVENTIONS RATIONALES DEMENTIA • Maintain safe environment. Avoid leaving solutions, equipment, The patient is unable to determine the harmful consequences of or medications near the patient that could result in injury misuse. through misuse or ingestion. (continued) Copyright © 2002 F.A. Davis Company 444 COGNITIVE-PERCEPTUAL PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Monitor environment to prevent overstimulating the patient With dementia, the patient has a reduced threshold for stress. with light, sounds, and frequent activity. • Schedule activities that are of short duration (usually 20-min Prevents stresses on an individual already suffering from attention sessions). deficits and anxiety. • Use short sentences and clear directions when communicating Allows processing of basic information without distraction. with the patient. • Determine self-care abilities that are intact, and encourage Provides stimulation and sense of pride. Promotes physical activity. continued participation in these activities. • Monitor food and fluid intake to determine that nutritional status is adequate. • Provide consistent staff. Reduces anxiety. • Refer the family to local Alzheimer’s and related diseases Provides long-term support. support group. DELIRIUM • Monitor for conditions that can induce delirium. Certain factors such as electrolyte imbalance, preoperative dehydration, unanticipated surgery, intraoperative hypotension, postoperative hypothermia, and a large number of medications have been found to be associated with acute confusional states in older adults.75,76 • Provide orienting information to the patient as often as necessary. Provides information to the patient about the current situation, and assists in reducing anxiety and confusion. • Ensure that sensory deficits are corrected to extent possible. Correcting sensory deficits enhances the patient’s ability to use available cues to person, place, and time. • Provide consistent staff. Avoids adding to confusion and promotes the patient’s security. • Provide sensory stimulation such as bathing, touching, and back Assists in restoring the patient’s sense of body image.77 massages. Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family to monitor for signs and symptoms Basic monitoring that allows for early intervention. of Disturbed Thought Process: � Poor hygiene � Poor decision making or judgment � Regression in behavior � Delusions � Hallucinations � Changes in interpersonal relationship � Distractibility • Involve the client and family in planning, implementing, and Involvement improves cooperation and motivation, thereby promoting appropriate thought processing: increasing the probability of an improved outcome. � Family conference � Mutual goal setting � Communication • Assist the client and family in lifestyle adjustments that may be necessary: � Providing safety and prevention of injury � Frequent orientation to person, place, and time � Providing reality testing and patient verification � Assisting in working through alterations in role functions in family or at work � Stopping substance abuse � Facilitating family communication � Setting limits � Learning new skills � Decreasing risk for violence � Preventing suicide � Explaining possible chronicity of disorder (continued) Copyright © 2002 F.A. Davis Company THOUGHT PROCESS, DISTURBED 445 (continued) ACTIONS/INTERVENTIONS RATIONALES � Referring the client to community resources for financial assistance � Reducing sensory overload � Teaching stress management � Teaching relaxation techniques � Referring the client and family to support groups • Assist the client and family to set criteria to help them determine Early identification of issues requiring professional evaluation will when professional intervention is required. increase the probability of successful interventions. • Teach the client and family purposes, side effects, and proper Provides necessary information for the client and family that administration techniques for medications. promotes safe self-care. • Consult with or refer to appropriate assistive resources as Efficient and cost-effective use of community resources. required. Copyright © 2002 F.A. Davis Company 446 COGNITIVE-PERCEPTUAL PATTERN Thought Process, Disturbed FLOWCHART EVALUATION: EXPECTED OUTCOME Review signs and symptoms on day of diagnosis. Reassess for presence of these same signs and symptoms. Has there been the designated percentage decrease? Yes No Record data, e.g., now Reassess using initial assessment factors. demonstrating only two symptoms indicative of Disturbed Thought Process—these are (list here); signs and symptoms have decreased by 75%. Record RESOLVED (may No Is diagnosis validated? want to use CONTINUE until all signs and symptoms are gone). Delete nursing diagnosis, expected outcome, target date, and nursing actions Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., still exhibiting all admission day signs and symptoms of Did evaluation show another Disturbed Thought Process except problem had arisen? Yes (list here); only a 5% decrease. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company UNILATERAL NEGLECT 447 Unilateral Neglect 3. Blindness secondary to diabetes mellitus 4. Spinal cord injury DEFINITION 5. Amputation 6. Ruptured cerebral aneurysm Lack of awareness and attention to one side of

the body.2 7. Brain trauma NANDA TAXONOMY: DOMAIN 5—PERCEPTION/ COGNITION; CLASS 1—ATTENTION HAVE YOU SELECTED NIC: DOMAIN 2—PHYSIOLOGICAL: COMPLEX; THE CORRECT DIAGNOSIS? CLASS I—NEUROLOGIC MANAGEMENT Disturbed Sensory Perception This NOC: DOMAIN I—FUNCTIONAL HEALTH; diagnosis refers to a problem with receiving CLASS C—MOBILITY sensory input and interpretation of this input. Unilateral Neglect could be, as indicated by DEFINING CHARACTERISTICS2 the related factors, an outcome of this disturbance in sensory input and/or 1. Consistent inattention to stimuli on an affected side perception of this input. 2. Does not look toward affected side 3. Positioning and/or safety precautions in regard to the affected side 4. Inadequate self-care 5. Leaves food on plate on the affected side EXPECTED OUTCOME RELATED FACTORS2 Will have decreased signs and symptoms of Unilateral Neglect by [date]. 1. Effects of disturbed perceptual abilities, for example, hemianopsia 2. Neurologic illness or trauma TARGET DATES 3. One-sided blindness A target date between 5 and 7 days would be appropriate to evalu- ate initial progress. RELATED CLINICAL CONCERNS 1. Cerebrovascular accident 2. Glaucoma NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Frequently remind the patient to attend to both sides of his or Repetition improves brain processing. her body. • Assist the patient to touch and feel neglected side of body. Help Increases brain’s awareness of neglected side. the patient, by providing a variety of sensations (warmth, cool, soft, harsh, etc.), to become more aware of and articulate sensations on neglected side. • Assist the patient with ROM exercises to neglected side of body Increases brain’s awareness of neglected side, and maintains every 4 h while awake at [times]. Teach extent of movement of muscle tone and joint mobility. each joint on neglected side of body. • Help the patient position neglected side of body in a similar way as attended side of body whenever position is changed. • Remind the patient to turn plate during each meal. Assists the patient to notice all of food, and increases cues to brain. • Turn every 2 h on [odd/even] hour. Monitor skin condition on Improves circulation. Relieves pressure areas. Avoids skin each turning. breakdown on affected side. • Refer to rehabilitation nurse clinician. Collaboration provides a more holistic plan of care, and rehabilitation nurse will have most up-to-date knowledge regarding this diagnosis. Copyright © 2002 F.A. Davis Company 448 COGNITIVE-PERCEPTUAL PATTERN Child Health See nursing actions under Disturbed Sensory Perception in addition to those listed here. ACTIONS/INTERVENTIONS RATIONALES • Allow 30 min every shift for the patient and family to express Ventilation of feelings is paramount in understanding the effect the how they perceive the unilateral neglect. problem has on the patient and the family; it is also critical as a means of evaluating needs. • Determine how the unilateral neglect affects the usual expected Previous and/or current developmental capacity may be affected by behavior or development for the child. the unilateral neglect depending on the degree of severity. To be able to judge the best means of therapy requires these data to be considered, e.g., does the child use the affected hand as a helper, or not try to use it at all? • Monitor for presence of secondary or tertiary deficits. Identification of primary deficits should alert all to monitor for possible secondary and tertiary deficits to minimize further sequelae, which can be treated early. • Establish, with family input, appropriate anticipatory safety Safety needs and measures must reflect the developmental capacity guidelines that are based on the unilateral neglect and the of the child and slightly beyond it. There is a special need to developmental capacity of the child. structure the environment to allow for appropriate exploratory behavior while maintaining safety without overprotection. • Stress appropriate follow-up prior to dismissal from hospital Arrangement for follow-up increases the likelihood of compliance with appropriate time frame for the family. and shows the importance of follow-up. Women’s Health This nursing diagnosis will pertain to women the same as any other adult. Psychiatric Health Nursing interventions for this diagnosis are those described in Adult Health. Gerontic Health The nursing orders for the older adult with this diagnosis are the same as those for Adult Health. Home Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for factors contributing to Unilateral Neglect, e.g., This action provides the database needed to identify interventions disturbed perceptual abilities, neurologic disease, or trauma. that will prevent or diminish unilateral neglect. • Involve the client and family in planning, implementing, and Family involvement is important to ensure success. Communication promoting reduction in effects of Unilateral Neglect: and mutual goals improve the outcome. � Schedule family conferences, e.g., to discuss concerns family members have. � Encourage the family’s ideas for addressing the concern. � Set mutual goals, e.g., establish two measures to offset the effect of unilateral neglect. Be sure roles for the participants are identified. � Maintain communication. � Provide support for the caregiver, e.g., plan respite time for the primary caregiver. Alternate caregivers are identified and trained. • Teach the client and family measures to decrease effects of These actions diminish the negative effects of Unilateral Neglect. Unilateral Neglect: � Active and passive ROM exercises � Ambulation with assistive devices (canes, walkers, or crutches) � Objects placed within field of vision and reach � Assistive eating utensils � Assistive dressing equipment � Safe environment, e.g., objects removed from area outside field of vision • Assist the family and client to identify lifestyle changes that may Lifestyle changes require changes in behavior. Self-evaluation and be required: support facilitate these changes. � Change in role functions � Coping with disability or dependency (continued) Copyright © 2002 F.A. Davis Company UNILATERAL NEGLECT 449 (continued) ACTIONS/INTERVENTIONS RATIONALES � Obtaining and using assistive equipment � Coping with assistive equipment � Maintaining safe environment • Consult with appropriate assistive resources as indicated. Appropriate use of existing community services is effective use of resources. Copyright © 2002 F.A. Davis Company 450 COGNITIVE-PERCEPTUAL PATTERN Unilateral Neglect FLOWCHART EVALUATION: EXPECTED OUTCOME Compare signs and symptoms of Unilateral Neglect today with presenting signs and symptoms on day of diagnosis. Have they decreased? Yes No Record data, e.g., now paying Reassess using initial assessment factors. attention to care of affected side; utilizes safety precautions for affected side; presenting no signs or symptoms of Unilateral Neglect. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., still not implementing either care or safety measures for affected Did evaluation show another side; no decrease in signs or symptoms of problem had arisen? Yes Unilateral Neglect. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company CHAPTER 8 Self-Perception and Self-Concept Pattern 1. ANXIETY 456 8. POWERLESSNESS, RISK FOR AND 2. BODY IMAGE, DISTURBED 465 ACTUAL 501 3. DEATH ANXIETY 471 9. SELF-ESTEEM, CHRONIC LOW, 4. FEAR 476 SITUATIONAL LOW, AND RISK 5. HOPELESSNESS 484 FOR SITUATIONAL LOW 508 6. LONELINESS, RISK FOR 491 10. SELF-MUTILATION, RISK FOR AND 7. PERSONAL IDENTITY, ACTUAL 515 DISTURBED 497 Pattern Description 6. Is the patient expressing worries about the impact of his or her death on his or her family and/or friends? As the nurse interacts with the client, the most important knowledge a. Yes (Death Anxiety) the client contributes is self-knowledge. It is this knowledge that de- b. No termines the individual’s manner of interaction with others. This 7. Does the patient verbalize a negative view of self? knowledge base is most often labeled “self-concept.” One’s self-concept a. Yes (Situational Low Self-Esteem) is composed of beliefs and attitudes about the self, body image, self- b. No esteem, and information about abilities. The individual’s behavior is 8. Does the patient believe he or she can deal with the current not only affected by those experiences prior to interactions with the problem that led to this admission? health care system but also by interactions with the health care system. a. Yes b. No (Situational Low Self-Esteem) 9. Does the patient or his or her family indicate that the self- Pattern Assessment negating impression is a long-standing (several years) problem? a. Yes (Chronic Low Self-Esteem) 1. Does the patient express concern regarding current situation? b. No (Situational Low Self-Esteem) a. Yes (Anxiety or Fear) 10. Does the patient question who he or she is or verbalize lack of b. No an understanding regarding his or her role in life? 2. Can the patient identify source of concern? a. Yes (Disturbed Personal Identity) a. Yes (Fear) b. No b. No (Anxiety) 11. Does the patient appear passive or verbalize passivity? 3. Is the patient going to have, as a result of this admission, a a. Yes (Hopelessness) change in body structure or function? b. No a. Yes (Disturbed Body Image) 12. Does the patient demonstrate decreased verbalization and/or b. No flat affect? 4. Does the patient verbalize a change in lifestyle as a result of this a. Yes (Hopelessness) admission? b. No a. Yes (Disturbed Body Image) 13. Does the patient have a problem with physical or social isola- b. No tion? 5. Does the patient express fear about dying? a. Yes (Risk for Loneliness) a. Yes (Death Anxiety) b. No b. No 14. Has the patient recently suffered the loss of a significant other? 451 Copyright © 2002 F.A. Davis Company 452 SELF-PERCEPTION AND SELF-CONCEPT PATTERN a. Yes (Risk for Loneliness) known. Mead5 expressly addresses the development of these mem- b. No ories and how they affect one’s behavior. 15. Does the patient verbalize lack of control? Mead5 describes the self-concept as evolving out of interactions a. Yes (Powerlessness) with others in social contexts. This process begins at the moment b. No of birth and continues throughout a lifetime. The definition of self 16. Is the patient participating in care and decision making re- can only occur in social interactions, for one’s self exists only in re- garding care? lation to other selves. The individual is continually processing the a. Yes reactions of others to his or her actions and reactions. This pro- b. No (Powerlessness) cessing is taking place in a highly personalized manner, for the in- formation is experienced through the individual’s selective atten- Conceptual Information tion, which is guided by the current needs that are struggling to be expressed. This results in an environment that is constructed by Definition of the self and of a self-concept has been an issue of de- one’s perceptions. Mead’s conceptualization leads to an interesting bate in philosophy, sociology, and psychology for many years, and feedback process in that we can only perceive self as we perceive many publications are available on this topic.1 The complexity of others perceive us. This continues to reinforce the idea that the self- the problem of defining self is compounded by the knowledge that concept is highly personalized. external observation provides only a superficial glimpse of the self, Many authors2,4,5 have addressed the process of developing a and introspection requires that the “knower” knows himself or her- concept of self. The model developed by Harry Stack Sullivan6 is self so that information actually gained is self-referential. In spite of presented here because it is consistent with the information pre- these problems, the concept continues to be pervasive in the liter- sented in the symbolic interaction literature and is used as the the- ature and in the universal experience of “self ” or “not self.” Intu- oretical base in much of the nursing literature. itively one would say, of course, “There is a self because I have ex- Sullivan6 describes the self-concept as developing in interactions periences separate from those around me; I know where I end and with significant others. Sullivan sees development of the self- they begin.” The importance of self is also emphasized by the lan- concept as a dynamic process resulting from interpersonal interac- guage in the multitude of self-referential terms such as self-actual- tions that are directed toward meeting physiologic needs. This ization, self-affirmation, ego-involvement, and self-concept. process has its most obvious beginnings with the infant and be- Turner2 addresses society’s need for the individual to conceptu- comes more complex as the individual develops. This increasing alize the self-as-object.

Recognizing the self-as-object allows society complexity results from the layering of experiences that occurs in to place responsibility, which becomes a very valuable asset in the developing individual. The biologic processes become less and maintaining social control and social order. This returns us to the less important in directing the individual the further away from initial problem of what the self is and how we can understand oth- birth one is and as the importance of interpersonal interaction in- ers’ selves and ourselves.3 creases. The initial interpersonal interaction is between the infant In this section, the assumption is made that self-concept refers to and the primary caregivers. An infant expresses discomfort with a the individual’s subjective cognitions and evaluations of self; thus, cry and the “parenting one” responds. This response, whether it be it is a highly personal experience. This indicates that the self is a tender or harsh, begins to influence the infant’s beliefs about her- personal construct and not a fact or hard reality. It is further as- self or himself and the world in general. If the interaction does not sumed that the individual will act, as stated earlier, in congruence provide the infant with a feeling of security, anxiety results and in- with the self-concept. This conceptualization is consistent with the terferes with the progress toward other life goals. Sullivan makes a authors who will be discussed and with the assumptions utilized in distinction between the inner experience and the outer event and psychological research.3 It is also important to recognize that lan- describes three modes of understanding experience. guage assists in developing a concept. This becomes crucial when The first developmental experience is the prototaxic mode. In this thinking about the concept of self in English, because the English mode, the small child experiences self and the universe as an un- language comes from a tradition of Cartesian dualism that does not differentiated whole. At 3 to 4 months, the child moves into the express integrated concepts well. Often it will appear that the in- parataxic mode. The parataxic mode presents experiences as sepa- formation presented is separating the individual into various parts, rated but without recognition of a connectedness or logical se- when, in fact, an integrated whole is being addressed. For example, quence. Finally, the individual enters the syntaxic mode, in which James4 talks about an “I” and “Me.” If these terms were taken at face consensual validation is possible. This allows for events and expe- value, it would appear that the individual is being divided into mul- riences to be compared with others’ experiences and for establish- tiple parts, when, in fact, an integrated whole is being discussed and ment of mutually understandable communication instead of the the words describe patterns of the whole person. Unless otherwise autistic thinking that has characterized the previous stages.7,8 stated, it can be assumed that the concepts presented in this book As one experiences the environment through these three modes reflect on the individual as an integrated whole. of thought, the self-system or self-concept is developed. Sullivan Symbolic interaction theory provides a basis for understanding conceptualized three parts of the self. The part of the self that is as- the self. James4 and Mead5 developed the foundation for the self in sociated with security and approval becomes the “good me.” That this theoretical model. James outlines the internal working of the which is within one’s awareness but is disapproved of becomes the self with his concepts of “I” and “Me.” “I” is the thinker or the state “bad me.” The “bad me” could include those feelings, needs, or de- of consciousness. “Me” is what the “I” is conscious of and includes sires that stimulate anxiety. Those feelings and understandings that all of what people consider theirs. This “Me” contains three aspects: are out of awareness are experienced as “not me.” These “not me” the “material me,” the “social me,” and the “spiritual me.”4 The self- experiences are not nonexistent but are expressed in indirect ways construction outlined by Mead5 indicates that there is the “knower” that can interfere with the conduct of the individual’s life.6,7 part of the self and that which the “knower” knows. Mead concep- As the social sciences adopted a cybernetic worldview, this the- tualizes the thoughts themselves as the “knower” to resolve the oretical perspective has been applied to developing a concept of metaphysical problem of who the “I” is. In Mead’s writings, the con- self. Glasersfeld9 spoke of the self as a relational entity that is given sciousness of self is a stream of thought in which the “I” can re- life through the continuity of relating. This relating provides the in- member what came before and continues to know what was Copyright © 2002 F.A. Davis Company DEVELOPMENTAL CONSIDERATIONS 453 tuitive knowledge that our experience is truly ours. This reflects the Sidney Jourard18 provides direction for interventions related to perspective of knowing presented at the beginning of this section. an individual’s self-concept. The healthy self-concept allows indi- Watts10 describes what many authors feel is the self, as it can be viduals to play roles they have satisfactorily played while gaining understood through a cybernetic worldview. Self is the whole, for personal satisfaction from this role enactment. This person also it is part of the energy that is the universe and cannot be separated. continues to develop and maintain a high level of physical wellness. “At this level of existence ‘I’ am immeasurably old; my forms are in- This high level of wellness is achieved by gaining knowledge of one- finite and their comings and goings are simply the pulses or vibra- self through a process of self-disclosure. Jourard18 states that: tions of a single and eternal flow of energy.” (p. 12) Within this view, an individual is connected to every other living being in the If self-disclosure is one of the means by which healthy personality universe. This places the self in a unique position of responsibility. is both achieved and maintained, we can also note that such activ- The self then becomes responsible to everything because it is every- ities as loving, psychotherapy, counseling, teaching and nursing, all thing. This conceptual model resolves the issue of responsibility to are impossible—without the disclosure of the client. (p. 427) society without relying on an individual self to which responsibil- Elaboration of this thought reveals that for the nurse to effectively ity is assigned. meet the needs of the client, an understanding of the client’s self Although the conceptual model represented here by Watts10 fits must be achieved. This understanding must go beyond the inter- with current theoretical models being utilized in nursing and the pretation of overt behavior, which is an indirect method of under- social sciences, it is not congruent with the experience of most per- standing, and access the client’s understanding of self through the sons in Western society. This limits its usefulness when working process of self-disclosure. with clients in a clinical setting. It is presented here to provide prac- Dufault and Martocchio19 present a conceptual model for hope titioners with an alternative model for themselves. that also provides a useful perspective for nursing intervention. Stake11,12 developed an instrument to measure self-perception. Hope is defined as multidimensional and process-oriented. Hope- Knowledge of the factors contributing to the development of the lessness is not the absence of hope but is the product of an envi- self-perception can assist in the formulation of interventions fo- ronment that does not activate the process of hoping. Vaillot20 sup- cused on improving perceptions of self. Five facets that contribute ports the view presented by Dufault and Martocchio with the to a positive perception of self emerged from Stake’s12 research: task existential philosophical perspective that hope arises from relation- accomplishment, power, giftedness, likeability. and morality. The ships and the beliefs about these relationships. One believes that characteristics of task accomplishment include perceptions of hav- help can come from the outside of oneself when all internal re- ing good work habits and the ability to manage and complete tasks sources are exhausted. Hopelessness arises in an environment where efficiently. Perceptions of personal power include having strength, hope is not communicated. This model supports nursing interven- toughness, and the ability to influence others. Perceiving oneself as tions from a systems theory perspective, because it validates the having special natural aptitudes and talents provides the founda- ever-interacting system, the whole. In this perspective, the nurse, tion for the facet of giftedness. Seeing oneself as pleasant and en- as well as the client, contributes to the “hopelessness,” and thus the joyable to be with constitutes the characteristic of likeability. Moral- responsibility of nurturing hope is shared.19–23 ity is made up of factors that indicate the individual perceives himself or herself as having qualities valued as good and virtuous. Additional facets have been added to these basic foundations.13,14 Developmental Considerations These factors include perceptions about physical appearance, be- havioral conduct and job, and athletic and scholastic competence. INFANT The complex interaction of facets that evolves into the self- concept is an ongoing process occurring throughout the individ- In general, the sources of anxiety begin in a very narrow scope with ual’s life. This process can be impacted by life events, including ill- the infant and broaden out as he or she matures. Initially the rela- ness,15,16 that impinge on any of the identified factors, positively or tionship with the primary caregiver is the source of gratification for negatively. the infant, and disruptions in this relationship result in anxiety. As The Search Institute17 has developed, as a result of their research, one matures, needs are met from multiple sources, and therefore a list of 40 assets that support the development of young people. If the sources of anxiety expand. Specific developmental considera- these assets are compared with the facets necessary to build a pos- tions are as follows: itive self-concept, many parallels can be identified. The 40 assets The primary source of anxiety for the infant appears to be a sense are divided into internal and external. The four general external as- of “being left.” This response begins at about 3 months. Sullivan,6 set categories are support, empowerment, boundaries and expecta- as indicated earlier, would contend that the infant could experience tions, and constructive use of time. The internal asset categories in- anxiety even earlier with any disruption in having needs met by the clude commitment to learning, positive values, social competencies, primary caregiver. At age 8 to 10 months, separation anxiety peaks and positive identity. These eight general categories are further di- for the first time. At 5 to 6 months, the infant begins to demonstrate vided into assets that are more specific. The assets of positive iden- stranger anxiety. Primary symptoms include disruptions in physi- tity, empowerment, positive values, and social competencies are ologic functioning and could include colic, sleep disorders, failure similar to the concepts of likeability, power, and morality discussed to thrive syndrome, and constipation with early toilet training. in the self-concept literature. Stranger anxiety and separation anxiety may be demonstrated with The Search Institute17 has found that the more assets the young screaming, attempting to withdraw, and refusing to cooperate. Both person has, the fewer their high-risk behaviors. Specific behaviors stranger anxiety and separation anxiety are normal developmental for nurturing the development of each asset have been identified. responses and should not be considered pathologic as long as they These asset development guidelines provide concrete direction fa- are not severe or prolonged and if the parental response is appro- cilitating the development of self-concept-enhancing experiences priately supportive of the infant’s need. in the young person’s life. Specific asset-building behaviors are dis- Fear is a normal protective response to external threats and will cussed in the next section under each developmental age to provide be present at all ages. It becomes dysfunctional at the point that it practitioners with direction in supporting the development of pos- is attached to situations that do not present a threat or when it pre- itive perceptions of self. vents the individual from responding appropriately to a situation. Copyright © 2002 F.A. Davis Company 454 SELF-PERCEPTION AND SELF-CONCEPT PATTERN Thus, it is important that children have certain fears to protect them continue throughout life with each new interaction in

each new ex- from harm. The hot stove, for example, should produce a fear re- perience. Thus, the child learns from primary caregivers that his or sponse to the degree that it prevents the child from touching the her expressions of need may or may not have an effect on those stove and being injured. Fear is a learned response to situations, around him or her and also learns what must be done to have an and children learn this response from their caregivers. Thus, it be- effect. If the caregiver responds to the earliest cries of the infant, a comes the caregivers’ responsibility to model and teach appropri- sense of personal influence has begun. The two areas that consis- ate fear. If a mother cannot tolerate being left alone in the house at tently influence one’s perceptions of influence are discipline and night with her children, her children will learn to fear being in this communication styles. situation. When this home is located in a low-crime area with sup- Implementation of discipline in a manner that provides the child portive neighbors and appropriate locks, fear becomes an inappro- with a sense of control over the environment while teaching appro- priate response, and the children may be affected by it for a lifetime. priate behavior can produce a perception of mutual system influence. Various developmental stages have characteristic fears associated Harsh, overcontrolling methods can produce the perception that the with them. In the mind of the child, these characteristic fears pre- child does not have any influence in the system if acting in a direct sent threats, so the fears can be seen both as a source of fear and as manner. This produces an indirect influencing style. An example of a source of anxiety. The characteristic fears result from strong or indirect influence is the child who always becomes ill just before his noxious environmental stimuli such as loud noises, bright lights, or parents leave for an evening on the town. The parents, out of concern sharp objects against the skin. The response to fears produces phys- for the child, decide to remain at home and thus never have time to- iologic symptoms. The most immediate and obvious response is gether as a couple. Authoritarian styles of interaction can also pro- crying and pulling away from the stressful object or situations. duce perceptions of powerlessness in adults in unfamiliar environ- Erickson23,24 indicated that he thought hope evolved out of the ments. If the hospital staff acts in an authoritarian manner, the client successful resolution of this first developmental stage, basic trust may develop perceptions of powerlessness. versus mistrust. Hope was perceived by Erickson to be a basic hu- Double-bind communication can place the individual in a posi- man virtue. The type of environment that has been identified as tion of feeling that “no matter what action I take, it appears to be promoting the development of this basic trust is warm and loving, wrong,” and also can produce a perception of powerlessness. They where there is respect and acceptance for personal interests, ideas, are “damned if they do and damned if they don’t.” If the individual needs, and talents.21 Several environmental conditions have been cannot influence this system in a direct manner, again, indirect be- associated with early childhood and are seen as increasing the per- havior patterns are chosen. Bateson26 proposes that this is the process ceptions consistent with hopelessness. These conditions are eco- behind the symptom cluster identified as schizophrenia. This sug- nomic deprivation, poor physical health, being raised in a broken gests that if the child is continually placed in the position of being home or a home where parents have a high degree of conflict, hav- wrong no matter what he or she has done, the child could develop ing a negative perception of parents, or having parents who are not the perception that his or her position is one of powerlessness and mentally healthy. From an existential perspective, Lynch25 identi- carry this attitude with him or her throughout life. fied five areas of human existence that can produce hopelessness. Infants have a need for consistent response to having physiologic If these areas are not acknowledged in the developmental process, needs met, and the most important relationship becomes that with the individual is at greater risk of frustration and hopelessness be- the “parenting one.” If this relationship is disrupted and needs are cause hope is being intermingled with a known area of hopeless- not met, symptoms related to infant depression or failure to thrive ness. The five areas that Lynch identified are death, personal im- could communicate a perception related to powerlessness. perfections, imperfect emotional control, inability to trust all It is important to remember that self-concept, including body people, and personal areas of incompetence. This supports Erick- image, is developed throughout life. For the infant, the primary son’s contention that hope evolves out of the first developmental source of developing self-concept and body image is physical in- stage, because these basic areas of hopelessness are issues primar- teraction with the environment. This includes both the environ- ily related to the resolution of trust and mistrust. It should be re- ment’s response to physical needs and the body’s response to envi- membered that previously resolved or unresolved developmental ronmental stimuli. issues must be renegotiated throughout life. Some behaviors that build assets in the infant and toddler in- Each developmental stage has a set of specific etiologies and clude playing with the child at eye level; exposing the child to pos- symptom clusters related to hopelessness. Because the relationship itive values by modeling sharing and being nice to others; reading between self-concept strength and degree of hopefulness is seen as to them; providing a safe, caring, stimulating environment; and a positive link, many of the etiologies and symptoms of hopeless- communicating to the child that he or she is important by spend- ness at the various developmental stages are similar to those of self- ing time with him or her.27 esteem disturbances.22 As conceptualized by Erickson,24 infancy is the primary age for de- TODDLER AND PRESCHOOLER veloping a hopeful attitude about life. If the infant does not experi- ence a situation in which trust in another can be developed, then the The basic sources of anxiety remain the same as for the infant. Sepa- base of hopelessness has begun. Thus, if the infant experiences fre- ration anxiety appears to peak again at 18 to 24 months, and stranger quent change in caregivers or has a caregiver who does not meet the anxiety peaks again at 12 to18 months. Loss of significant others is basic needs in a consistent and warm manner, the infant will become the primary source of anxiety at this age. In addition to the physio- hopeless. Research25 has indicated that children who have been logic responses already mentioned, the child may demonstrate anxi- raised in an environment of despair are at greater risk for experienc- ety by motor restlessness and regressive behavior. The preschooler ing hopelessness. Symptoms of hopelessness in infants resemble in- can begin to tolerate longer periods away from the parenting one and fant depression or failure to thrive. Because symptoms in infants are enjoys having the opportunity to test his or her new abilities. Lack of a general response, the diagnosis of Hopelessness must be considered opportunity to practice independent skills can increase the discom- equally with other diagnoses that produce similar symptom clusters fort of this age group. Increased anxiety can be seen in regressive be- such as Powerlessness and Ineffective Coping. havior, motor restlessness, and physiologic response. One’s perceptions of place in the larger system and of influence Sources of anxiety can include concerns about the body and body in this system begin at birth. These perceptions are developed mutilation, concerns about death, and concerns about loss of self- through interactions with those in the immediate environment and control. These concerns can be expressed in the ways previously dis- Copyright © 2002 F.A. Davis Company DEVELOPMENTAL CONSIDERATIONS 455 cussed as well as with language and dramatic play as language abili- the child to learn how to deal nonviolently with challenges and ties increase. This could include playing out anxiety-producing situ- frustrations.27 ations with dolls or other toys. This play can assume a very aggres- sive nature. The anxieties of the day can also be expressed in dreams SCHOOL-AGE CHILD and result in nightmares or other sleep disturbance. In this age group, fears evolve from real environmental stimuli Typically, fears are aroused by strange noises; ghosts and imagined and from imagined situations. Typical fears of specific age groups phantoms; natural elements such as fire, drowning, or thunder (6 are fear of sudden loud noise (2 years), fear of animals (3 to 4 years), years); not being liked or being late for school (7 years); and per- fear of the dark (4 to 5 years), and fear of the dark and of being lost sonal failure or inadequacy (8 to 10 years). Symptoms of these fears (6 years). Symptoms of fears include regressive behavior, physical include physical symptoms of autonomic stimulation, increased and verbal cruelty, restlessness, irritability, sleep disturbance, dra- verbalization, withdrawal, aggression, sleep disturbance, or need- matic play around issues related to the fear, and increased physical ing to repeat a specific task many times. closeness to the caregiver. Concerns about imagined future events produce the anxieties of Alterations to the body or its functioning place a child at this age the school-age child. The specific concern varies with the develop- at the greatest risk of experiencing hopelessness. If the child expe- mental age. Young school-age children demonstrate concerns re- riences a difference between self and other or is ashamed about lated to the unknowns in their environment, such as dark rooms, body functioning, in a nonsupportive environment, hopelessness and natural elements, such as fire or tornadoes. Older school-age can develop. A specific issue encountered at this stage is toilet train- children have anxieties related to personal inadequacies. Preado- ing. If the child is placed in a position of being required to gain con- lescence brings increasing concerns about the valuation of peers trol over bowel and bladder functions before the ability to physi- and concerns about the acceptance of peers. Expression of anxiety cally master these functions has developed, the child can experience can occur in the ways discussed in the previous level, with the ad- hopelessness in that he or she truly cannot make his or her body dition of increased verbalization and compulsive behavior such as function in the required manner. Peer interactions are also impor- repeating a specific task many times. tant at this time because they foster the beginnings of trust in some- Peers’ perceptions of the individual assume a role in the develop- one other than the “mothering” one, thus understanding that hope ment of attitudes related to personal hopefulness and influence can be gained elsewhere. within the larger social system. This is built on the perceptions Struggle between self-control and control by others becomes the achieved during earlier stages of development. The sense of a strong primary psychosocial issue. If appropriate expansion of self-control peer group can produce perceptions of help coming from the outside is encouraged, the child will develop perceptions related to mutual as long as the child thinks and believes along with the group, but can systemic influence. This appropriate support is crucial if the child produce perceptions of exaggerated personal influence. Problems at is to develop a perception of a personal role in the social system. If this developmental stage can be demonstrated by withdrawal, day- this struggle for self-control is thwarted, the child can express dreaming, increased verbalizations of helplessness and hopelessness, themes of overcontrol in play or become overly dependent on the angry outbursts, aggressive behavior, irritability, and frustration. primary caregiver and withdraw completely from new situations Self-perception expands to include ethnic awareness, ambition, and learning. ideal self, ordinal position, and conscience. There is increasing For the preschooler, there is a continuation and refinement of a awareness of self as different from peers. Peers become increasingly sense of personal influence. Varying approaches are explored, and important in developing a concept of self, and there is increased a greater sense of what can be achieved

is developed. One of the comparison of real to ideal self. primary sources of anxiety during this stage is loss of self-control. Behaviors that can build assets in this age group include expos- Symptoms of difficulties in this area include playing out situations ing the child to caring environments and role models outside the with personal influence as a theme and aggressive play. family; providing the child with useful, age-appropriate roles; pro- Sources of the self-concept perceptions are the responses of signif- viding clear and appropriate boundaries and expectations; pro- icant others to exploration of new physical abilities and to the tod- moting involvement in creative activities; promoting involvement dler’s place in these relationships. The primary concept of self is re- with positive learning experiences; exposing the child to values that lated to physical qualities, motor skills, sex type, and age. A concept include caring, honesty, and appropriate responsibility; and pro- of physical differences and of physical integrity is developed. Thus, viding the child opportunities to make age-appropriate decisions.27 situations that threaten the toddler’s perception of physical wholeness can pose a threat. This would include physical injury. Toilet training ADOLESCENT poses a potential threat to the successful development of a positive self-concept or body image. Failure at training could produce feelings The developmental theme that elicits anxiety in this age group re- of personal incompetence or of the body being shameful. volves around the development of a personal identity. This is facili- In the preschooler, physical qualities, motor skills, sex type, and tated by peer relationships, which can also be the source of anxiety. age continue to be the primary components of self-concept. Peers Expression of this anxiety can occur in any of the ways previously begin to assume greater importance in self-perceptions. Physical in- discussed and with aggressive behavior. This aggression can take tegrity continues to be important, and physical difference can have both verbal and physical forms. A certain amount of “normal” anx- a profound effect on the preschool child. iety is experienced as the adolescent moves from the family into the Actions that build assets in the preschooler include playing and adult world. Anxiety would be considered abnormal only if it vio- talking to them on eye level; asking them to talk with you about lates societal norms and was severe or prolonged. Parental educa- things they have seen; working with them to use words to express tion and support during this development crisis can be crucial. themselves; reading to them; taking them to community events, Peer relationships, independence, authority figures, and changing museums, and cultural events; modeling for them how to behave; roles and relations can contribute to fears for adolescents. Expression providing a supportive family life; providing clear rules and conse- of these fears produces cognitive and affective symptoms. These symp- quences; involving child in creative activities; modeling expectation toms could include difficulties with attention and concentration, poor that others will do things well; valuing expressions of caring; as- judgment, alterations in mood, and alterations in thought content. sisting the child to learn the difference between truth and lying; as- The cognitive development of adolescents would suggest that their sisting the child to make simple choices and decisions; and helping perceptions of situations are guided by hypothetical-deductive Copyright © 2002 F.A. Davis Company 456 SELF-PERCEPTION AND SELF-CONCEPT PATTERN thought, and as a result they could develop reasonable models of self-perceptions. Perceived failures in meeting role expectations can hopefulness. This cognitive process occurs in conjunction with a lack produce negative self-evaluation. The number of roles a person has of a variety of life experience and self-discipline and with a height- assumed and the personal, cultural, and support system value ened state of emotionality. This can result in a situation in which the placed on the identified roles determine the threat that negative immediate goal can overshadow future consequences or possibilities. evaluation of performance can be to self-perception. Cultural value An adolescent who appears very hopeful when cognitive functioning and personal identity formation determine the degree to which is not overwhelmed by emotions can be filled with despair when in- body image remains important in providing a positive evaluation of volved in a very emotional situation. Consideration of this ability is self. The adult endows unique significance to various body parts. important when caring for this age group. It is important to distin- This valuing process is personal and is often not in personal aware- guish problem behavior from normal behavior and mood swings. ness until there is a threat to the part. Kinds of behavior that could indicate problems in this area include withdrawal and increased or amplified testing of limits. Situations OLDER ADULT that affect the peer group hope can place the adolescent at great risk. Again, issues of dependence-independence assume a primary As the older adult continues to age, he or she faces numerous chal- role. The focus of this struggle is dependence on peers and inde- lenges to self-perception and self-concept. Roles may change sec- pendence from family. The challenge for the adolescent becomes ondary to retirement or loss of significant others, such as a spouse achieving what Erickson and Kinney28 refer to as “affiliated indi- or child. Financial resources may become limited or fixed as a re- viduation.” This requires that they learn how to be dependent on sult of illness, retirement, or loss of spouse.31 Chronic illness that support systems while maintaining their independence from these necessitates a decrease in social interactions or increased depen- same support systems and feeling accepted in both positions. dence on others and the resulting loss of control has a negative im- Body image becomes a crucial area of self-evaluation because of pact on self-esteem for some elderly.32 changing physical appearance and heightened sexual awareness. Negative societal feedback, such as ageism, sends a message to This evaluation is based on the cultural ideal as well as that of the older adults that they are somehow no longer valuable to the soci- peer group. Perceived personal failures are often attributed to phys- ety. In the face of these decremental losses, it is necessary to con- ical differences. sider what health care professionals can do to assist the older adult The importance of a positive self-concept for adolescents is high- in maintaining a positive regard for self. lighted by research that indicates a complex relationship between self-concept, psychological adjustment, and behavior. Most signif- icant is the consistent finding that low self-concept leads to a greater APPLICABLE NURSING DIAGNOSES incidence of delinquency. This relationship appears to be strongest with factors that are associated with the moral-ethical self-concept.29 Theoretical explanations for this phenomenon consider the behav- Anxiety ior as a method for balancing the negative view of self or as part DEFINITION of a cycle of punishment resulting in shame, guilt, and expulsion rather than reconstruction.29 This link between self-concept and A vague uneasy feeling of discomfort or dread accompanied by an the complex of behaviors termed delinquency increases the impor- autonomic response; the source is often nonspecific or unknown to tance of providing adolescents with asset-building experiences. the individual; a feeling of apprehension caused by anticipation of Assets important for adolescents include family love and support, danger. It is an alerting signal that warns of impending danger and parent involvement in schooling, positive family communication, enables the individual to take measures to deal with threat.33 caring school environment, useful community roles, safe commu- nity environment, clear rules and consequences, positive adult role NANDA TAXONOMY: DOMAIN 9—COPING/STRESS models, participation in creative activities, involvement in commu- TOLERANCE; CLASS 2—COPING RESPONSES nity activities, spending most evenings at home, positive learning experiences, development of planning and decision-making skills, NIC: DOMAIN 3—BEHAVIORAL; CLASS T— development of interpersonal skills, development of a sense of per- PSYCHOLOGICAL COMFORT PROMOTION sonal power, a sense of purpose, and a positive view of the future.27 NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; Specific asset-building behaviors can include asking teens for their CLASS O—SELF CONTROL opinion or advice, helping teens to contribute to their communi- ties, encouraging them to assume leadership roles in addressing is- DEFINING CHARACTERISTICS33 sues that are of concern to them, talking with teens about their goals, providing challenging learning opportunities, providing in- 1. Behavioral creasing opportunities for teens to make their own decisions, cele- a. Diminished productivity brating their accomplishments, providing listening time, learning b. Scanning and vigilance their names, and asking them about their interests.30 c. Poor eye control d. Restlessness ADULT e. Glancing about f. Extraneous movement (e.g., foot shuffling and hand and arm Changes in role and relationship patterns generate the fears specific movements) to these age groups. These could include parenthood, marriage, di- g. Expressed concerns due to change in life events vorce, retirement, or death of a spouse. Fear expression in these age h. Insomnia groups produces cognitive and affective symptoms similar to those i. Fidgeting described for the adolescent. 2. Affective A specific developmental crisis can produce a perception of a. Regretful hopelessness and powerlessness. The situations that place the adult b. Irritability at risk are marriage, pregnancy, parenthood, and divorce. c. Anguish Concerns about role performance assume an important role in d. Scared Copyright © 2002 F.A. Davis Company ANXIETY 457 e. Jittery a. Blocking of thought f. Overexcited b. Confusion g. Painful and persistent increased helplessness c. Preoccupation h. Rattled d. Forgetfulness i. Uncertainty e. Rumination j. Increased wariness f. Impaired attention k. Focus on self g. Decreased perceptual field l. Feelings of inadequacy h. Fear of unspecified consequences m. Fearful i. Tendency to blame others n. Distressed j. Difficulty concentrating o. Worried, apprehensive k. Diminished ability to problem solve and learn p. Anxious l. Awareness of physiologic symptoms 3. Physiologic m. Focus on self a. Voice quivering n. Expressed concerns due to changes in life events b. Increased respiration (sympathetic) c. Urinary urgency (parasympathetic) RELATED FACTORS33 d. Increased pulse (sympathetic) e. Pupil dilation (sympathetic) 1. Exposure to toxins f. Increased reflexes (sympathetic) 2. Threat to or change in role status g. Abdominal pain (parasympathetic) 3. Familial association or heredity h. Sleep disturbance (parasympathetic) 4. Unmet needs i. Tingling in extremities (parasympathetic) 5. Interpersonal transmission or contagion j. Increased tension 6. Situational or maturational crises k. Cardiovascular excitation (sympathetic) 7. Threat of death l. Increased perspiration 8. Threat to or change in health status m. Facial tension 9. Threat to or change in interaction patterns n. Anorexia (sympathetic) 10. Threat to or change in role function o. Heart pounding (sympathetic) 11. Threat to self-concept p. Diarrhea (parasympathetic) 12. Unconscious conflict about essential values or goals in life q. Urinary hesitancy (parasympathetic) 13. Threat to or change in environment r. Fatigue (parasympathetic) 14. Stress s. Dry mouth (sympathetic) 15. Threat to or change in economic status t. Weakness (sympathetic) 16. Substance abuse u. Decreased pulse (parasympathetic) v. Facial flushing (sympathetic) RELATED CLINICAL CONCERNS w. Superficial vasoconstriction (sympathetic) x. Twitching (sympathetic) 1. Any hospital admission y. Decreased blood pressure (parasympathetic) 2. Failure to thrive z. Nausea (parasympathetic) 3. Cancer or other terminal illnesses aa. Urinary urgency (parasympathetic) 4. Crohn’s disease bb. Faintness (parasympathetic) 5. Impending surgery cc. Respiratory difficulties (sympathetic) 6. Hyperthyroidism dd. Increased blood pressure (sympathetic) 7. Substance abuse 4. Cognitive 8. Mental health disorders HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Fear Fear is the response to an identified threat, Dysfunctional Grieving This would be considered whereas Anxiety is the response to threat that an appropriate diagnosis if the loss was real, cannot be easily identified. Fear is probably the whereas the diagnosis of Anxiety would be used diagnosis that is most often confused with Anxiety. when the loss is a threat that is not necessarily real, An example of a situation in which Fear would be such as a perceived loss of esteem from others. an appropriate diagnosis is: After being released Ineffective Individual Coping This would be the from jail, the prisoner threatened to kill the judge appropriate diagnosis if the individual is not who placed him or her in jail. The judge, if making the necessary adaptations to deal with experiencing psychological stress due to this threat daily life. This may or may not occur with Anxiety and knowing the prisoner was out of jail, would as a companion diagnosis. receive the diagnosis of Fear. Spiritual Distress This diagnosis occurs if the in- Disturbed Personal Identity This

diagnosis is the dividual experiences a threat to his or her value or most appropriate diagnosis if the individual’s belief systems. This threat may or may not produce symptoms are related to a general disturbance in Anxiety. If the primary expressed concerns are the perception of self. Anxiety would be used related to the individual’s value or belief system, then when the discomfort was related to other areas. the appropriate diagnosis would be Spiritual Distress. Copyright © 2002 F.A. Davis Company 458 SELF-PERCEPTION AND SELF-CONCEPT PATTERN EXPECTED OUTCOME TARGET DATES Will demonstrate, verbally or behaviorally, at least a [number] per- A target date of 3 days would be realistic to start evaluating cent decrease in anxiety by [date]. progress. The sooner anxiety is reduced, the sooner other problems can be dealt with. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Obtain a thorough history upon admission. Allows identification of all possible contributing factors to anxiety. • Monitor anxiety behavior and relationship to activity, events, When anxiety increases, the ability to follow instruction or people, etc. every 2 h on [odd/even] hour. cooperate in plan of care decreases. Identification of the behavior and causative factors enhances intervention plans. • Reassure the patient that anxiety is normal. Assist the patient to Helps identify connection between the precipitating cause and the learn to recognize and identify the signs and symptoms of anxiety experience; reassures the patient that he or she is not anxiety, e.g., hyperventilation, rapid heartbeat, sweaty palms, “going crazy.” inability to concentrate, and restlessness. • Provide calm, nonthreatening environment: Conveys calm and helps the patient focus on conversation or � Explain all procedures and rationale for procedure in clear, activity. concise, simple terms. � Decrease sensory input and distraction, e.g., lighting or noise. � Encourage significant other(s) to stay with the patient but not force conversation, etc. • Monitor vital signs at least every 4 h while awake at [times]. Assists in determining the effects of anxiety. Helps determine pathologic effects of anxiety. • Attend to primary physical needs promptly. Conserves the patient’s energy, and allows the patient to focus on coping with and reducing anxiety. Failure to attend to physical needs would serve to increase anxiety. • Administer antianxiety medications as ordered. Monitor and Effectiveness of medication is determined so modification can be document effects of medication within 30 min of administration. provided if needed. Medication helps reduce anxiety to a manageable level. • Assist the patient to develop coping skills: � Review past coping behaviors and success or lack of success. Determines what has helped, and determines whether these measures are still useful. � Help identify and practice new coping strategies such as Methods that can be used successfully to decrease anxiety. Allows progressive relaxation, guided imagery, rhythmic breathing, the patient to practice and become comfortable with skills in a balancing exercise and rest, appropriate food and fluid supporting environment. intake (e.g., reduced caffeine intake), and using distraction. � Challenge unrealistic assumptions or goals. Assists the patient to avoid placing extra stress on himself or herself. � Place limits on maladaptive behavior, e.g., use of alcohol or Promotes use of appropriate techniques for reducing anxiety while fighting. avoiding harm to self and others. • Provide at least 20–30 min every 4 h while awake for focus on Provides opportunity for practice of technique and expression of anxiety reduction. List times here. anxiety-provoking experiences. � Encourage the client to express feelings verbally and through activity. � Answer questions truthfully. � Offer realistic reassurance and positive feedback. • Collaborate with psychiatric nurse clinician regarding care (see Collaboration helps provide holistic care. Specialist may help Psychiatric Health nursing actions). discover underlying events for anxiety and assist in designing an alternate plan of care. • Refer the patient to and collaborate with appropriate community Support groups can provide ongoing assistance after discharge. resources. Copyright © 2002 F.A. Davis Company ANXIETY 459 Child Health ACTIONS/INTERVENTIONS RATIONALES • Review, with the child and parents, coping measures used for The identification of coping strategies provides essential information daily changes and crises. to deal with anxiety. Once they are identified, the nurse can begin to evaluate those strategies that are effective. • Identify ways the parents can assist the child to cope with A major starting point is to describe the feelings and attempt to anxiety, e.g., set realistic explanations or demands and avoid create a sense of control, which is more likely in patients of a bribing or not telling the truth. certain developmental capacity, e.g., those capable of abstract thinking. In younger infants, rocking can provide soothing repetitious notion when all other measures seem not to have calmed the infant. • Adapt routine to best help the child regain control, e.g., use of Allowing the child to plan for meals or snacks with choices when speech according to situation and simple but firm speech pattern. possible or structuring the room to offer a sense of self is conducive to empowerment. • Modify procedures, as possible, to help reduce anxiety, e.g., do Unnecessary pain or invasive procedures make overwhelming not use intramuscular injection when an oral route is possible. demands on the already stressed hospitalized child. • Use the child’s developmental needs as a basis for care, especially The developmental level of the patient serves to guide the nurse in for ventilation of anxiety, e.g., use of toys. care. A holistic approach is more likely to meet holistic health needs. • Allow the child and parents adequate time and opportunities to Appropriate time in preparation offers structure and allows focused handle required care issues and thus reduce anxiety, e.g., when attention, which empowers and helps reduce anxiety as efforts are painful treatments must be done, prepare all involved according directed to what is known. to an agreed-upon plan. • Encourage the family to assist with care as appropriate, including Family involvement provides a sense of empowerment and growth feeding, comfort measures, and stories. in coping, thereby reducing anxiety and promoting a sense of security in the child. • Offer sufficient opportunities for rest according to age and sleep Proper attention to rest for each individual child will foster coping requirements. capacities by conserving energy for coping. • Identify knowledge needs, and address these by having the family Allows teaching opportunity that increases the patient’s and family’s explain what they understand about treatments, procedures, knowledge about situation, which assists in reducing anxiety. needs, etc. • Point out and reinforce successes in conquering anxiety. Positive reinforcement assists in learning. • Assist the patient and family to apply coping in future potential Allows practice in a non-anxiety-producing environment. Increases anxiety-producing situations by presenting possible scenarios skill in using coping strategy. Empowers the patient and family. that would call for utilization of the new skills, e.g., someone pushes ahead of you in line, or a salesperson is rude to you. Women’s Health ACTIONS/INTERVENTIONS RATIONALES ACUTE ANXIETY ATTACK • Provide a realistic, tranquil atmosphere, e.g., close door, sit with Provides an atmosphere that assists in calming the patient, and the patient, remind the patient you are there to help: promotes the initiation of coping by the patient. � Do not leave the patient alone. � Speak softly using short, simple commands. � Be firm but kind. � Be prepared to make decisions for the patient. � Decrease external stimuli, and provide a “safe” atmosphere. • Administer antianxiety medication as ordered, and monitor effectiveness of medication within 30 min to 1 h of administration. MILD OR MODERATE ANXIETY • Guide the patient through problem solving related to the anxiety: � Assist the patient to verbalize and describe what she thinks is going to happen. � Describe to the patient what will happen (to the best of your ability), and compare with her expectations. � Assist the patient in describing ways she can more clearly express her needs. (continued) Copyright © 2002 F.A. Davis Company 460 SELF-PERCEPTION AND SELF-CONCEPT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Assist the patient in changing unrealistic expectations by By providing factual information, clarification of misconceptions, explaining procedures, e.g., labor process or sensations during a and emotional support, the patient’s coping can be enhanced.34,35 pelvic examination. • Encourage the patient to participate in assertiveness training. PREGNANCY AND CHILDBIRTH • Provide the patient and significant others with factual information about the physical and emotional changes experienced during pregnancy. • Review daily schedule with the patient and significant other. Helps reduce anxiety about financial concerns due to having to quit Assist them to identify lifestyle adjustments that may be needed work. Good planning and working with the patient and partner to for coping with pregnancy. establish a realistic work schedule to present to employer can assist � Practicing relaxation techniques when stress begins to build the patient to reduce edema and fatigue and thus remain on job � Establishing a routine for relaxing after work longer. � Developing a plan to provide frequent rest breaks throughout the day (particularly in the last trimester) • Refer to a support group, e.g., childbirth education classes or maternal-child health (MCH) nurses in the community. • Provide the patient and significant other with factual information Factual information provides the family with the essential about sexual changes during pregnancy: knowledge needed in planning for the pregnancy, accomplishing � Answer questions promptly and factually. the task of pregnancy, and adapting to a new infant. � Introduce them to people who have had similar experiences. � Discuss fears about sexual changes. � Discuss aspects of sexuality and intercourse during pregnancy: (1) Positions for intercourse during different stages of pregnancy (2) Frequency of intercourse (3) Effect of intercourse on pregnancy or fetus � Describe healing process post partum and timing of resumption of intercourse. • Provide patient support during birthing process, e.g., Montrice, Assists in reducing anxiety. Increases coping. support person, or coach. • Provide support for significant others(s) during this process: Support of significant others leads to more support for the patient. � Encourage verbalization of fears. � Answer questions factually. � Demonstrate equipment. � Explain procedures. POST PARTUM (EARLY DISCHARGE) • Provide support for new parents during the first few days of the Provides support and information from an “expert,” helping to postpartum period. Provide new parents with telephone number reduce anxiety of being new parents. to call with questions and concerns. Call new parents 36–48 h after discharge: � Formulate questions to receive simple one- or two-word answers. � Allow new parents time to ask questions and voice concerns. • Give the new mother appointment before discharge from Provides a continuity of services and support and education for the hospital to return to follow-up clinic, or schedule home visit by new family during time between discharge and follow-up visit to nurse for herself and her infant. primary health care provider. � Assess the mother and baby for appropriate physical recovery from the birth: (1) Maternal: Episiotomy, cesarean section incision, breasts (lactating and nonlactating), involution of uterus, lochia flow, fatigue level, etc. (2) Infant: Number of wet diapers in 24-h period, number of stools in 24-h period, color and consistency of stools, feeding patterns, bilirubin check � Discuss with the mother and partner or family psychosocial aspects of being new parents. � Assist in developing and planning coping skills for new roles. • Provide appropriate education. (May have to repeat all education done on postpartum unit in acute care setting.) (continued) Copyright © 2002 F.A. Davis Company ANXIETY 461 (continued) ACTIONS/INTERVENTIONS RATIONALES • Monitor the infant and parents for attachment behaviors. • Refer the parents to appropriate resources for support and further follow-up: � Lactation consultants � Primary care provider (obstetrician, pediatrician, certified nurse midwife, family practitioner, or nurse practitioner) � Public health nurse � Visiting nursing services • Provide documentation of follow-up to the patient’s primary care provider. MIDLIFE WOMEN • Provide information about hormone influences on sleep disorders, cardiac and mental functioning, and perceptions of anxiety.36 • Refer the client to appropriate resources for support and further follow-up: � Physicians well versed in women’s health � Women’s health centers � Alternative health centers � Menopause and midlife centers: Her Place Dallas—817-355-8008 Tucson—520-797-9131 Cleveland Menopause Clinic 216-442-4747 Women’s Medical Diagnostic Center & Climacteric Clinic 1-900-372-5600 NOTE: These are only representative of women’s clinics that are emerging all over the country. Investigate local health care

agencies for health services specifically for women. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Provide a quiet, nonstimulating environment that the client Inappropriate levels of sensory stimuli can contribute to the perceives as safe. For the client experiencing severe or panic client’s sense of disorganization and confusion. anxiety, this may be a seclusion setting. This may include providing objects that symbolize safety to the client. (Note here the special environmental adaptations necessary for this client.) • Provide frequent, brief interactions that assist the client with Appropriate levels of sensory stimuli promote the client’s sense of orientation. Verbal information should be provided in simple, control. brief sentences. • If the client is experiencing severe or panic anxiety, provide Communicates acceptance of the client, which facilitates the support in a nondemanding atmosphere. development of trust and self-esteem. • If the client is experiencing severe or panic anxiety, provide a High levels of anxiety decrease the client’s ability to process here-and-now focus. information. • Provide the client with a simple repetitive activity until anxiety High levels of anxiety decrease the client’s ability to problem solve. decreases to the level at which learning can begin. Promotes the client’s sense of control. • If the client is hyperventilating, guide him or her in taking slow, Reestablishes a normal breathing pattern, and promotes the client’s deep breaths. If necessary, breathe along with the client, and sense of control. provide ongoing, positive reinforcement. • Approach the client in a calm, reassuring manner, assessing the Anxiety is contagious and can be communicated from the social caregiver’s level of anxiety and keeping this to a minimum. network to the client. • Provide a constant, one-to-one interaction for the client Presence of a calm, trusted individual can promote a sense of experiencing severe or panic anxiety. This should preclude control and calm in the client. use of physical restraints, which tend to increase the client’s anxiety. (continued) Copyright © 2002 F.A. Davis Company 462 SELF-PERCEPTION AND SELF-CONCEPT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide the client with alternative outlets for physical tension. Promotes the client’s sense of control, and begins the development This should be stated specifically and could include walking, of alternative, more adaptive coping behaviors. running, talking with a staff member, using a punching bag, listening to music, doing a deep muscle relaxation sequence [number] times per day at [state specific times]. The outlet should be selected with the client’s input. • Discuss relaxation techniques with the client (visual imagery, These techniques promote physiologic relaxation and shift the deep muscle relaxation, massage, meditation, or music). Have client to a state of parasympathetic nervous system recuperation.37 the client select one activity he or she would like to incorporate Repeated practice of a behavior internalizes and personalizes the into his or her coping behaviors. Schedule 30 min per day to behavior. practice this activity with the client. (Note here activity and practice time.) • Sit with the client [number] times per day at [times] for Identification of precipitating factors is the first step in developing [number] minutes to discuss feelings and complaints. As the alternative coping behaviors and promoting the client’s sense of client expresses these openly, the nurse can then explore the control. onset of the anxiety with the purpose of identifying the sources of the anxiety. • After the source of the anxiety has been identified, the time set Promotes the client’s sense of control. aside can be utilized to assist the client in developing alternative coping styles. • Provide [number] times per day to discuss with the client Provides positive reinforcement through the nurse’s attention for interests in the external environment (especially with those improved coping behaviors. clients who tend to focus strongly on nonspecific physical complaints). • Talk with the client about the advantages and disadvantages of Identification of contributing factors is the first step in developing the current condition. (Help the client to identify secondary alternative coping behaviors. gain from the symptoms.) This would be done in the individual discussion sessions or in group therapy when a trusting relationship has been developed. • Provide the client with feedback on how his or her behavior Assists the client with consensual validation. affects others (this could be done in an individual or group situation). (The target behavior and goals should be listed here with appropriate reinforcers.) • Provide positive feedback as appropriate on changed behavior. Positive feedback encourages behavior and enhances self-esteem. (The target behavior and goals should be listed here.) • Provide appropriate behavioral limits to control the expression Client safety is of primary importance. of aggression or anger. These limits should be specific to the client and listed here on the care plan, e.g., the client will be asked to go to seclusion room for 15 min when he raises his voice to another client. The client should be informed of these limits, and the limits should not exceed the client’s capability. The client should be informed of the limits of the limits, e.g., the time limit of the limit for raising his voice is 15 min. No limit should be set for an indefinite time. All staff should be aware of the limits so they can be enforced consistently with consistent consequences. • Provide the client with an opportunity to discuss the situation Assists the client with an opportunity to review behavioral limits, after the consequences have been met. and provides the staff with an opportunity to communicate to the client that limit setting is not a punishment. • Interact with the client in social activities [number] times per Promotes the development of a trusting relationship. day for [number] minutes. This will provide the client with staff time other than that which is used to set limits. The activities selected should be done with the client’s input and stated here in the care plan. • Provide medication as ordered, and observe for appropriate effects (these should be listed here). • Inform the client of community resources that provide assistance Promotes the client’s sense of control and self-esteem. with crisis situations, and provide a telephone number before the client leaves the unit. • Develop a list of alternative coping strategies that the client can use Repeated practice of a behavior internalizes and personalizes the at home, and have the client practice them before leaving the behavior. unit. (Note strategies to be practiced and practice schedule here.) (continued) Copyright © 2002 F.A. Davis Company ANXIETY 463 (continued) ACTIONS/INTERVENTIONS RATIONALES • When signs of increasing anxiety are observed, talk the client Repeated practice of a behavior internalizes and personalizes the through one of the coping strategies they have identified. (Note behavior. here the client’s symptoms of anxiety that are to be addressed and the identified coping strategy.) • Provide the client with a written list of appointments that have Provides visible documentation of the importance of follow-up. been scheduled for outpatient follow-up. Increases likelihood that appointments will be kept. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Monitor daily for side effects of antianxiety agents if prescribed. The potential for side effects and drug interactions are increased with older adults because of the decreased metabolism of drugs. • Identify environmental factors that may increase anxiety, such The environmental factors mentioned, if not addressed, induce as noise level, harsh lighting, and high traffic flow. more stress in the older individual. • Provide direct, basic information on usual routines and May help decrease autonomic nervous system activity and feelings procedures. of anxiety. Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family appropriate monitoring of signs and Provides baseline data for early recognition and intervention. symptoms of anxiety: � Increased pulse � Sleep disturbance � Fatigue � Restlessness � Increased respiratory rate � Inability to concentrate � Short attention span � Feeling of dread � Faintness � Forgetfulness • Involve the client and family in planning and implementing Family and client involvement enhances effectiveness of strategies to reduce and cope with anxiety: intervention. � Family conference: Identification of sources of anxiety and interventions designed to decrease anxiety � Mutual goal setting: Specific ways to decrease anxiety, and identification of role of each family member � Communication • Assist the client and family in lifestyle adjustments that may be Lifestyle changes require changes in behavior. Self-evaluation and required: support facilitate these changes. � Relaxation techniques, e.g., yoga, biofeedback, hypnosis, breathing techniques, or imagery � Problem-solving techniques � Crisis intervention � Maintaining the treatment plan of health care professionals who are guiding the therapy � Redirecting energy to meaningful or productive activities, e.g., active games and hobbies, walking, or sports � Decreasing sensory stimulation • Assist the client and family to set criteria to help them determine Early identification of issues requiring professional evaluation will when the intervention of a health care professional is required, increase the probability of successful interventions. e.g., inability to perform activities of daily living or threat to self or others. • Teach the client and family purposes, side effects, and proper Provides necessary information for self-care. administration techniques of medications. • Consult with or refer to assistive resources as indicated. Use of existing community services; provides for effective utilization of resources. Copyright © 2002 F.A. Davis Company 464 SELF-PERCEPTION AND SELF-CONCEPT PATTERN Anxiety FLOWCHART EVALUATION: EXPECTED OUTCOME Interview or observe the patient. Compare number of comments or behavior today regarding anxiety with number of comments or behavior on admission day. Has anxiety decreased? Yes No Record data, e.g., verbalized Reassess using initial assessment factors. only one anxiety statement today compared with 12 on day of admission; positive statements made regarding coping strategies. Record RESOLVED. (May wish to use CONTINUE until anxiety No Is diagnosis validated? negated to extent possible.) Delete nursing diagnosis, expected outcome, target date, and nursing actions Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., verbalized 10 anxiety statements today compared with 12 on Did evaluation show another day of admission. Record CONTINUE problem had arisen? Yes and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company BODY IMAGE, DISTURBED 465 Body Image, Disturbed 6. Subjective a. Refusal to verify actual change DEFINITION b. Preoccupation with change or loss c. Personalization of part or loss by name Confusion in mental picture of one’s physical self.33 d. Depersonalization of part or loss by impersonal pronouns e. Extension of body boundaries to incorporate environmental NANDA TAXONOMY: DOMAIN 6— objects SELF-PERCEPTION; CLASS 3—BODY IMAGE f. Negative feelings about body (e.g., feelings of helplessness, hopelessness, or powerlessness) NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING g. Verbalization of changes in lifestyle ASSISTANCE h. Focus on past strength, function, or appearance NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; i. Fear of rejection or of reaction by others CLASS M—PSYCHOLOGICAL WELL-BEING j. Emphasis on remaining strengths or heightened achievement k. Heightened achievement DEFINING CHARACTERISTICS33 RELATED FACTORS33 1. Nonverbal response to actual or perceived change in structure 1. Psychosocial and/or function 2. Biophysical 2. Verbalization of feelings that reflect an altered view of one’s body 3. Cognitive or perceptual in appearance, structure, or function 4. Cultural or spiritual 3. Verbalization of perceptions that reflect an altered view of one’s 5. Developmental changes body in appearance, structure, or function 6. Illness 4. Behaviors of avoidance, monitoring, or acknowledgment of 7. Trauma or injury one’s body 8. Surgery 5. Objective 9. Illness treatment a. Missing body part b. Trauma to nonfunctioning part RELATED CLINICAL CONCERNS c. Not touching body part d. Hiding or overexposing body part (intentional or unintentional) 1. Amputation e. Actual change in structure and/or function 2. Mastectomy f. Change in social involvement 3. Acne or other visible skin disorders g. Change in ability to estimate spatial relationship of body to 4. Visible scarring from surgery or burns environment 5. Obesity h. Not looking at body part 6. Anorexia nervosa HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Situational Low Self-Esteem This diagnosis Disturbed Personal Identity Disturbed Personal addresses the lack of confidence in one’s self and is Identity is defined as the inability to distinguish characterized by negative self-statements, lack of between self and nonself. This diagnosis is more concern about personal appearance, and with- involved in the mental health arena. Disturbed drawal from others not related to physical problems Body Image is a reaction to

an actual or perceived or attributes. Disturbed Body Image relates to change in the body structure or function and alterations in the perceptions of self due to actual or incorporates the adult health area as well as perceived alterations in body structure or function. mental health. EXPECTED OUTCOME TARGET DATES Will verbalize at least [number] positive body image statements by A target date of 3 to 5 days would be acceptable to use for initial [date]. evaluation of progress. Copyright © 2002 F.A. Davis Company 466 SELF-PERCEPTION AND SELF-CONCEPT PATTERN NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for pain every 2 h on [odd/even] hour. Administer Uncontrolled pain contributes significantly to problems with body analgesics. Monitor effectiveness of analgesic within 30 min of functioning, thus promoting the development and continuation of administration, and use noninvasive techniques to keep pain Disturbed Body Image. under control. • Use anxiety-reducing techniques as often as needed. Assists the patient in adapting to the changed body image. • Stay in frequent contact with the patient: Promotes verbalization of feelings, and allows consistent intervention. � Be honest with the patient. Any dishonesty in terms of recovery, return of function, or rehabilitation needs causes the patient to distrust caregivers and promotes maintenance of body image disturbance. � Point out and limit self-negation statements. Self-negating statements prolong the problem and interfere with rehabilitation potential. � Do not support denial. Focus on reality and adaptation (not The patient does not have to accept the problem, but he or she necessarily acceptance). does have to, and can, adapt to the problem. � Set limits on maladaptive behavior. Maladaptive behavior supports the continuation of Disturbed Body Image. � Focus on realistic goals. Supports continued progress. Allows positive feedback for achievement, and permits the patient to see progress. � Be aware of own nonverbal communication and behavior. Any avoidance behavior or nonverbal communication that � Avoid moral, value judgments. indicates dismay would support the patient’s idea of his or her unacceptability as a damaged person. • Assist and encourage the patient to look at and use affected Helps the patient attend to altered body image constructively, and body part during activities of daily living. assists the patient to accept himself or herself. • Promote calm, safe environment throughout hospitalization. When using adaptive equipment, the patient’s safety must be foremost. A calm environment allows the patient to focus on working with the equipment or techniques without undue pressure. • Collaborate with psychiatric nurse clinician regarding care as Collaboration promotes a holistic care plan and hastens solving of needed (see Psychiatric Health nursing actions). the patient’s problem. • Teach the patient and significant others self-care requirements. Helps the patient adapt to body change, and improves self-care management. Provides support for self-care, and assists significant others to adapt also. • Encourage the patient to use available resources: Facilitates adaptation and decreases isolation. Provides long-term � Prosthetic devices support. � Assistive devices � Reconstructive and corrective surgery � Occupational therapy � Physical therapy � Rehabilitation services • Refer to and collaborate with community resources. Provides long-term support. Cost-effective use of already available support. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for contributory factors for Disturbed Body Image, e.g., Provides database needed to more accurately plan interventions. disfigurement or perceived disfigurement. (The family may perceive such on behalf of the young infant or child.) • Utilize developmentally appropriate communication to assess Developmental capacity has to guide the interaction to gain accurate and determine exact expression of Disturbed Body Image, e.g., information. use puppet play or constructive dialogue with the toddler. • Provide factual information to assist in dealing with Disturbed Knowledge serves to reduce anxiety and assists the patient to cope. Body Image, e.g., availability of assistive devices or surgery. Provides options to assist in decision making. (continued) Copyright © 2002 F.A. Davis Company BODY IMAGE, DISTURBED 467 (continued) ACTIONS/INTERVENTIONS RATIONALES • Include other specialists, such as occupational, physical, and Promotes a more accurate and holistic plan of care. speech therapist, as required. • Monitor, on a daily basis, for attitude toward body. Allows daily evaluation, which promotes changes in plan of care to best meet the patient’s current status. NOTE: In some instances, such as an infant or child with an anomaly or a condition offering no hope of resolution, this alteration may accompany other disturbances such as self-esteem, parental coping, and loss. Women’s Health ACTIONS/INTERVENTIONS RATIONALES BODY IMAGE: SURGERY • Assist the patient to identify lifestyle adjustments that may be Initiates discharge planning. needed, e.g., recuperation time or prosthesis as necessary (mastectomy). • Monitor the patient’s anxiety level and discuss preoperatively: � Routines related to surgery, e.g., anesthesia, pain, length of surgery, or postoperative care � Physical changes, e.g., cessation of menstruation or menopausal symptoms • Allow the patient to grieve loss of body image, e.g., no longer able to have children, and provide an empathetic atmosphere that will allow the patient to ventilate concerns about appearance or reaction of significant other. • Dispel “old wives’ tales” (usually connected to hysterectomy) Provides factual information, allowing the patient to ask further such as: questions and be realistic about her status and goals. � You will no longer feel like a woman. (Reassure the patient that although there will be no more pregnancies or menstruation, hysterectomy does not affect sexual performance, enjoyment, or response.) � There will be masculinization. (There is no basis for this belief, and it does not occur.) � There will be weight gain. (Weight gain will not occur if the patient follows former lifestyle, participates in an exercise routine, and follows proper diet.) • Involve significant others in discussion and problem-solving Provides basic information, and allows early intervention for activities regarding life cycle changes that might affect self-esteem anxiety. Provides opportunity for teaching and clarification of and interpersonal relationships, e.g., hot flashes, appearance, misinformation.38 sexual relationships, or ability to have children. • In collaboration with physician, provide factual information on Assists the patient in making decision regarding use or nonuse of estrogen replacement therapy. estrogen therapy. BODY IMAGE: PREGNANCY • Assist the patient in identifying lifestyle adjustments due to Knowledge that body changes in pregnancy are normal and physiologic, physical, and emotional changes that will occur temporary encourages the patient to follow through on care. throughout pregnancy and post partum. Assists the patient to cope with the pregnancy and adapt to the changing images. • Review with the patient the body changes that occur during pregnancy and the effect on body image (particularly for teenagers): � Weight gain � Breast tenderness and enlargement � Enlargement of abdomen � Change in gait � Chloasma (mask of pregnancy) � Striations (stretch marks) from pregnancy • Consider the patient’s age and preparation for pregnancy, Continued home care planning that encourages the patient to including (particularly for teenagers): better apply good health practices and thus increase maternal and � Stress weight loss after delivery usually takes 1 or 2 wk. fetal well-being. (continued) Copyright © 2002 F.A. Davis Company 468 SELF-PERCEPTION AND SELF-CONCEPT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Discuss physical development. � Evaluate the patient’s attitude toward health care providers. � Discuss self-esteem. � Provide emotional support. � Prepare the patient for lifestyle interruptions. � Encourage the patient to bring an attractive, loose-fitting dress to wear home. � Caution breastfeeding women against purposeful weight loss while lactating. � Encourage non-breastfeeding mothers to follow low-calorie, high-protein diet for weight loss. � Encourage exercise (begin slowly and work up to desired plan). � Caution the patient to avoid fatigue. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Spend [number] minutes with the client at [times] discussing Promotes the client’s sense of control, and provides information perception of disruption in lifestyle necessitated by change. that can be utilized in developing a plan of care that will fit within the client’s perception of self. • Discuss with the client meaning of loss or change from a Expression of feelings in an accepting environment can facilitate personal and cultural perspective. the client’s problem solving. • Discuss with the client his or her significant others’ reaction to Support system understanding and support can facilitate the loss or change. client’s adjustment. • Set an appointment to discuss with the client and significant Expression of feelings and concerns in an accepting environment others effects of the loss or change on their relationships. (Time can facilitate problem solving. and date of appointment and all follow-up appointments should be listed here.) • Provide the client with information on bingeing and purging Provides the client with increased information about his or her and the impact they have on dieting and the body. behaviors.39 Do not impact calorie loss because of physiology of digestion and destruction of tissue. • Have the client develop a daily food diary that records time of Assists clients with linking thoughts with behaviors.39 day, amount and type of food, and binge or purge with feelings and thoughts. • Assess the client for suicidal thoughts or depression relating to Change in body shape can negatively impact self-esteem and weight gain. increase feelings of depression.40 • Spend [number] minutes with the client each day to focus on Cognitive maps influence behavior.40 values, thoughts, and feelings that perpetuate body image problems. • Spend [number] minutes each day to discuss assertive Assists in developing appropriate interpersonal boundaries.39 communication skills and practice these with the client. Note specific behaviors to be practiced here. • Discuss with the client role exercise plays in health, and develop Provides the client with the information necessary to make healthy an appropriate exercise plan. (Note here the plan for this lifestyle choices. client.) • Schedule time with the client’s significant other to assess his or Support assists with the development of lifestyle changes. her perception of the client and provide him or her with the necessary information to support the client’s change. Note here the time and person responsible for this meeting. • Spend [number] minutes with the client at [times] to assist with Promotes the client’s sense of control, and enhances self-esteem. efforts to enhance appearance. • Provide physical activities 2 times per day at [times] that provide Assists the client in developing a new perception of body. the client opportunities to define boundaries of body. These activities should be ones the client identifies as enjoyable and that are easily accomplished by the client. Those activities that are selected should be listed here. If this diagnosis is in conjunction with an eating disorder, adjust exercise to appropriate levels for the client. (continued) Copyright © 2002 F.A. Davis Company BODY IMAGE, DISTURBED 469 (continued) ACTIONS/INTERVENTIONS RATIONALES • Discuss with the client the difference between the cultural ideal Helps promote reality orientation by contrasting real with ideal, and of physical appearance and the population norm based on the confronts irrational goals. realities of physiology. This activity should be done by the primary care nurse who has developed a relationship with the client. • Have the client draw a picture of self before and after body Assists the client in contrasting and externalizing his or her change, and discuss this with him or her. This activity can perceptions of self to facilitate development of congruence also be done with clay models constructed by the client. This between real and ideal. activity should be done by the primary care nurse who has developed a relationship with the client. • Have the eating disorder client draw a life-size picture of self on Assists the client in confronting the difference between his or her paper hung on the wall; then have the client stand against the perception of his or her body and the real body size and shape. picture and trace the real outline, and discuss the differences. This activity should be done by the primary care nurse who has developed a relationship with the client. • When the client has begun to discuss issues related to body Facilitates the development of a congruence between real and change with the primary care nurse, the client can then be asked perceived self. to discuss reactions to image of self in a mirror. One hour should be allowed for this activity. This activity should be done by the primary care nurse who has developed a relationship with the client. • Discuss with the client the mental images held of

what the Discussion of concerns in a safe environment facilitates the altered body is like and what life will be like. One hour should development of strategies of coping. be allowed for this activity, and it should be implemented by the primary care nurse after a relationship has been established. Gerontic Health The nursing actions for the older adult with this diagnosis are the same as those for the adult. Home Health ACTIONS/INTERVENTIONS RATIONALES • Involve the client and family in planning and implementing Family involvement enhances effectiveness of interventions. strategies to reduce and cope with disturbance in body image: � Family conference: Discuss meaning of loss or change from family perspective and from perspective of individual members. Discuss the effects of the loss on family relationship roles. � Mutual goal setting: Establish realistic goals, and identify specific activities for each family member, e.g., assisting with activities as required or attending support groups as needed. � Communication: Clarify responses to Disturbed Body Image. • Assist the client and family in lifestyle adjustments that may be Rehabilitation is a long-term process. Permanent changes in required: behavior and family roles require evaluation and support. � Obtaining and providing accurate information regarding specific Disturbed Body Image and potential for rehabilitation � Maintaining safe environment � Encouraging appropriate self-care without encouraging dependence or expecting unrealistic independence � Maintaining the treatment plan of the health care professionals guiding therapy � Altering family roles as required • Consult with or refer to assistive resources as indicated. Utilization of existing services is efficient use of resources. Rehabilitation therapists and support groups can enhance the treatment plan. Copyright © 2002 F.A. Davis Company 470 SELF-PERCEPTION AND SELF-CONCEPT PATTERN Body Image, Disturbed FLOWCHART EVALUATION: EXPECTED OUTCOME Interview the patient. Does the patient make during the interview at least X number of positive body image statements? Yes No Record data, e.g., spoke positively Reassess using initial assessment factors. of visitor from Reach to Recovery; has chosen prosthesis and believes “no one will be able to tell I’ve had the mastectomy”; is doing exercises; plans to go home tomorrow and “get on with my life.” Record RESOLVED. Delete No Is diagnosis validated? nursing diagnosis, expected outcome, target date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., still cries when trying to talk about mastectomy; Did evaluation show another refuses to look at incision. problem had arisen? Yes Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company DEATH ANXIETY 471 Death Anxiety RELATED CLINICAL CONCERNS DEFINITION 1. Cancer 2. Any hospital admission The apprehension, worry, or fear related to death or dying.33 3. Impending surgery 4. Cardiovascular diseases NANDA TAXONOMY: DOMAIN 9—COPING/STRESS 5. Serious symptoms related to unknown cause TOLERANCE; CLASS 2—COPING RESPONSES 6. Autoimmune diseases NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING 7. Neurologic diseases ASSISTANCE NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; CLASS N—PSYCHOSOCIAL ADAPTATION HAVE YOU SELECTED THE CORRECT DIAGNOSIS? DEFINING CHARACTERISTICS33 Anticipatory Grieving This would be 1. Worrying about the impact of one’s own death on significant appropriate if the symptoms of grief are others related to another’s death. If the symptoms 2. Powerlessness over issues related to dying are related to one’s own death, then the 3. Fear of loss of physical and/or mental abilities when dying correct diagnosis would be Death Anxiety. 4. Deep sadness Anxiety If the symptoms are nonspecific or 5. Fear of the process of dying unknown to the individual, then this would 6. Concerns of overworking the caregiver as terminal illness in- be the appropriate diagnosis. Symptoms of capacitates self anxiety that relate to one’s own death 7. Concern about meeting one’s creator or feeling doubtful about support the diagnosis Death Anxiety. the existence of a god or higher being 8. Total loss of control over any aspect of one’s own death 9. Negative death images or unpleasant thoughts about any event related to death or dying EXPECTED OUTCOME 10. Fear of delayed demise Will verbally express concerns about death by [date]. 11. Fear of premature death because it prevents the accomplish- ment of important life goals 12. Worrying about being the cause of other’s grief or suffering TARGET DATES 13. Fear of leaving family alone after death Any type of anxiety requires a sufficient amount of time to deal with 14. Fear of developing a terminal illness causes of the anxiety and to learn coping skills. A minimum of 7 15. Denial of one’s own mortality or impending death days would be appropriate before checking for progress. RELATED FACTORS33 To be developed. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Take time to create a trusting relationship and a safe place for A trusting relationship in which the patient feels free to express his the patient to talk about the things that make him or her feel or her fears will assist the patient to open up. anxious about death. • Examine your own fear about life, death, and the death Caregivers need to understand their own feelings so they can experience. Develop a support system for yourself. support the patient and care for him or her nonjudgmentally. • Invite questions; answer honestly the questions that are asked Promotes a trusting relationship. (but not necessarily the ones that are not asked); give reassurance where reassurance is possible, and emotional support to grieve when reassurance is not possible. • Listen when the patient describes his or her pain, and help ease Promotes a trusting relationship. both the physical and emotional pain.41 • Explain that predictions about life expectancy are often wrong, Encourages hope but not false hope. and support the patient while the situation clarifies itself.41 (continued) Copyright © 2002 F.A. Davis Company 472 SELF-PERCEPTION AND SELF-CONCEPT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Support and draw out the family of the patient. Involve them Families are experiencing death anxiety also, but often put aside in care. their fears to support the patient. • Encourage patients to share their perception of the implications Promotes a trusting relationship, and encourages the patient to of the illness for their life.42 seek value of his or her life. • Treat the patient with respect; do not patronize families, Pity undermines respect for the patient. infantilize or denigrate the patient.41 • Respect the patient’s spirituality. Allow the patient to express Promotes a trusting relationship. his or her own beliefs about what his or her life has meant, death, and after death. • Give antianxiety or antidepressant drugs as ordered. Child Health NOTE: Review developmental conceptual considerations with a keen appreciation of unique needs per each client plus, as applicable, those orders for Adult Health. ACTIONS/INTERVENTIONS RATIONALES • Assess for all possible contributing factors to include, as A holistic assessment provides the most thorough database for applicable, the client’s verbalization of feelings, family or individualized care. caregiver perceptions, related family interactions or stressors, and risk indices, with attempt to identify anxiety to be mild, moderate, or acute. • Once determined, provide appropriate factual information to There will be a difference in how mild, moderate, or acute anxiety assist in how best to deal with anxiety. is dealt with. • Determine previous effective coping strategies. Successful coping strategies will assist in establishing possible ways to augment current needs with modification to offer a sense of empowerment. • Identify ways to assist the child in coping with appropriate Feelings of empowerment will result when attempts are made to incorporation of these strategies in daily care, with identification adhere to a regimen that values previously successful coping of additional coping strategies. strategies on which new strategies may then be more readily accepted. • Provide a calm atmosphere with limitation of excessive noise, Enhancement of coping is likely when the surrounding atmosphere interruptions, or numbers of caregivers. does not make more stress. • Provide all health team members updates, and seek information The nurse is in the best position to offer coordination of care. as needed to coordinate care on a daily basis. • Assist in appropriate involvement of all members of the health Child specialists are most appropriately suited to assist in anxiety care team, especially the child life specialist, psychiatrist, or reduction strategies. psychologist. • Encourage the child and family to share thoughts of death-related Creating a sense of safe haven for all fears and thoughts to be anxiety issues or related feelings on an ongoing basis, with a shared demonstrates a valuing of open communication and the sensitivity to unexpected potential for same. worth of the individual, thereby reducing anxiety. • Allow for creative modes per developmental preferences such as Age-appropriate expression of anxiety is fostered by preferences of puppets, video viewing, art, or story telling to share ways to the child per developmental capacity. deal with death. • Assess for cultural practices to augment care. Individualized sensitivity to culture provides valuing of the person and the importance he or she places on food, beliefs, or specific ways to cope. • Identify with the child and family ways to cope with dying and When anxieties are diminished, actual engagement with dying can meaning of death. be realistically approached. • Offer assistance in obtaining or notifying clergyman, counselors, Anxiety may be further reduced with assistance from those who are or other supportive personnel as needed. experts in death and dying. • Provide reassurance according to personal family beliefs about Anxiety may be further reduced when the child’s fears of being an afterlife or beliefs of same according to age-appropriate alone or separated can be alleviated, while also supporting valued concerns of the child. family beliefs. Women’s Health The interventions for this diagnosis in Women’s Health are the same as those given in Adult Health and Gerontic Health. Copyright © 2002 F.A. Davis Company DEATH ANXIETY 473 Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Provide a quiet, nonstimulating environment. (Note these Inappropriate levels of sensory stimuli can contribute to the client’s adaptations to the environment that promote the client’s sense of anxiety. relaxation, i.e., music, scents, lighting, etc.) • Spend [number] minutes per shift talking with the client about Assists the client in establishing the link between the feelings of concerns and feelings. anxiety and thoughts, which facilitates development of coping behaviors.43 An expression of feeling helps reduce intense emotion that can block problem solving.44 • After concerns are identified, validate and normalize the Validation of affect can decrease feelings of isolation and assist the emotional response. client to connect with others, including the family.44 • When concerns involve the family and/or support system, Assists the support system in bringing forth their own resources schedule [number] minutes each day to bring the family and strengths to support one another and problem solve. Decreases together and facilitate discussion of the issues and concerns. the feeling of isolation in members of the support system who are coping with the impending death.44 • Spend [number] minutes [number] times per day with the Empowers the client, and facilitates growth-promoting change.44 client identifying alternative ways of responding to concerns that decrease anxiety. • Discuss with the support system their need to provide care, and Provides the support system with a sense of helpfulness and provide them the necessary information and equipment to control.44 accomplish this at the level they feel comfortable. (Note the assistance needed to accomplish this care.) • Assess the support system’s need for respite, and talk with them Assists the family in coping with guilt about their need to take a about taking breaks to increase their ability to support the client. break to enhance their coping resources.44 (Note the family’s need here.) • Provide the client with information about his or her care. Empowers the client, and decreases concerns about the unknown. • Spend [number] minutes [number] times each day assisting the Shifts physiologic state from sympathetic nervous system arousal client with a relaxation sequence he or she has identified as to a state of parasympathetic recuperation.37 helpful. This could be deep muscle relaxation, visual imagery, meditation, or deep breathing exercises. (Note the method identified by the client here.) • Provide massage for [number] minutes as needed to reduce Promotes physical and psychological relaxation.45 anxiety. (Note the client’s preference for massage here.) • Identify support

systems in the community, and provide the Provides visual documentation of the importance of follow-up and client with a connection to these systems before discharge. community support, increasing the likelihood that these referrals (Note those identified for this client here.) will be utilized. Gerontic Health NOTE: Research on the presence of death anxiety in older adults is slowly evolving, with no clear pre- dictors of which older adults are at risk for experiencing death anxiety. Generally, elders with increased physical and psychological problems, and decreased ego integrity, are more likely to have death anx- iety. Which physical and/or psychological problems have an impact on death anxiety are not yet clearly identified. In addition to selecting interventions from the psychiatric health section, nurses caring for older adults may find the following actions to be effective.46–50 ACTIONS/INTERVENTIONS RATIONALES • Consult as needed with social services, mental health Enables clients to discuss and address issues that may be professionals, and/or religious counselors as signs of death contributing to distress. anxiety are noted. • Monitor older adults for signs of decreased ego integrity, such Decreased ego integrity is a contributor to death anxiety noted in as statements of regret related to past life experiences, older adults. unresolved relational problems, and expressions of despair. • Assist and encourage the older adult in life review process. Provides opportunity to review prior successes, effective and ineffective coping strategies, personal strengths and sense of life satisfaction, and psychological well-being. • Refer the client to hospice services if the client meets admission The hospice care team is prepared to address needs surrounding criteria for hospice care. death and dying. Copyright © 2002 F.A. Davis Company 474 SELF-PERCEPTION AND SELF-CONCEPT PATTERN Home Health ACTIONS/INTERVENTIONS RATIONALES • Manage the client’s pain and other troubling symptoms, such Physical symptoms often contribute to anxiety. as nausea. • Encourage the family to become involved in the care of the A sense of purpose and usefulness can replace anxiety. client as much as they are able. • Help the client to talk about his or her anxiety and its source. Makes the client, the nurse, and the family more aware of issues that need discussing or problems that need to be addressed. • Listen to client and family concerns, and answer all questions Understanding helps promote a sense of control and order. truthfully. Tell the client and family as much as you can to decrease the number of “surprises” they may experience with the dying process.51 • Acknowledge all fears, feelings, and perceived threats as valid to All client fears are valid to the client, whether they are realistic the client. or not. • Reassure the client that even though the dying process cannot Fear of abandonment is an almost universal fear of dying persons.51 be stopped, someone will be with them and they will not be left alone. Then ensure that a family member or caregiver is with the patient at all times. • Administer anxiolytics as ordered, and educate the family or Promotes sense of well-being. caregivers about prescribed medications, their effects, side effects, and scheduling.51 Copyright © 2002 F.A. Davis Company DEATH ANXIETY 475 Death Anxiety FLOWCHART EVALUATION: EXPECTED OUTCOME Is the patient verbally expressing concerns about death? Yes No Record data, e.g., states, “no Reassess using initial assessment factors. longer afraid to die, have business affairs in order, wife knows how to handle things now.” Still concerned about how going to handle planning of funeral. Record RESOLVED. Delete nursing diagnosis, No Is diagnosis validated? expected outcome, target date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., refuses to discuss any information related to death even Did evaluation show another though knows has terminal diagnosis problem had arisen? Yes and approximately 6 weeks to live. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 476 SELF-PERCEPTION AND SELF-CONCEPT PATTERN Fear c. Impulsiveness d. Narrowed focus on “it” (i.e., the focus of the fear) DEFINITION 5. Physiologic a. Increased pulse Response to perceived threat that is consciously recognized as b. Anorexia danger.33 c. Nausea d. Vomiting NANDA TAXONOMY: DOMAIN 9—COPING/STRESS e. Diarrhea TOLERANCE; CLASS 2—COPING RESPONSES f. Muscle tightness g. Fatigue NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING h. Increased respiratory rate and shortness of breath ASSISTANCE i. Pallor NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; j. Increased perspiration CLASS O—SELF-CONTROL k. Increased systolic blood pressure l. Pupil dilation m. Dry mouth DEFINING CHARACTERISTICS33 1. Self-reported symptoms of: RELATED FACTORS33 a. Apprehension b. Increased tension 1. Natural or innate origin, for example, sudden noise, height, c. Decreased self-assurance pain, or loss of physical support 2. Self-reported feelings of: 2. Learned response, for example, conditioning or modeling from a. Excitement or identification with others b. Scared 3. Separation from support system in a potentially threatening sit- c. Jitteriness uation, for example, hospitalizations or procedures d. Dread 4. Unfamiliarity with environment experience(s) e. Alarm 5. Language barriers f. Terror 6. Sensory impairment g. Panic 7. Phobic stimulus 3. Cognitive 8. Innate releasers (neurotransmitters) a. Identifies object of fear b. Stimulus believed to be a threat RELATED CLINICAL CONCERNS c. Diminished productivity, problem solving ability, learning ability 1. Any hospitalization 4. Behaviors 2. Any threat to loss of a body part, loss of functioning, or loss of a. Increased alertness life b. Avoidance or attack behaviors HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Anxiety Anxiety is a vague uneasy feeling each time an injection is indicated. During the combined with an autonomic response to a source assessment, the nurse discovers that the parent tells that is usually nonspecific or unknown. Fear is the the child that if he or she does not behave, the anxiety that is a response to recognized and nurse or doctor will give him or her a shot as a realistic danger. The response to meeting a bear in reinforcer to discipline at home. In this situation, the woods or the anticipation of this would be fear. the parent’s inappropriate use of the threat of the A threat that cannot be identified or linked to a injection produced a fear in the child. specific situation would be anxiety. Deficient Knowledge If the patient indicates that Impaired Parenting This diagnosis should be he or she is afraid of not being able to care for considered as the appropriate diagnosis when the himself or herself, then the most appropriate child’s fears result from the parent’s modeling or diagnosis would be Deficient Knowledge. reinforcing of a child’s fear or when the parent is Providing the patient with information, teaching, not providing the appropriate support for the and reinforcement of self-care ability will developmental fears. An example might be the overcome this diagnosis. child who becomes uncontrollable in the clinic EXPECTED OUTCOME TARGET DATES Will be able to identify specific source of fear by [date]. A target date of 2 to 3 days would be acceptable, because the sooner the fear can be reduced, the sooner other problems can be resolved. Copyright © 2002 F.A. Davis Company FEAR 477 NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient to correct any sensory deficits. Inability to correctly sense and perceive stimuli may increase fear. • Maintain calm, safe environment throughout the A nonthreatening environment decreases fear. hospitalization: � Use frequent reassurance. � Touch the patient frequently. � Have someone remain with the patient. • Administer antianxiety medications as ordered. Observe and Determines effectiveness of medication, and allows changing of record response to medication within 30 min after medication as needed. administration. • Monitor, at least every 4 h while awake: Determines physiologic changes due to fear. Assists in determining � Vital signs whether physiologic changes are causing pathology. � Degree of confusion � Degree of reality orientation • Provide information to the patient in both written and verbal Fear interferes with interpretation of verbal input. Written forms forms. provide reinforcement and assist the patient to focus and attend to activities. • Sit down and visit with the patient at least 15–20 min every 4 h Provides an opportunity for the patient to ask questions and while awake: verbalize fears. � Listen carefully. � Support positive coping. � Give clear, concise, straightforward information. • Assist the patient to increase development of decision-making Helps the patient practice, in a nonthreatening environment, the skills: problem-solving process. Increases feeling of personal control of � Review decision-making process with the patient. situation. � Provide opportunity for decision making regarding care. � Assist the patient in developing a list of potential solutions to the threatening situation. � Review the developed list of solutions with the patient, and assist him or her in evaluating the benefits and costs of each solution. � Rehearse with the patient, if necessary, the solution selected, or have the patient practice a new response to the threatening situation. � Give positive feedback regarding decision making. � Involve significant others in promoting the patient’s decision making. • Collaborate with psychiatric nurse clinician regarding care (see Collaboration promotes a holistic and thorough plan of care. Psychiatric Health nursing actions). • Teach the patient and significant others: Gives additional methods that are successful in dealing with fear. � Use of progressive relaxation and guided imagery � Use of exercise balanced with rest � Proper food and fluid intake • Refer to appropriate community resources for assistance. Provides support resources for follow-up on plan after discharge from the hospital. Child Health ACTIONS/INTERVENTIONS RATIONALES • Offer brief interactions that assist the patient and family with Brief explanations and factual information serve to empower the orientation, e.g., hospital unit, procedures, and aspects of care. patient and family as the unknown is made known. The patient and family can then focus on dealing with the identified fear rather than dealing with added fears. (continued) Copyright © 2002 F.A. Davis Company 478 SELF-PERCEPTION AND SELF-CONCEPT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • In instances of severe fear: Avoids overwhelming the patient. Promotes a sense of trust. � Provide support in a nondemanding atmosphere. � Provide a here-and-now focus. � Provide one-to-one care. � Offer simple, direct, repetitive tasks. • Provide the patient and family with alternative outlets for physical Providing such outlets promotes release of tension. tension. These outlets should be stated specifically and could include walking, talking, etc., at least [number] times per day at [times]. These outlets should be designed with input from the patient. • Sit with the patient and parents [number] times per day at As the patient or parents express these factors openly, the nurse [times] for [number] minutes to discuss feelings and complaints. can explore the possible onset of fear with the purpose of individualizing the plan according to the patient’s needs. The subjective verbalization of fears helps reduce the preoccupation of the patient with the fear. • Provide feedback to the patient and parents to clarify and Reflection on an ongoing basis demonstrates a sensitivity to need. re-explore changes regarding feelings about fear. • Provide appropriate behavioral limits to control the expression Structured rules regarding behavioral consequences create a sense of aggression or anger. These limits should be specific in time, of limits, which provides security for the child. expected behavior, and consequences. • Provide the patient and parents with opportunities to discuss Rediscussing and clarification of events serves to update needs the situation after consequences have been met. and provides feedback for evaluation. Valuing of the patient is also shown. • Provide opportunities for socialization appropriate for the Socialization is vital as the individual or family assumes coping patient and family. behaviors and learns new coping skills. • Develop a list of alternative coping strategies to be practiced Allows practice in a nonthreatening environment. Increases skills. by the patient and family before dismissal, e.g., communication or progressive relaxation. • Ensure follow-up appointments by scheduling them for the Follow-up appointments help ensure follow-up care. patient before dismissal. • Assist the patient and family to view situation represented as Validation of success in coping provides a sense of empowerment. something that can be managed. Encourage positive reinforcement of desired behavior patterns. Women’s Health NOTE: Phobias affect approximately 2 to 3 percent of the adult population, and 80 percent of the af- fected

group are female. The most common phobias among women are agoraphobia, fear of animals, and fear of social situations.52,53 ACTIONS/INTERVENTIONS RATIONALES • Obtain a detailed history of the patient’s fears: Provides essential database for planning appropriate interventions. � Encourage the patient to discuss signs and symptoms or precipitating event. � Ascertain how often problem occurs. � Have the patient describe her reaction. � Identify coping mechanisms that have previously helped. � Identify those factors or coping mechanisms that do not help. DOMESTIC VIOLENCE • Provide a nonjudgmental, safe environment for the patient to verbalize her fears. In childbirth and parenting classes, discuss family violence. Obtain a good history that can identify high-risk families. Be alert to subtle clues in the patient’s history or physical examination that hint at physical abuse. • Patiently explain all procedures and their purpose to the patient before performing them. Be aware that procedures in labor and delivery can trigger unpleasant fears and anxieties in the patient, with possible flashbacks to an abusive situation or rape. Perform necessary procedures as quickly as possible and with empathy, allowing the patient to direct as much of the care as possible. Encourage the patient to verbalize her fears and verbally relive the birth experience in a nonjudgmental environment. (continued) Copyright © 2002 F.A. Davis Company FEAR 479 (continued) ACTIONS/INTERVENTIONS RATIONALES • Inform patients of services and shelters for the battered woman. It is important to provide information about resources to these Post telephone numbers in conspicuous places. Post telephone women in an unobtrusive manner, so they can access the resources numbers in women’s bathroom (unavailable to men, so they when they are ready. cannot see partner getting number). Tell women to memorize number, never write it down. BIRTHING PROCESS • Provide a comfortable, nonjudging atmosphere to encourage Assists in decreasing fear through promotion of verbalization. the patient and her significant other to verbalize their fears of: � The unknown � Safety for herself and her baby � Pain during the birthing process � Mutilation during the birthing process � “Losing control” during the birthing process • Refer the patient to appropriate support groups for information: Provides effective use of existing resources and long-range support. � Childbirth education classes in the community � Schools of nursing (students in obstetrics who have follow-through of families of pregnant women) � Special national organizations • Monitor the patient’s level of confidence using prepared Use of relaxation techniques and provision of information childbirth techniques during labor: regarding progress facilitate the labor process by easing anxiety � Encourage use of relaxation and prepared childbirth and promoting comfort.38 techniques during labor. � Provide ongoing and accurate information, during the labor and birth process, to both the patient and her significant other. � Assist the patient in using “imagery” to overcome fears during the birthing process. • Provide continuity of care by remaining with and providing Encourages involvement in process, which enhances coping. comfort for the laboring woman throughout the birthing process: � Provide clear answers to the patient’s questions. � Keep the patient informed of her progress in the birthing process. • Provide the patient and significant others with as many opportunities as possible to make decisions about her care during the birthing process. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Provide a quiet, nonstimulating environment for the client. This Inappropriate levels of environmental stimuli can increase would include removing persons and objects that the person disorientation and confusion. Manipulation of the environment perceives as threatening. If the person is experiencing a thought can eliminate the fear response.54 disorder with delusions and hallucinations, attention should be paid to the details of the environment that could be misinterpreted. At times a same-sex caregiver can increase fear in the client. • Obtain the client’s understanding of the threat. Facilitates the development of interventions that directly address the client’s concerns. • Provide a one-to-one relationship for the client with a member Promotes a trusting relationship, and enhances the client’s of the nursing staff. This should be maintained until the self-esteem. symptoms return to normal levels. • Provide clear answers to the client’s questions. Inappropriate amounts of sensory stimuli can increase the client’s confusion and disorganization. • Carry on conversations in the client’s presence or vision in a Meets safety needs of the client by eliminating stimuli that could voice that the client can hear. be misinterpreted in a personalized manner. • Inform the client of plans related to care before the plans are Promotes the client’s sense of control, and enhances self-esteem. implemented. If possible, discuss these with the client (e.g., if it is necessary to move the client to another room or institution, the client should be informed of this change before it takes place). (continued) Copyright © 2002 F.A. Davis Company 480 SELF-PERCEPTION AND SELF-CONCEPT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Orient the client to the environment. Promotes safety needs by increasing the client’s familiarity with the environment in the accompaniment of a trusted individual. • Maintain a consistent environment and routine. Record the Promotes the client’s sense of safety and trust by maintaining client’s daily routine here, along with notes about client’s consistency in the environment. special reactions to visitors and staff members. • Provide a primary care nurse for the client on each shift. Promotes the development of a trusting relationship. • Sit with the client [number] minutes [number] times per shift. Promotes the development of a trusting relationship. Interaction (Initially the times should reflect short, frequent contact. This with the nurse can provide positive reinforcement and enhance can change with the client’s needs.) self-esteem. • Provide the client with objects in the environment that promote Meets the need for affiliation by providing meaningful objects to security. These may be symbolic items from home or religious which the client is attached.55 objects. List significant items here. • Note the client’s desired personal space, and respect these limits Communicates respect for the client, while decreasing the client’s (the general guidelines should be stated here). anxiety by maintaining a comfortable personal space. • Assist the client with sorting out the fearful situation by: Communicates respect for the client, while encouraging reality � Recognizing that the experience is real for the client even testing. though that is not your experience of the situation: “I can see that you are very upset. I can understand how those thoughts could make you fearful.” � Providing feedback about distorted thoughts: “No, I am not going to punish you. I am here to talk with you about your concerns.” � Encouraging the client to develop an understanding of the threat by talking about it in specific terms and not vague generalizations: “When you say your family is out to get you, who and what do you mean?” � Focusing conversations in the here and now: This would include information about the effects of the client’s behavior on those around him or her, your experience of the client, and your perceptions of the environment. � Not arguing about the client’s perceptions: Instead, provide feedback in the here and now with your perceptions of the situation. The client tells you that you must be angry with him or her because of the look you had on your face while reviewing the client’s chart. Your response is, “I am not angry with you, when I was looking at your chart, I was thinking about the conversation we had this morning about your job.” • Provide the client with as many opportunities as possible to Promotes the client’s sense of control, and enhances self-esteem. make decisions about his or her care and current situation. • Assist the client in developing a list of potential solutions to the Teaches the client problem-solving skills, while promoting the threatening situation. client’s sense of control and strengths. • Review developed list of solutions with the client, and assist Facilitates the client’s decision-making process. him or her in evaluating the benefits and costs of each solution. • Rehearse with the client, if necessary, the solution selected, or Behavioral rehearsal helps facilitate the client’s learning new skills have the client practice a new response to the threatening through the use of feedback and modeling by the nurse.55 situation. • Provide positive feedback to the client about efforts to resolve Positive feedback encourages behavior and enhances self-esteem. the threatening situation. • Assist the client in developing alternative outlets for the feelings Planned coping strategies facilitates the enactment of new generated by the threatening situation, and provide the behaviors when the client is experiencing stress. opportunity for the use of these outlets. These would be noted in the chart so other staff members would be aware of them and could encourage their use when they notice the client’s discomfort increasing. • Assist the client in identifying early behavioral cues that indicate Early recognition and intervention enhances the opportunities for fear or that he or she is entering a fearful situation. new coping behaviors to be effective. • Encourage the client in alternative coping strategies developed by: Promotes the client’s perception of control. Positive reinforcement � Providing the necessary environment encourages behavior. � Providing the appropriate equipment � Spending time with the client doing the activity � Providing positive reinforcement for the use of the strategy (this could be verbal as well as with special privileges) (continued) Copyright © 2002 F.A. Davis Company FEAR 481 (continued) ACTIONS/INTERVENTIONS RATIONALES • If fear is related to a specific object or situation, teach the client The relaxation response inhibits the activation of the autonomic to use deep muscle relaxation, and then teach this along nervous system’s fight-or-flight response. with progressively real mental images of the threatening situation. This is for those situations that will not cause the client harm if he or she is approached, such as riding in elevators. This could also include other methods of relaxation such as music, deep breathing, thought stopping, fantasy, assertiveness training, audiotapes with relaxation images or sequences, yoga, hypnosis, and meditation. • Explore ways to increase the client’s feeling of control in threatening situation; e.g., a fear of elevators could be altered by the client only riding in elevators with emergency telephones and only riding when he or she could stand near the telephone. The fear may also indicate that the client is feeling out of control in an unrelated area of his or her life. If this is suspected, this should be explored and ways of increasing control should be explored; e.g., a woman’s fear of driving could indicate that she feels out of control in her marriage, and increased assertive behavior with her husband removes the fear. • When the client shows signs and symptoms of fear (note those Shifts physiologic state from sympathetic nervous system arousal signs and symptoms unique to this client here), talk him or her to a state of parasympathetic recuperation.37 Behavioral rehearsal through the coping and/or relaxation strategies that have been helps facilitate mastery of new behavior through the use of feedback identified as useful to him or her. Note the client’s specific and modeling by the nurse.35 Promotes sense of control.43 coping strategies to be used here. This may include removing Contextual stimuli can elicit the fear response.54 the client from the fear-producing context. • Provide positive reinforcement for the client’s implementation Positive reinforcement encourages behavior. of the new coping behaviors. Note those things that are to be used to reinforce this client here. • If the method to increase control involves interactions with the Promotes the client’s sense of control, and enhances self-esteem. health care team, these should be noted in specific terms on the client’s chart. • Assist the client in developing strategies to be used in the Behavioral rehearsal provides opportunities for feedback and community after discharge, and role-play various situations modeling from the nurse. with the client for at least 1 h for at least 2 days. • Collaborate with other members of the health care team to GABA agonists inhibit the amygdala, which is the location of the provide clients with pharmacologic agents to be administered fear response.54 prior to exposure to a context that elicits fear. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient in identifying the source of fear—e.g., pain, Identifying the source of fear enables the patient to develop a death, or loss of function—by scheduling

at least 30 min twice specific plan of action to reduce the fear. a day at [times] to confer with the patient about fear. • Assist the patient in determining what resources are available to Knowledge and use of appropriate resources aid in reducing enhance his or her coping skills. fear-provoking experiences by increasing the patient’s inventory of skills to deal with fear. Home Health ACTIONS/INTERVENTIONS RATIONALES • Ask the client to describe the precipitating event. Assists the nurse in understanding the client’s perception of the fear. • Determine the client’s perception of the fear. Assists the nurse in understanding the client’s perception of the fear. • Assess sources of support, resources, and usual coping methods. Assists the nurse in understanding the client’s perception of the fear. • Identify which coping strategies that the client has previously Growth can occur if effective skills are applied in future situations. used have been effective and which have not. Discuss ways that effective strategies can be used to cope with future fearful events. (continued) Copyright © 2002 F.A. Davis Company 482 SELF-PERCEPTION AND SELF-CONCEPT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Help the client to talk about his or her fear and its source. Makes the client, the nurse, and the family more aware of issues that need discussing or problems that need to be addressed. • Listen to client and family concerns, and answer all questions Understanding helps promote a sense of control and order. truthfully. Tell the client and family as much as you can to decrease the number of “surprises” they may experience with the fear-producing event. • Acknowledge all fears, feelings, and perceived threats as valid All client fears are valid to the client, whether they are realistic to the client. or not. • Administer anxiolytics as ordered, and educate the family or Promotes sense of well-being. caregivers about prescribed medications, their side effects, and scheduling. • Consult with and/or refer the patient to assistive resources as Utilization of existing services is an efficient use of resources. needed. Copyright © 2002 F.A. Davis Company FEAR 483 Fear FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient identify primary source(s) of fear? Yes No Record data, e.g., has identified Reassess using initial assessment factors. primary source of fear of flying as having no control over situation. Record RESOLVED (may wish to use CONTINUE until patient has identified and successfully implemented coping mechanisms). Delete nursing diagnosis, No Is diagnosis validated? expected outcome, target date, and nursing actions Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., stated, “know I’m afraid to fly—not sure of the reasons why.” Did evaluation show another Record CONTINUE and change target problem had arisen? Yes date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 484 SELF-PERCEPTION AND SELF-CONCEPT PATTERN Hopelessness 5. Decreased appetite 6. Decreased response to stimuli DEFINITION 7. Increased or decreased sleep 8. Lack of initiative A subjective state in which an individual sees limited or no alterna- 9. Lack of involvement in care or passivity allowing care tives or personal choices available and is unable to mobilize energy 10. Shrugging in response to speaker on own behalf.33 11. Turning away from speaker NANDA TAXONOMY: DOMAIN 6— RELATED FACTORS33 SELF-PERCEPTION; CLASS 1—SELF-CONCEPT 1. Abandonment NIC: DOMAIN 3—BEHAVIORAL; CLASS R— 2. Prolonged activity restriction creating isolation COPING ASSISTANCE 3. Lost belief in transcendent values or God NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; 4. Long-term stress CLASS M—PSYCHOLOGICAL WELL-BEING 5. Failing or deteriorating physiologic condition DEFINING CHARACTERISTICS33 RELATED CLINICAL CONCERNS 1. Any disease of a chronic nature 1. Passivity, or decreased verbalization 2. Any disease with a terminal diagnosis 2. Decreased affect 3. Any condition where a diagnosis cannot be definitely established 3. Verbal cues (despondent content, “I can’t,” sighing) 4. Closing eyes HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Powerlessness This diagnosis is present when the This situation could develop when the client is individual perceives that his or her actions will not feeling overwhelmed with the perception that change a situation regardless of the options that the there are no alternatives in a difficult situation. The person may see in a situation. Hopelessness occurs primary diagnosis evolves from the symptoms when the individual perceives that there are few or sequence. If Anxiety is the predominant symptom limited choices in a situation. Powerlessness may cluster, it should be the primary diagnosis because evolve out of Hopelessness. Powerlessness is the of the strong influence it has on the client’s perception that one’s actions will not make a perceptions. difference, whereas Hopelessness is the perception Disturbed Thought Process If the individual that there are not options to act on. The decision cannot accurately assess the situation, then a sense about which is the most appropriate diagnosis is of Hopelessness might occur. In this instance, based on the clinical judgment of the nurse about Hopelessness would be a companion diagnosis. which symptoms predominate. Fear If the client is fearful in a situation, Anxiety Anxiety may have as a component a perception can be narrowed and alternative perception of Hopelessness. This could evolve out options may be overlooked. When Fear and of the narrowed perception of the anxious client. Hopelessness occur together, Fear should be the Hopelessness may have Anxiety as a component. primary diagnosis. EXPECTED OUTCOME TARGET DATES Will initiate a realistic plan to reduce perception of hopelessness by A target date ranging between 3 and 5 days would be appropriate [date]. for initial evaluation. A target date later than 5 days might lead to increased complications, such as potential for self-injury. A target date sooner than 3 days would not provide a sufficient length of time for realizing the effects of intervention. Copyright © 2002 F.A. Davis Company HOPELESSNESS 485 NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Establish a therapeutic and trusting relationship with the patient Promotes a safe environment to encourage the patient and/or and family by actively listening, being nonjudgmental, sitting family to verbalize concerns. Promotes empathetic environment. with the patient, touching (as welcomed by the patient), etc. • Identify other primary nursing needs, and deal with these as Inattention to basic needs increases feelings of hopelessness and needed. of being of no value. • Support the patent’s efforts at objectively describing feelings of Assists the patient in releasing tension. Allows the patient to hopelessness when interacting with the patient. validate reality. • Assist the patient to find alternatives to feelings of hopelessness Validates reality and encourages use of coping techniques. Points as the patient expresses them. out the variety of solutions available. • Assist the patient to engage in social interaction at least once Provides diversion, and decreases sense of isolation. per shift. • As health status permits, increase activity level. Have the patient Encourages the patient to regain control in small increments. participate in self-care management, adding an activity such as Decreases the idea that the personal self is responsible for the washing face one day, washing face and arms the next day, etc., situation. or have the patient walk to bathroom first day and ambulate 30 ft down the hall the next day. • Encourage food and fluid intake to at least 1500 calories per Hopelessness may prompt unhealthy eating patterns. day and at least 2000 mL per day. • Moderate sleep-wake cycles: Maintains diurnal rhythm and promotes rest. � Provide diversional activities during the day. � Do not let the patient take naps during the day. � Provide massage at bedtime. � Darken the room, but provide a night light for sleep. � Give sleep medication as ordered, and monitor effects. • Encourage active participation in activities of daily living. Allow Helps restore sense of being in control. for preferences in day-to-day decisions, e.g., establishing a bath time. Provide explanations and appropriate teaching for procedures and treatments. • Refer to psychiatric nurse clinician as needed (see Psychiatric Collaboration promotes a more holistic and complete plan of care. Health nursing actions). • Identify religious, cultural, or community support groups prior Support groups can provide advocacy for the patient and to discharge. Provide appointments for follow-up. continued monitoring and support of the patient after discharge from the hospital. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for the etiologic components contributing to Provides database that results in a more accurate and complete hopelessness pattern. plan of care. • Encourage the patient and family to verbalize feelings about Verbalization helps reduce anxiety and assigns value to the current status with 30 min set aside each shift at [times] for this patient’s concerns. Allows ongoing assessment. purpose. • Assist the patient and family to explore growth potential Opportunity for growth may be overlooked in times of crisis. afforded by this specific experience. • Allow opportunities for the child to “play out” feelings under Play and the acting out of feelings provide insight into coping and appropriate supervision: perceptions of the child in a noninvasive mode. Provides valuable � Play with dolls for toddler data to monitor feelings, concerns, etc. � Art and puppets for preschooler � Peer discussions for adolescents Copyright © 2002 F.A. Davis Company 486 SELF-PERCEPTION AND SELF-CONCEPT PATTERN Women’s Health NOTE: The following nursing actions are for the couple (husband or wife) who have been unable to conceive a child. See Chapter 10 for detailed information on infertility. Provide a nonjudgmental at- mosphere to allow the infertile couple to express their feelings such as anger, denial, inadequacy, guilt, depression, or grief. ACTIONS/INTERVENTIONS RATIONALES INFERTILITY • Support and allow the couple to work through grieving process Provision of support for and encouragement of discussion for loss of fertility, for loss of children, for loss of idealized regarding emotions allows the couple to begin to deal with lifestyle, and for the loss of feminine life experiences such as emotions and lays groundwork for future decision making.38 pregnancy, birth, and breastfeeding. • Encourage the couple to talk honestly with one another about feelings. • Encourage the couple to seek professional help if necessary to deal with feelings related to sexual relationship, conflicts, anxieties, parenting, and coping mechanisms used for dealing with loss of fertility (their expectations, relatives’ expectations, and society’s expectations). • Be alert for signs of depression, anger, frustration, and Allows early intervention and avoidance of complications. impending crisis. • Provide the infertile couple with accurate information on Provides informational support for decision making. adoption and living without children. POSTPARTUM DEPRESSION NOTE: The majority of patients who experience hopelessness leading to postpartum depression have been found to have underlying psychiatric disorders or life experiences other than pregnancy that accounted for the depression.56 • Provide factual information to the patient and partner on Give the patient and partner realistic guidelines for when they postpartum depression. Describe difference between might need to seek professional help for depression beyond “baby blues” and depression. Identify potential psychosocial “baby blues.” triggers in the patient’s environment that could lead to postpartum depression, such as: � Feelings of ambivalence � Feelings of inadequacy � Marital discord � Guilt and irritability DOMESTIC VIOLENCE57 • Provide nonjudgmental atmosphere that allows the patient to express anger, fears, and feelings of hopelessness. Refer the patient to appropriate agency for assistance to find shelter and psychological counseling. Assist the patient in developing a plan of action in the event of a situation that could threaten her or her children’s safety. • Place telephone numbers for assistance in women’s bathroom Provides resources and information to patients without putting and other places women can see and memorize it without fear them or their children in further danger. of reprisal from partner. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Monitor health care team’s interactions with the client for Negative attitudes from staff can be communicated to the client. behavior (verbal and nonverbal) that would encourage the client not to be hopeful. If situations are identified, they should be noted here, and the team should discuss alternative ways of behaving in the situation. The actions that are determined to be needed to support the client’s hope should be noted on the client’s chart. (continued) Copyright © 2002 F.A. Davis Company HOPELESSNESS 487 (continued) ACTIONS/INTERVENTIONS RATIONALES • Sit with the client [number] times per day at [times] for 30 min Promotes positive orientation by assisting

the client in to discuss feelings and perceptions the client has about the remembering past successes and important aspects of life that identified situation. These times should also include discussions make it important that they succeed this time.58 about the client’s significant others, times the client has enjoyed with these persons, the projects or activities the client was planning with or for these persons that have not been accomplished, the client’s values and beliefs about health and illness, and the attitudes about the current situation. • Identify with the client’s significant others times that they can talk Negative expectations from the support system can be with the staff about the current situation. Themes that should communicated to the client. be explored during this interaction should be their thoughts and feelings about the current situation, ways in which they can support the client, the importance of their support for the client, questions they may have about the client’s situation, and possible outcomes. (Note the time for this interaction here as well as the name of the person who will be talking with the significant others.) • Note times when significant others will be visiting, and schedule Assists the client in maintaining connections with the support this time so there will be a private time for them to interact with systems, and increases awareness of contributions the client has the client. (Note these times here, and designate those times that made in the past and can make in the future to this system. are scheduled as private visitation times.) Inform the client and significant others of those places on the unit where they can have privacy to visit. • Identify with the client preferences for daily routine, and place Promotes the client’s sense of control. this information on the chart to be implemented by the staff. It is vital to this client to have the information shared with all staff so that it will not appear that the time spent in providing information was wasted. • Provide answers to questions in an open, direct manner. Promotes the client’s sense of control, while building a trusting relationship. • Provide information on all procedures at a time when the client can ask questions and think about the situation. • Allow the client to participate in decision making at the level to Promotes the client’s sense of control in a manner that increases which he or she is capable of doing so. The client who has never the opportunities for success. This success serves as positive made an independent decision would be overwhelmed by the reinforcement. complexity of the decisions made daily by the corporation executive. If necessary, offer decision situations in portions that the client can master successfully (the amount of information that the client can handle should be noted here as well as a list of decisions the client has been presented with). • Provide positive reinforcement for behavior changed and Positive reinforcement encourages behavior while enhancing decisions made. Those things that are reinforcing for this client self-esteem. should be listed here along with the reward system that has been established with the client; e.g., play one game of cards with the client when a decision about ways to cope with a specific problem has been made. • Provide verbal social reinforcements along with behavioral Promotes the development of a trusting relationship. reinforcements. • Keep promises (specific promises should be listed on the chart so that all staff will be aware of this information). • Accept the client’s decision if the decision was given to the Promotes the client’s sense of control, while enhancing self-esteem. client to make. These decisions should be noted on the chart. • Provide ongoing feedback to the client on progress. Provides positive reinforcement for accomplishments. • Spend 30 min a day talking with the client about current coping Interaction with the nurse can provide positive reinforcement. strategies and exploring alternative coping methods. Note time Behavioral rehearsal provides opportunities for feedback and for this discussion here as well as the person responsible for this modeling of new behaviors from the nurse. interaction. When alternative coping styles have been identified, this time should be used to assist the client with necessary practice. The alternative styles that the client has selected should be noted on the chart, and the staff should assist the client in implementing the strategy when appropriate. These could include deep muscle relaxation, visual imagery, prayer, or talking about alternative ways of coping with stressful events. (continued) Copyright © 2002 F.A. Davis Company 488 SELF-PERCEPTION AND SELF-CONCEPT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Allow the client to express anger, and assist with discovering Promotes the development of a positive orientation. constructive ways of expressing this feeling (e.g., talking about this feeling, using a punching bag, playing Ping-Pong, or throwing or hitting a pillow). Talk with the client about signs of progress, and assist him or her in recognizing these as they occur with verbal reminders or by keeping a record of steps taken toward progress. • Assist the client in establishing realistic goals and realistic Goals that are achieved serve as positive reinforcement for expectations for situations. The goals should be short term and behavior change and enhance self-esteem and a positive be stated in measurable behavioral terms. Usually, dividing the expectational set. goal set by the client in half provides an achievable goal. This could involve dividing one goal into several smaller goals. Note goals and evaluation dates here. • Determine times with the client to evaluate progress toward Provides positive reinforcement for movement toward goal, and these goals and to discuss his or her observations about this provides opportunity for the nurse to provide positive verbal progress. These specific times should be listed here with the reinforcement. name of the person responsible for this activity. Initially this may need to be done on a daily basis until the client develops competency in making realistic assessments. • Assist the client in developing a list of contingencies for possible Provides direction for the client, with an opportunity to mentally blocks to the goals. These would be “what-if ” and “if-then” rehearse situations that could require alteration of goals. This discussions. This would be done in the goal-setting session, protects the client from all-or-none situations. and a record of the alternatives discussed would be made in the chart for future reference. • Discuss with the client values and beliefs about life, and assess Spirituality can provide hope-giving experiences. importance of formal religion in the client’s life. If the client requires contact with a person of his or her belief system, arrange this, and note necessary information for contacting this person here. Provide the client with the time necessary to perform those religious rituals that are important to him or her. Note the rituals here with the times scheduled and any assistance that is required from the nursing staff. • Provide the client with opportunities to enjoy aesthetic Promotes the client’s interest in the positive aspect of life, experiences that have been identified as important, such as promoting a positive orientation. listening to favorite music, having favorite pictures placed in the room, enjoying favorite foods, or having special flowers in the room. Spend 5 min 3 times a day discussing these experiences and assisting the client in becoming involved in the enjoyment of them. Note here those activities that have been identified by the client as important and times when they will be discussed with the client. • Assist the client in developing an awareness and an appreciation Provides the client with an opportunity to access past positive for the here and now by helping him or her focus attention in experiences in the present, thus promoting a positive orientation. the present by pointing out to him or her the beauty in the flowers in the room, the warmth of the sunshine as it comes through the window, the calmness or aliveness of a piece of music, the taste and smell of a special food item, the odor of flowers, etc. • Establish a time to talk with the client about maximizing Promotes the client’s sense of control, enhancing self-esteem. potential at his or her current level of functioning. Note date and time for this discussion here. This may need to be done in several stages during more than one time, depending on the client’s level of denial. Note here the person responsible for these discussions. Gerontic Health The nursing actions for the older adult with this diagnosis are the same as for the adult health and men- tal health patient. Copyright © 2002 F.A. Davis Company HOPELESSNESS 489 Home Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for factors contributing to the hopelessness, e.g., Provides database for earlier recognition and intervention. psychological, social, economic, spiritual, or environmental factors. • Involve the client and family in planning, implementing, and Clarifies roles. Personal involvement in planning, etc. Increases the promoting reduction or elimination of hopelessness: likelihood of success in resolving problem. � Family conference: To identify and discuss factors contributing to hopelessness � Mutual goal setting: Setting goals with roles of each family member identified � Communication � Support for the caregiver • Assist the client and family in making lifestyle adjustments that Lifestyle changes require significant behavior change. Self- may be required: evaluation and support can assist in ensuring that changes are � Use relaxation techniques: Yoga, biofeedback, hypnosis, not transient. breathing techniques, or imagery. � Provide assertiveness training. � Provide opportunities for individual to exert control over situation. Give choice when possible; support and encourage self-care efforts. � Provide sense of mastery; set accomplishable and meaningful goals in secure environment. � Look for meaning in situation, e.g., what can be learned from the situation. � Provide treatment for physiologic condition. � Provide grief counseling. � Provide spiritual counseling. • Consult with or refer to assistive resources as indicated. Effective use of existing community resources. Copyright © 2002 F.A. Davis Company 490 SELF-PERCEPTION AND SELF-CONCEPT PATTERN Hopelessness FLOWCHART EVALUATION: EXPECTED OUTCOME Has the patient implemented a realistic plan to reduce perception of hopelessness? Yes No Record data, e.g., has attended Reassess using initial assessment factors. continuing education course on assertiveness; has appointment at pain clinic; has redistributed workload. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., has plans to purchase assistive devices and to attend class on Did evaluation show another stress management; has not implemented. problem had arisen? Yes Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company LONELINESS, RISK FOR 491 Loneliness, Risk for HAVE YOU SELECTED DEFINITION THE CORRECT DIAGNOSIS? At risk of experiencing vague dysphoria.33 Social Isolation Social Isolation is an actual diagnosis. Loneliness is a risk diagnosis. NANDA TAXONOMY: DOMAIN 6— Social Isolation is a risk factor for the SELF-PERCEPTION; CLASS 1—SELF-CONCEPT diagnosis of Loneliness. NIC: DOMAIN 5—FAMILY; CLASS X—LIFE Impaired Social Interaction This diagnosis SPAN CARE is also an actual diagnosis. In Impaired Social Interaction, the problem can be NOC: DOMAIN VI—FAMILY HEALTH; insufficient or excessive quantity of social CLASS X—FAMILY WELL-BEING activity. RISK FACTORS33 1. Affectional deprivation EXPECTED OUTCOME 2. Social isolation 3. Cathectic deprivation Will implement a plan to reduce risk for loneliness by [date]. 4. Physical isolation TARGET DATES RELATED CLINICAL CONCERNS This is a fairly long term diagnosis and will require much support 1. Any chronic illness to offset. Therefore, an appropriate initial target date would be 10 2. AIDS to 14 days. 3. Mental health diagnoses 4. Cancer 5. Any condition causing impaired mobility NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for symptoms of loneliness. Symptoms are often hidden Helps develop a database on which planning can take place. or disguised: expressed through withdrawal, depression, or a profound sense of hopelessness; or vague physical symptoms such as headache; hostility; anger toward those around him or her or with life in general. Prolonged internal conflicts may manifest as inappropriate coping, such as overeating, excessive drinking or smoking, drug use, or other self-destructive behaviors. • Note significant other(s) who visit or call the patient. Assess

the The separation from significant other(s) and from previously degree of support and availability of significant other(s). established support systems may contribute to loneliness.59 • Help identify beliefs, values, hobbies, and areas of interest. • Encourage him or her to join a group with common interests. The older adult is not as easily accepted into social interactions or Age-related groups may be helpful for the older patient. Group relationships because of social bias toward the aged.60 The use of process should focus on realistic, relevant issues. groups and group process has been most successful in treating loneliness.61 • Encourage the patient to be involved in his or her care. Involving the patient in care directly influences movement away from loneliness.62 It also reduces feelings of powerlessness and fosters interest in self-care.59 • Discuss body image, hygiene, visible signs of illness, function The person becomes isolated either because of rejection of others loss, and his or her perceptions of how he or she can change or because he or she seeks little interaction as a result of the things. self-consciousness he or she feels.60 Negative ways of viewing self arising from physical or emotional disabilities can confound problems, lower self-esteem, and lead to loneliness.61 • Assist the patient to find alternate support systems, even short, Patients perceive that nurses can offer psychological support with quality interactions with the nurse. even short visits.61 • Assign a primary nurse to care for the patient. Provides consistency in care. (continued) Copyright © 2002 F.A. Davis Company 492 SELF-PERCEPTION AND SELF-CONCEPT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Use multidisciplinary approach to patient care. Ensures continuity in care. • Assist the patient to establish relationship with one other patient. Decreases social isolation. Child Health Same as for Adult Health, with attention to developmentally appropriate approach for all interventions. When other diagnoses (e.g., Grief or Loss, Parent-Infant Separation, Coping), also contribute to this pat- tern, seek follow-up with concurrent plan for loneliness as well. ACTIONS/INTERVENTIONS RATIONALES • If anaclitic depression is to be considered, stage appropriately In separation anxiety, the infant or child may have different needs, for current/ongoing status, i.e., protest, despair, or withdrawal. but all will help direct caregivers to support client regain bonding with others. • Determine best how to support the infant, child, or adolescent Holistic planning according to realistic capacity of the infant, child, coping with loneliness as applicable: or adolescent will provide appropriate chance to reestablish sense � Play therapy or counseling of belonging. � Consideration of developmental capacity � Access to activities within the local community � Assessment of physical or emotional readiness, for both the individual and the family � Allowance for regression due to illness � Support services, foster grandparents, volunteers, Child Protective Services (CPS), or college interest groups • Involve all who have input in establishing consistent long-term Often underlying dynamics may require long-range planning. goals. • When necessary, advocate for the infant or child. Loneliness may be related to abuse on part of parents and must be considered appropriately. • Ensure allowance for counseling for appropriate valuing of Loneliness will undermine family dynamics if left unrecognized. family needs. • Offer 30 min each shift for the client or parents to ventilate Frequent verbalization will offer cues to suggest insight into how feelings about loneliness. loneliness is being perceived and provide basis for most appropriate treatment. Women’s Health NOTE: The heath care provider will see this diagnosis in many more female clients than in male clients as a result of women outliving men. This is one of the most frequent diagnoses in geriatric women. ACTIONS/INTERVENTIONS RATIONALES POST PARTUM • Provide the patient with access to support by providing telephone number and name of available support person she can call with questions. • Encourage new parents to attend parenting support groups and Provides new parents support and guidance during the first days participate in parent education programs in the acute care of the postpartum period, and assists in the transition to setting and in the community after discharge. Suggest to parents: parenthood. � YWCA � Churches � Neighborhood groups � Friends who have had babies � State-funded follow-up programs SINGLE PARENTS • Assist the new mother to develop a plan for coordinating activities of daily living with the new infant. • Assist the patient in identifying available resources: � Family � Significant others � Community agencies � Peer groups Copyright © 2002 F.A. Davis Company LONELINESS, RISK FOR 493 (continued) ACTIONS/INTERVENTIONS RATIONALES • Assist the patient in identifying and developing intrapersonal skills. • Encourage attendance at parenting classes or support groups. � Learn about baby cues and how to provide for psychological needs of new infant. � Identify others with similar concerns and needs. � Identify new sources of support and contact opportunities for developing new friendships. • Encourage the patient to identify friends or acquaintances who Provides support and guidance during the transition to parenthood, have recently had new babies and to begin: as well as provides additional resources specific to assisting the � Discussing similar concerns and problems with caring for single parent. a new baby � Sharing babysitting activities to reduce costs and increase opportunities for new mom to get away for a while DIVORCE AND WIDOWHOOD • Provide a relaxed atmosphere that will encourage the patient to express feelings, identify concerns, and allow for grieving. • Evaluate need for professional assistance and/or family support. • Identify and clarify with the patient feelings of abandonment, anger, and loss of previous lifestyle. • Assist the patient in identifying new opportunities for involvement with others, i.e., church groups, community volunteer groups, social groups (ski club, travel clubs, etc.) for people with similar interests, returning to college, cultural events, etc. • Provide opportunities for new interactions in a supportive atmosphere; e.g., identify friend to accompany the patient to social events or identify friend she can talk to. • Provide referrals to appropriate professional resources for Provides support and guidance during a time of crisis for the assistance if necessary. patient. Assists the client to find and utilize available resources. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Spend [number] minutes [number] times a day discussing with Assists in understanding the client’s worldview, which facilitates the client his or her perception of the source of the loneliness, the development of client-specific interventions. Increases the and have them discuss how they have tried to resolve the client’s sense of involvement and empowerment.63 situation. • Have the client list those persons in the environment who are Facilitates the client’s reality testing of perception of being alone. considered family, friends, and acquaintances. Then have the client note how many interactions per week occur with each person. Have the client identify what interferes with feeling connected with these persons. Note here the person responsible and schedule for this interaction. • When contributing factors have been identified, develop a plan Facilitates the development of alternative coping behaviors, and to alter them. This could include: improves social skills, which improves role performance and social � Assertiveness training confidence. � Role-playing difficult situations � Teaching the client relaxation techniques to reduce anxiety in social situations � Providing the client with aids to compensate for sensory deficits � Providing the client with special clothing or prosthetic devices to enhance physical appearance � Teaching the client personal hygiene necessary to maintain aesthetic appearance (ostomy care, incontinence care, or wound care) (continued) Copyright © 2002 F.A. Davis Company 494 SELF-PERCEPTION AND SELF-CONCEPT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Note here the specific interventions, and schedule necessary for this client with person responsible for the activity. For example, the primary nurse will interact with the client 30 min 2 times a day to teach assertive skills, or the client will attend social skills group at [time]. • Develop a list of those things the client finds rewarding, and Positive reinforcement encourages behavior and enhances provide these rewards as the client successfully completes self-esteem. Increases the client’s competence, and thus enhances progressive steps in treatment plan. This schedule should be role performance and self-esteem. developed with the client. Note here the schedule for rewards and the kinds of behavior to be rewarded. • Consult with occupational therapist if the client needs to learn specific skills to facilitate social interactions, such as cooking skills so friends can be invited to dinner, craft skills, or dancing so the client can join others in these social activities. • Include the client in groups on the unit. Assign the client Successful accomplishment of a valued task can provide positive activities that can be accomplished easily and that will provide reinforcement, which encourages social behavior. Provides positive social reinforcement from other persons involved in the opportunities for the client to practice social interaction skills. activities. Note here the group and activity schedule. • If lack of activities contributes to the loneliness, refer to Decreased activities can increase the sense of time passing slowly, Deficient Diversional Activity (Chap. 5) for detailed interventions. which perceptually increases the time spent alone, increasing the sense of loneliness.63 • Consult with social services if transportation or financial resource Decreased mobility can decrease social interaction and sense of problems contribute to social isolation. aloneness. • Discuss with clients those times it would be appropriate to be Promotes the client’s sense of control, while facilitating the alone, and develop a plan for coping with these times in a development of alternative coping behaviors. positive manner. For example, the client will develop a list of books to read and music to listen to, or call a friend.64 • When the client is demonstrating socially inappropriate Lack of positive reinforcement decreases a behavior. behavior, keep interactions to a minimum, inform the client that the behavior is inappropriate, and escort him or her to a place away from group activities. Note here the target behaviors for this client. • When inappropriate behaviors stop, discuss the behavior with Promotes the client’s sense of control, while promoting the the client, and develop a list of alternative kinds of behavior for development of alternative coping behaviors. the client to use in situations in which the inappropriate behavior is elicited. Note here those behaviors that are considered problematic, with the action to be taken if they are demonstrated. For example, the client will spend time out in seclusion or sleeping area. • Primary nurse will spend 30 min once a day with the client at Provides positive reinforcement for appropriate problem solving. [time] discussing the client’s reactions to social interactions and assisting the client with reality testing of social interactions, for example, what others might mean by silence, or various nonverbal and common verbal expressions. This time can also be used to discuss role relationships and the client’s specific concerns about relationships. • Assign the client a room near areas with high activity. Facilitates the client’s participation in unit activities. • Assign one staff person to the client each shift, and have this Decreases the client’s opportunities for socially isolating self. person interact with the client every 30 min while awake. • Have the client identify those activities in the community that are of interest and would provide opportunities for interactions with others. List the client’s interests here. • Develop with the client a plan for making contact with the Promotes the client’s sense of control, and begins the development identified community activities before discharge. of adaptive coping behaviors. • Arrange at least 1 h a week for the client to interact with his or Support system understanding facilitates the maintenance of new her support system in the presence of the primary nurse. This behaviors after discharge. will allow the nurse to assess and facilitate these interactions. Note here the schedule and responsible person. • Discuss with the support system ways in which they can facilitate client interaction, e.g., frequent telephone calls, teaching the client to use public transportation, meals-on-wheels, or community telephone call check-in services. (continued) Copyright © 2002 F.A. Davis Company LONELINESS, RISK FOR 495 (continued) ACTIONS/INTERVENTIONS RATIONALES • Model for the support system and for the client those kinds of Provides opportunities for the client to practice new role behaviors behavior that facilitate communication. in a safe, supportive environment. • Limit the amount of time the client can spend alone in room. This should be a gradual alteration and should

be done in steps that can easily be accomplished by the client. Note specific schedule for the client here. For example, the client will spend 5 min per hour in day area. Have staff person remain with the client during these times until the client demonstrates an ability to interact with others.63 • Provide a guest book in the client’s room for visitors to sign. This intervention assists with those situations where the client’s This should include a space for visitor’s name, date, and time perception of visitation is not congruent with actual contact with of visit. A space for a summary of the discussion could also be support systems. Provides the client and staff with documentation included. of visits to aid with reality testing. • Refer the client to appropriate community agencies. Gerontic Health See actions and interventions under Psychiatric Health. The older adult who is experiencing losses asso- ciated with aging, such as loss of a spouse, decline in physical health, and changes in role, is especially vulnerable to loneliness. Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family to identify and prevent risk factors Early recognition and intervention can interrupt development of of loneliness: loneliness. � Physical and social isolation � Deprivation • A terminal diagnosis can result in less outside interaction. If Reestablishes previous social contacts. friends stop visiting, assist the family and client to understand possible reasons: � It is difficult for others to face their own mortality. � Others may fear that the client is too sick for visitors. The client and family should speak frankly with friends and family about these issues and their wishes regarding visitors. • Assist the client and family in lifestyle adjustments that may be Home-based care requires involvement of the family. Loneliness necessary: can disrupt family schedules and role relationships. Adjustments in � Develop a plan for increased involvement; e.g., begin with family activities and roles may be required. social contacts that are least threatening. � Provide for personal hygiene. � Provide supportive environment. • Assist the family to set criteria to help them determine when Provides the family with background knowledge to seek additional intervention is required, e.g., inability of the client appropriate assistance as need arises. or family to care for the client. • Refer to appropriate assistive resources as indicated. Additional assistance may be required for the family to care for the family member with loneliness. Copyright © 2002 F.A. Davis Company 496 SELF-PERCEPTION AND SELF-CONCEPT PATTERN Loneliness, Risk for FLOWCHART EVALUATION: EXPECTED OUTCOME Has the patient implemented a plan to reduce the risk for loneliness? Yes No Record data, e.g., has joined Reassess using initial assessment factors. senior citizens dance club and local chapter of AARP. Works one day/wk as volunteer at children’s library. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and No Is diagnosis validated? nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., has made some telephone calls re: clubs to join Did evaluation show another but no activity beyond calls. problem had arisen? Yes Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company PERSONAL IDENTITY, DISTURBED 497 Personal Identity, Disturbed DEFINING CHARACTERISTICS33 DEFINITION To be developed. Inability to distinguish between self and nonself.33 RELATED FACTORS33 NANDA TAXONOMY: DOMAIN 6— None given. SELF-PERCEPTION; CLASS 1—SELF-CONCEPT RELATED CLINICAL CONCERNS NIC: DOMAIN 3—BEHAVIORAL; CLASS R— COPING ASSISTANCE 1. Autism 2. Mental retardation NOC: DOMAIN III—PSYCHOSOCIAL 3. Dissociative disorders, for example, psychogenic amnesia, psy- HEALTH; CLASS M—PSYCHOLOGICAL chogenic fugue, multiple personality, depersonalization disorder WELL-BEING 4. Borderline personality disorder HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Chronic Low or Situational Low Self-Esteem This most appropriate diagnosis is Disturbed Personal diagnosis addresses the lack of confidence in one’s Identity. An example would be the client who self and is characterized by negative self- perceives a life-support machine as part of the self. statements, lack of concern about personal Disturbed Body Image This diagnosis relates to appearance, and withdrawal from others not alterations in perceptions of self in conjunction related to physical problems or attributes. The self with actual or perceived alterations in body is defined. If the client demonstrates an inability to structure or function. Again, the self is known with differentiate self from the environment, then the this diagnosis. EXPECTED OUTCOME TARGET DATES Will list at least [number] characteristics of self versus nonself by A target date of 5 days would be acceptable for initial evaluation of [date]. progress toward expected outcomes. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health NOTE: Should the patient develop this nursing diagnosis on an adult health care unit, referral should be made immediately to a mental health nurse clinician. See nursing actions under Psychiatric Health. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for contributing factors that might predispose the Provides the database needed to more accurately and completely development of Disturbed Personal Identity: plan care. � Risk indicating an altered maternal-infant attachment, e.g., parents’ overprotection or ignoring of the infant � Altered development norms related to independent functioning, e.g., following commands (Check for organic or sensory-perceptual deficits.) � Preference for solitary play � Display of self-stimulation and/or self-mutilation behaviors � History of altered identity problems in the family • Provide basic care for other needs with prioritization for safety In anticipatory safety planning, standards must be in accord with needs. Close observation is mandatory. both the known as well as the unknown self-injury potential of the patient. • Administer medications as ordered, with attention to hydration The patient is prone to dehydration and malnutrition due to and nutritional concerns. inability to rely on usual thirst or appetite regulators. (continued) Copyright © 2002 F.A. Davis Company 498 SELF-PERCEPTION AND SELF-CONCEPT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide appropriate follow-up and collaboration with the family. Appropriate use of specialists will offer a more individualized plan of care with greater likelihood of meeting needs. • Assist the family in decision making regarding long-term care, Assistance and support in identification of options assists in e.g., institutionalization versus day care. decision making, reducing stress, and empowering the family. Women’s Health The nursing actions for the woman with this nursing diagnosis would be the same as those for the men- tal health client. Also see Risk for Loneliness and Anxiety. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Assign primary care nurse to establish trusting nurse-client Establishes boundaries so changes can be immediately processed.63 relationship. • Provide the client with information about unit structure, Assists the client in establishing clear interpersonal boundaries. policies, expectations, and requirements. • Provide a quiet, nonstimulating environment. Inappropriate levels of sensory stimuli can increase confusion and sense of disorganization. • Provide frequent interactions that assist the client with Promotes the development of a trusting relationship within the orientation. client’s attention span. • Verbal information should be provided in simple, brief Interactions with others also assist in reestablishing weak ego sentences. boundaries. • Sit with the client [number] minutes [number] times per day at Promotes the development of a trusting relationship. Provides [times] to provide the client with an opportunity to discuss positive reinforcement for the client, meeting needs in a more feelings and thoughts. constructive way. • Provide the client with honest, direct feedback in all interactions. Promotes the development of a trusting relationship. • Utilize constructive confrontation if necessary, to include: Assists the client in establishing ego boundaries, while supporting � “I” statements self-esteem. � Relationship statements that reflect nurse’s reaction to the interaction � Responses that will assist the client in understanding, such as paraphrasing and validation of perceptions • Develop, with the health team, a clear set of boundaries and Firm limits facilitate the client’s focusing on feelings rather than expectations and the consequences for inappropriate behaviors. moving away from them.65 Prevents staff splits, which are Schedule frequent team meetings to review the client’s behavior detrimental to clients who have identity and splitting problems.65 and to make revisions in care. Note times of meetings here. • Discuss with the client the source of the threat. Assists the client in developing more adaptive coping behaviors. • Develop with the client alternative coping strategies. Those Promotes the client’s sense of control and positive expectational set activities, items, or verbal responses that are rewarding for the by providing a concrete plan for responding to stressful situations. client should be listed here. • When the client is presented with a threat, assist with Behavioral rehearsal provides opportunities for feedback and progressing through one of the alternative coping methods, or modeling from the nurse. practice with the client the alternative coping methods [number] minutes twice a day. • Develop achievable goals with the client. (The goals that are Goal achievement enhances self-esteem and promotes a positive appropriate for this client should be listed here.) expectational set, which motivates the client to move on to more complex goals and behavior change. • As the client masters the first set of goals, develop increasingly Moves the client toward health goals in a manner that promotes complex goals and problems. self-esteem. • Provide positive reinforcement for accomplishments at any level. Positive reinforcement encourages behavior while enhancing (Those activities, items, or verbal responses that are rewarding self-esteem. for the client should be listed here.) • Do not argue with the client who is experiencing an alteration Arguing with the belief interferes with the development of a in thought process (refer to Chap. 7 for nursing actions related trusting relationship and does not serve to change the perceptions. to Disturbed Thought Process). • Monitor the client’s mental status before attempting learning or Alterations in mental status can interfere with the client’s ability to confrontation. If the client is disoriented, orient to reality as process information, and teaching at this point could increase needed. stimuli to a level that would only increase the client’s confusion and disorganization. (continued) Copyright © 2002 F.A. Davis Company PERSONAL IDENTITY, DISTURBED 499 (continued) ACTIONS/INTERVENTIONS RATIONALES • For clients with Dissociative Identity Disorder: � Do not ask for alter personalities. Does not further dissociation.37,65 Discourages dissociation and encourages integration. � Remind alters they are part of the host personality. Discourages dissociation, while encouraging integration. � Discuss the feelings that have been dissociated, rather than Encourages integration. asking for alternates. � Emphasize the normalcy of having a range of feelings. Point out that one day the host will be able to tolerate all feelings. � Do not reassure calm alters that they will be protected from Prevents the strengthening of angry alters and dissociation. hostile alters. • If disorientation is present related to organic brain dysfunction, Short-term memory loss will assist with changing the client’s distract the client from those disorientations that are not correct orientation without getting into a strong confrontation. with a brief, simple explanation. Gerontic Health NOTE: In the event the patient is unable to distinguish between self and nonself, it is necessary to con- tact a mental health clinician to further assess and devise the plan of care. Please see Psychiatric Health nursing actions. Home Health ACTIONS/INTERVENTIONS RATIONALES • Involve the client and family in planning and implementing Family involvement enhances effectiveness of interventions. strategies to reduce and cope with disturbance in personal identity: � Family conference: Discuss feelings related to disturbance in personal identity of the client. � Mutual goal setting: Establish realistic goals, and identify roles of each family member, e.g., provide a quiet environment and provide the client with honest and direct feedback. � Communication: Clear and honest communication among family members is essential. If organic brain dysfunction is present, the nurse may need to use distraction techniques. • Assist the client and family in lifestyle adjustments that may Disturbed Personal identity can be a chronic condition that alters be required: family relationships. Permanent changes in behavior and family � Maintaining a safe environment roles require evaluation and support. � Altering roles as necessary � Maintaining the treatment plan of the health care professionals guiding therapy • Consult with or refer to assistive resources as indicated. Utilization of existing services is efficient use of resources. Psychiatric nurse clinicians and support groups can enhance the treatment plan. Copyright © 2002 F.A. Davis Company 500 SELF-PERCEPTION AND SELF-CONCEPT PATTERN Personal Identity, Disturbed FLOWCHART

EVALUATION: EXPECTED OUTCOME Can the patient list X number of characteristics of self and same number of characteristics of nonself? Yes No Record data, e.g., easily lists Reassess using initial assessment factors. five characteristics of self with 100% accuracy; also accurately lists items that are nonself. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., cannot list more than two characteristics of self; listed four Did evaluation show a new nonself items as being self. Record problem had arisen? Yes CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company POWERLESSNESS, RISK FOR AND ACTUAL 501 Powerlessness, Risk for and Actual 2. Moderate a. Nonparticipation in care or decision making when op- DEFINITIONS33 portunities are provided b. Expressions of dissatisfaction and frustration over inabil- Risk for Powerlessness Risk for perceived lack of control over a ity to perform previous tasks and/or activities situation and/or one’s ability to significantly affect an outcome. c. Does not monitor progress Powerlessness Perception that one’s own action will not signifi- d. Expression of doubt regarding role performance cantly affect an outcome; a perceived lack of control over a current e. Reluctance to express true feelings situation or immediate happening. f. Fearing alienation from caregivers g. Passivity h. Inability to seek information regarding care NANDA TAXONOMY: DOMAIN 6— i. Resentment, anger, and guilt SELF-PERCEPTION; CLASS 1—SELF-CONCEPT j. Does not defend self-care practices when challenged NIC: DOMAIN 3—BEHAVIORAL; CLASS O— k. Dependence on others that may result in irritability BEHAVIORAL THERAPY, AND CLASS R—COPING 3. Severe ASSISTANCE a. Verbal expressions of having no control or influence over situation, outcome, or self-care NOC: DOMAIN IV—HEALTH KNOWLEDGE AND b. Depression over physical deterioration that occurs de- BEHAVIOR; CLASS R—HEALTH BELIEFS spite patient compliance with regimens c. Apathy DEFINING CHARACTERISTICS33 RELATED FACTORS33 A. Risk for Powerlessness 1. Physiologic A. Risk for Powerlessness a. Chronic or acute illness (hospitalization, intubation, ven- The defining characteristics serve also as the risk factors. tilator, suctioning) B. Powerlessness b. Acute injury or progressive debilitating disease process 1. Health care environment (e.g., spinal cord injury or multiple sclerosis) 2. Interpersonal interaction c. Aging (e.g., decreased physical strength, decreased mobility) 3. Illness-related regimen d. Dying 4. Lifestyle of helplessness 2. Psychosocial a. Lack of knowledge of illness or health care system RELATED CLINICAL CONCERNS b. Lifestyle of dependency with inadequate coping patterns c. Absence of integrality, for example, essence of power 1. Any diagnosis that is unexpected or new to the patient d. Decreased self-esteem 2. Any diagnosis resulting from a sudden, traumatic event e. Low or unstable body image 3. Any diagnosis of a chronic nature B. Powerlessness 4. Any diagnosis with a terminal prognosis 1. Low a. Expressions of uncertainty about fluctuation of energy levels b. Passivity HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Anxiety Anxiety may have as a component a Disturbed Thought Process This diagnosis can perception of Powerlessness. This would evolve into produce a sense of Powerlessness because of the a situation where the anxious client would not individual’s inability to accurately assess the attempt to resolve the situation. Powerlessness can situation. Thus, the most appropriate diagnosis also have Anxiety as a component. Deciding on the would be Disturbed Thought Process. primary diagnosis is based on the clinical judgment Fear Fear can produce a sense of Powerlessness, of the nurse about which symptoms predominate. just as Powerlessness can produce Fear. Ineffective Individual Coping A perception of Differentiation is based on the predominant Powerlessness can produce Ineffective Individual symptom sequence. Coping because if one perceives that one’s own Deficient Knowledge If the client lacks sufficient actions cannot influence a situation, appropriate knowledge about a situation, a perception of actions may not be taken. If Ineffective Individual Powerlessness may result. Therefore, Deficient Coping is determined to result from a perceived Knowledge would be the primary diagnosis. lack of influence, then Powerlessness would be the primary diagnosis. EXPECTED OUTCOME TARGET DATES Will describe at least [number] areas of control over self by [date]. A target date of 3 days would be realistic to check for progress to- ward reduced feeling of powerlessness. Copyright © 2002 F.A. Davis Company 502 SELF-PERCEPTION AND SELF-CONCEPT PATTERN ADDITIONAL INFORMATION tually exercising power to motivate other parts of the system to act in certain ways. Understanding this conceptual model provides the The paradox of the metaphor of power has been presented in the client with an opportunity to know how one’s behavior affects the literature. Systems theorists and cyberneticians have presented the situation and provides nurses with an opportunity to understand most useful information when one is planning intervention strate- their reactions to and feelings toward the client with the diagnosis gies. Keeney66 presents a summary of the debate over the power of Powerlessness. If the power metaphor is not accepted, this metaphor. In sum, most cyberneticians find this to be an invalid affects the concept of internal versus external locus of control. metaphor when discussing systems of interaction. The process of The concepts of internal and external loci of control become a system involves mutual interactions, and within a system each metaphors for how a person perceives personal influence within member exerts influence over the other members. Therefore, the an interactional system. Persons with an external locus of control individual who acts as if he or she is powerless is exerting “power” do not understand their influence on the system, whereas persons over the other parts of the system to act in a manner that would with an internal locus of control have an understanding of per- increase this “lost” personal power. The “powerless” one is then ac- sonal influence. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Plan care with the patient on a daily basis: Allows the patient to have control over environment and care � Likes and dislikes attributes. Imparts to the patient a sense of power. � Where he or she wants personal items placed � Routines, to extent possible, according to the patient’s own pace and schedule � Diet selected by the patient • Encourage the patient to provide as much of self-care as possible. • Avoid, when interacting with the patient: Sets limits on behavior. Facilitates a nonthreatening environment. � Reinforcing manipulative behavior � Using negative feedback, e.g., arguing with the patient � Overuse of health care terminology • Do not ignore cultural and religious preferences. • Provide calm, safe environment throughout hospitalization: Allows for verbalization of feelings and acceptance of those feelings. � Answer question truthfully. Avoids overwhelming the patient and increasing sensation of � Explain all procedures and rationale for procedures. powerlessness. � Give positive reinforcement to extent possible. � Reduce sensory input. Balance high technology with high touch and appropriate attention. � Provide diversional activity. � Use same staff to degree possible. • Involve significant others in care. Promotes involvement in care and advocacy for the patient, thus empowering both the patient and significant others. • Monitor, at least once per shift: Changes in these signs may signal dysfunctions in other patterns � Vital signs and deterioration of diagnosis to depression. � Exercise � Sleep-rest periods � Food and fluid intake • Refer to appropriate community resources prior to discharge. Support groups can encourage progress in building self-esteem, provide advocacy, and provide long-term support. Child Health ACTIONS/INTERVENTIONS RATIONALES • Perform a thorough assessment appropriate for the patient’s Developmentally appropriate assessment will provide cues and developmental needs to identify specific factors that are causing reveal data to generate a more accurate and complete plan of care. powerlessness: � Use of art � Use of puppetry � Use of group therapy (continued) Copyright © 2002 F.A. Davis Company POWERLESSNESS, RISK FOR AND ACTUAL 503 (continued) ACTIONS/INTERVENTIONS RATIONALES • Allow the family to participate in care as they are able and Family participation provides security to the child and choose to. empowerment for the parents, with increased growth in coping skills. • Adopt plan of care to best meet the child’s and family’s needs Valuing individual preferences is demonstrated by frequent by including them in voicing preferences whenever appropriate. encouragement to express choices. Promotes a sense of control. • Identify and address educational needs that might be Misinformation and inadequate knowledge are contributing factors contributing to powerlessness. that can be easily overcome by teaching. • Refer to the patient by preferred name or nickname. List that Promotes personalized communication. Points out individuality, name here. and serves to empower the patient. • Allow for privacy and need to withdraw to the family as a unit. Demonstrates appropriate respect for the family. Attaches value to the family unit. • Keep the patient and family informed as changes occur. Frequent updates and provision of information help clarify actions and reduce anxiety, which results in a greater sense of control. • Provide opportunities for the parents to demonstrate appropriate Allows practice in a nonthreatening environment, which increases care for the child, to aid in feeling in control on dismissal from sense of control. hospital. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Provide the prospective parents with factual information about Provides basic information that assists the family in decision the type of choices available for birth, and assist them to identify making, thus promoting empowerment of the family unit.34 their preference: � Traditional obstetric services � Family-centered maternity care units � Single-room maternity care � Mother-baby care � Birthing center • Provide answers to questions in an open, direct manner. • Provide information on all procedures so the patient can make informed choices: � Assist the patient and significant others in establishing realistic goals (list goals with evaluation dates here). � Allow the patient and significant others to participate in decision making. • Allow the patient maximum control over the environment. This Decreases perception of powerlessness, and assists in transition to could include the husband’s staying in postpartum room to parenthood. assist with infant care, keeping the newborn with the mother at all times, using different positions for birth (e.g., squatting or hand-knee position), having grandparents and siblings in the room with the mother and newborn. • Provide positive reinforcement for parenting tasks. • Assist the patient in identifying infant behavior patterns and understanding how they allow her infant to communicate with her. • Support the patient’s decisions, e.g., to breastfeed or not to breastfeed or who she wants as significant others during the birthing process. • Reassure the new mother that it takes time to become acquainted with her infant. • Support and reassure the mother in learning infant care, e.g., breastfeeding, bathing, changing, holding a newborn, cord care, or bottle-feeding. • Allow the parents to verbalize fears and insecure feelings about Promotes decision making, and leaves decisions up to family by their new roles as parents. providing the guidance and support that is needed. • Assist the parents in identifying lifestyle adjustments that may be needed because of the incorporation of a newborn into the family structure. • Involve significant others in discussion and problem-solving Involvement enhances motivation to stay with plan, thus activities regarding role changes within the family. reinforcing decision-making capacity of new parents.67 ACTIONS/INTERVENTIONS RATIONALES (continued) Copyright © 2002 F.A. Davis Company 504 SELF-PERCEPTION AND SELF-CONCEPT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES DOMESTIC VIOLENCE (See Hopelessness also) • Provide the patient with support, and assist in identifying actions the patient can take to begin helping herself. Recognize that leaving the abuser is not necessarily the best option at all times and that leaving is a process that may take time for a client. • Provide safe atmosphere for identifying needs and making decisions. • Provide information in an honest, clear manner to help with decision-making process. Do not attempt to “convince” the client of the correct course of action. Tell the client that there are options, that no one deserves to be beaten, and that she can stop the cycle of violence with outside help. • Assist the patient in identifying resources available to her and her children. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Sit with the client [number] times per day at [times] for 30 min Promotes the development of a trusting relationship,

and assists to discuss feelings and perceptions the client has about the the client in identifying factors contributing to the feelings of identified situation. powerlessness. • Identify client preferences for daily routine, and place this It is vital to this client to have the information shared with all information on the chart to be implemented by the staff. staff so that it will not appear that the time spent in providing information was wasted. Promotes the client’s perception of control. • Provide information to questions in an open, direct manner. Facilitates the development of a trusting relationship. • Provide information on all procedures at a time when the client Facilitates the development of a trusting relationship, and can ask questions and think about the situation. promotes the client’s sense of control. • Allow the client to participate in decision making at the level to The client who has never made an independent decision would be which he or she is capable. If necessary, offer decision situations overwhelmed by the complexity of the decisions made daily by the in portions that the client can master successfully. (The amount corporation executive. Promotes the client’s sense of control. of information that the client can handle should be noted here as well as a list of decisions the client has been presented with.) • Identify the client’s needs and how these are currently being met. Assertive direct communication increases the opportunity for the If these involve indirect methods of influence, discuss alternative client’s needs being met. When the client is successful in getting direct methods of meeting these needs. (The client who requests needs met in a direct manner, his or her sense of control and medication for headache every 15 min is requesting attention self-esteem will increase. and is encouraged to approach the nurse and ask to talk when the need for attention arises.) • Provide positive reinforcement for behavior changed and Positive reinforcement encourages behavior while enhancing decisions made. (Those things that are reinforcing for this client self-esteem. should be listed here along with the reward system that has been established with the client, e.g., play one game of cards with the client when a decision about what to eat for dinner is made, or walk with the client on hospital grounds when a decision in made about grooming.) • Provide verbal social reinforcements along with behavioral Promotes the development of a trusting relationship. reinforcements. • Keep promises (specific promises should be listed here so that all staff will be aware of this information). • Assist the client in identifying current methods of influence and Promotes positive orientation by assisting the client in identifying in understanding that influence is always there by providing way in which they are already “powerful.” feedback on how influence is being used in the client’s interactions with the nurse. • Accept the client’s decisions if the decisions were given to the Promotes the client’s sense of control, and enhances self-esteem. client to be made—e.g., if the decision to take or not take medication was left with the client, the decision not to take the medication should be respected. (continued) Copyright © 2002 F.A. Davis Company POWERLESSNESS, RISK FOR AND ACTUAL 505 (continued) ACTIONS/INTERVENTIONS RATIONALES • Allow the client maximum control over the environment. This Promotes the client’s sense of control. could include where clothes are kept, how room is arranged, and times for various activities. Note preferences here. • Spend 30 min 2 times per day at [times] allowing the client to Promotes the client’s sense of control in a manner that increases role-play interactions that are identified as problematic. (The opportunities for success. This success serves as positive specific situations as well as new behavior should be noted here). reinforcement. • Provide opportunities for significant others to be involved in Provides opportunities for the support system and the client to care as appropriate. Careful assessment of the interactions practice new ways of interacting while in a situation where they between the client and significant others must be made to can receive feedback from the health care team. determine the best balance of influencing behavior between the client and support system. Specific situation should be listed here. • Monitor the health care team’s interactions with the client for The role of the nurse in the therapeutic milieu is to promote behavior patterns that would encourage the client to choose healthy interpersonal interactions. indirect methods of influence. This could include interactions that encourage the adult client to assume a childlike role. If situations are identified, they should be noted here. • Provide ongoing feedback to the client on progress. Positive reinforcement encourages behavior. • Assist the client in establishing realistic goals. List goals with Realistic goals increase the client’s opportunities for success, evaluation dates here. Usually dividing the goal set by the providing positive reinforcement and enhancing self-esteem. client in half provides an achievable goal; this could also involve dividing one goal into several smaller goals. • Refer the client to outpatient support systems, and assist him Provides the client with support for continuing new behaviors in or her with making arrangements to contact these before the community after discharge. discharge. These could be systems that would assist the client in maintaining a perception of influencing ability and could include assertiveness training groups, battered persons’ programs, and legal aid. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Ensure access to call light, telephone, personal care items, and Increases the patient’s ability to take control of some aspects of care. television control.32 • Advocate for the patient, ensuring that health care professionals Stereotyping of older adults is problematic in health care are not leaving the patient out of the decision loop because of professions.68 the patient’s chronologic age. Home Health ACTIONS/INTERVENTIONS RATIONALES • Involve the client and family in planning and implementing Personal involvement and goal setting according to personal wishes strategies to reduce Powerlessness: enhance the likelihood of success in resolving problem. � Family conference: Identify and discuss strategies. � Mutual goal setting: Agree on goals to reduce Powerlessness. Identify roles of all participants. � Discuss effective communication techniques. • Assist the client and family in lifestyle adjustments that may be Lifestyle adjustments require permanent changes in behavior. required: Self-evaluation and support facilitate the success of these lifestyle � Relaxation techniques: Yoga, biofeedback, hypnosis, changes. breathing techniques, imagery � Providing opportunities for the individual to exert control over situation, giving choices when possible, supporting and encouraging self-care efforts � Problem solving and goal setting � Providing sense of mastery and accomplishable goals in secure environment (continued) Copyright © 2002 F.A. Davis Company 506 SELF-PERCEPTION AND SELF-CONCEPT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Maintaining the treatment plan of the health care professionals guiding therapy � Obtaining and providing accurate information regarding condition • Consult with or refer to assistive resources as indicated. Use of existing community resources provides for effective use of resources. • Assist the client and family to set criteria to help them Early identification of issues requiring professional evaluation will determine when the intervention of a health care professional increase the probability of successful intervention. is required—e.g., inability to perform activities of daily living, or condition has declined rapidly. Copyright © 2002 F.A. Davis Company POWERLESSNESS, RISK FOR AND ACTUAL 507 Powerlessness, Risk for and Actual FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient describe at least X areas of life he or she has control over? Yes No Record data, e.g., has listed Reassess using initial assessment factors. areas of control such as leisure time, diet, work hours, and budget; states, “Guess I hadn’t really thought enough about it.” Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and No Is diagnosis validated? nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., “I don’t have any control—well, maybe I do, but I don’t Did evaluation show another know what.” Record CONTINUE and problem had arisen? Yes change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 508 SELF-PERCEPTION AND SELF-CONCEPT PATTERN Self-Esteem, Chronic Low, Situational Low, C. Risk for Situational Low Self-Esteem The risk factors also serve as the defining characteristics. and Risk for Situational Low DEFINITIONS33 RELATED FACTORS23 Chronic Low Self-Esteem Long-standing negative self-evaluation A. Chronic Low Self-Esteem or feelings about self or self-capabilities. To be developed. B. Situational Low Self-Esteem Situational Low Self-Esteem Development of a negative percep- 1. Developmental changes (specify) tion of self-worth in response to a current situation (specify). 2. Body image disturbance Risk for Situational Low Self-Esteem Risk for developing a negative 3. Functional impairment (specify) perception of self-worth in response to a current situation (specify). 4. Loss (specify) 5. Social role changes (specify) 6. Lack of recognition or rewards NANDA TAXONOMY: DOMAIN 6— 7. Behavior inconsistent with values SELF-PERCEPTION; CLASS 2—SELF-ESTEEM 8. Failures or rejections NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING C. Risk for Situational Low Self-Esteem (Risk Factors) ASSISTANCE 1. Developmental changes (specify) 2. Body image disturbance NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; 3. Functional impairment (specify) CLASS M—PSYCHOLOGICAL WELL-BEING 4. Loss (specify) 5. Social role changes (specify) DEFINING CHARACTERISTICS33 6. History of learned helplessness 7. History of abuse, neglect, or abandonment A. Chronic Low Self-Esteem 8. Unrealistic self-expectations 1. Rationalizes away or rejects positive feedback and exag- 9. Behavior inconsistent with values gerates negative feedback about self (long standing or 10. Lack of recognition or rewards chronic) 11. Failures or rejections 2. Self-negative verbalization (long standing or chronic) 12. Decreased power or control over environment 3. Hesitant to try new things or situations (long standing or 13. Physical illness (specify) chronic) 4. Expressions of shame or guilt (long standing or chronic) RELATED CLINICAL CONCERNS 5. Evaluates self as unable to deal with events (long standing or chronic) 1. Pervasive developmental disorders 6. Lack of eye contact 2. Disruptive behavior disorders 7. Nonassertive or passive 3. Eating disorders 8. Frequent lack of success in work or other life events 4. Organic mental disorders 9. Excessively seeks reassurance 5. Substance use or dependence or abuse disorders 10. Overly conforming or dependent on others’ opinion 6. Mood disorders 11. Indecisive 7. Adjustment disorders B. Situational Low Self-Esteem 8. Personality disorders 1. Verbally reports current situational challenges to self-worth 9. Trauma 2. Self-negating verbalizations 10. Surgery 3. Indecisive, nonassertive behavior 11. Medical problems that contribute to the loss of body functions 4. Evaluates self as unable to deal with situations or events 12. Pregnancy 5. Expressions of helplessness and uselessness 13. Chronic diseases HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Disturbed Body Image This diagnosis relates to Disturbed Personal Identity. Working with the alterations in the perception of self when there is Disturbed Personal Identity will take care of the an actual or perceived change in body structure or self-esteem problem. function. If interviewing reveals the patient Ineffective Individual Coping This diagnosis perceives a potential change in body structure or results from the client’s inability to appropriately function, then Disturbed Body Image is the most cope with stress. If the client demonstrates a appropriate diagnosis. decreased ability to cope appropriately, he or she Disturbed Personal Identity When the patient may also have some defining characteristics cannot differentiate self from nonself, there related to self-esteem disturbance. Teaching and probably also exists some self-esteem problems; supporting coping will also assist in correcting the however, the primary diagnosis would be self-esteem problem. Copyright © 2002 F.A. Davis Company SELF ESTEEM, CHRONIC LOW, SITUATIONAL LOW, AND RISK FOR SITUATIONAL LOW 509 EXPECTED OUTCOME TARGET DATES Will list at least [number] positive aspects about self by [date]. A target date of 3 to 5 days would be acceptable to begin monitor- ing progress. NURSING ACTIONS/INTERVENTIONS AND RATIONALES NOTE: An attitude of genuine warmth, acceptance of clients, and respect for uniqueness are charac- teristics required for successful nursing interventions.49 Adult Health ACTIONS/INTERVENTIONS RATIONALES • Collaborate with psychiatric nurse clinician regarding care (see Collaboration promotes a more holistic and total plan of care. Psychiatric Health nursing actions). • Teach the patient and significant others the patient’s self-care Participation in own care increases confidence and self-esteem. requirements as needed. Support the patient’s self-care management activities. • Control pain with medication, stress management techniques, Conserves energy to focus on adaptive

coping strategies. and diversional activities. • Encourage the patient to use anxiety-reducing techniques, e.g., Assists the patient to reduce anxiety and regain self-control, thus progressive muscle relaxation, deep breathing, yoga, meditation, increasing self-esteem. assertiveness, or guided imagery. • Encourage assertive behavior in interacting with the patient. Helps the patient avoid vacillating from one behavior to another. Assist the patient to review passive and aggressive behavior. Promotes self-control and a “win-win” situation, which increases self-esteem. • Promote calm, safe environment by avoiding judgmental Decreases anxiety and promotes a trusting relationship. attitude, actively listening, using reflection, being consistent in approach, and setting boundaries. • Allow the patient to progress at own rate. Start with simple, Helps the patient have sense of mastering of tasks, and promotes concrete tasks. Reward success. self-esteem. • Use frequent contact, 15 min every 2 h on [odd/even] hour, Assists in self-understanding and facilitates self-acceptance. with the patient to encourage verbalization of feelings: � Be honest with the patient. � Point out and limit self-negating statements. � Do not support denial. � Focus on reality and adaptation (not necessarily acceptance). � Set limits on maladaptive behavior. � Focus on realistic goals. � Be aware of own nonverbal communication and behavior. � Avoid moral value judgments. � Encourage the patient to try to note differences in situations and events. • Help the patient to ascertain why he or she can maintain self-esteem in one situation and not in another situation. • Build on coping mechanisms or interpretations that maintain Supports adaptive coping, and helps broaden inventory of coping or increase self-esteem. Assist to find alternative coping strategies. mechanisms. • Encourage the patient to use available resources: Decreases feelings of loss, and increases self-esteem when patient � Prosthetic devices does not feel “different” from previous self. � Assistive devices � Reconstructive and corrective surgery • Refer to and collaborate with community resources. Provides ongoing and long-term support. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for contributory factors related to poor self-esteem, Generates the database needed to more accurately and completely including: plan care. (continued) Copyright © 2002 F.A. Davis Company 510 SELF-PERCEPTION AND SELF-CONCEPT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Family crisis � Lack of adequate parenting � Lack of sensory stimulation � Physical scars, malformation, or disfigurement � Altered role performance � Social isolation � Developmental crisis • Identify ways the patient can formulate or reestablish a positive Developmental norms serve as the conceptual framework for self-esteem according to developmental needs: assisting the child to increase self-esteem. � Coping skills � Communication skills � Role expectations � Self-care � Activities of daily living � Basic physiologic needs; primary health care � Expression of self � Peer and social relationships � Feelings of self-worth � Decision making � Validation of self, e.g., setting developmentally appropriate expectations • Praise and reinforce positive behavior. Reinforcement of desired behavior serves to enhance permanence of behavior. • Explore value conflicts and their resolution. Values must be clarified as one strives to find one’s identity. A healthy sense of self contributes to a positive self-image. • Collaborate with other health care team members as needed. Collaboration promotes a more holistic plan of care. • Meet primary health needs in an expedient manner. Conserves energy, minimizes stress, and enhances trust. • Provide appropriate attention to other alterations, especially Related issues must be considered as contributing factors to the those directly affecting this diagnosis such as Risk for Violence diagnosis. Inattention to these factors means resolution of or Impaired Parenting. problem will not occur. • Provide for follow-up before the child is dismissed from hospital. Attaches value to follow-up, and promotes likelihood of compliance. • Use developmentally appropriate strategies in care of these Developmentally based strategies are most likely to not frighten children: the child or parent unnecessarily. � Infant and Toddlers: Play therapy or puppets � Preschoolers: Art � School-agers: Art or role-playing � Adolescents: Discussion or role-playing • Carry out teaching of appropriate health maintenance. This Personal hygiene and self-care will enhance a positive self-esteem could be the appropriate way of dealing with crisis related to as the patient copes with daily living. shyness or poor communication skills. Women’s Health ACTIONS/INTERVENTIONS RATIONALES POST PARTUM AND PARENTING ROLES • Allow the patient to “relive” birthing experience by listening Promotes ventilation of feelings, and provides a database for quietly to her perception of the birthing experience. intervention. • Encourage the patient to express her concerns about her physical appearance. • List here the activities in which the patient can engage to gain positive feelings about herself. • Join friends or an exercise group with the same goals as the Provides a support system that demonstrates adaptive behaviors. patient. • Encourage participation in activities outside the home as Support and positive activities assist in adaptation to new parental appropriate—e.g., parenting support groups or women’s groups. role and increase sense of self-worth. • Encourage networking with other women with similar interests. • Encourage the patient to “do something for herself ”: � Buy a new dress. (continued) Copyright © 2002 F.A. Davis Company SELF ESTEEM, CHRONIC LOW, SITUATIONAL LOW, AND RISK FOR SITUATIONAL LOW 511 (continued) ACTIONS/INTERVENTIONS RATIONALES � Fix her hair differently. � Find some time for herself during the day. � Take a walk. � Take a long bath. � Rest quietly. � Do a favorite thing, e.g., reading, sewing, or some hobby. � Spend time with spouse, without the children. • Encourage the patient to engage in positive thinking. • Encourage the patient to engage in assertiveness training. NOTE: Pregnant teenagers, single mothers, and battered women have similar needs in building or rebuilding their self-esteem. • Provide a safe, nonjudgmental atmosphere that will encourage the patient to verbalize her needs and concerns. • Assist the patient in identifying support groups with similar concerns and available community resources. • Encourage teen mothers to take advantage of opportunities provided by various school systems to finish their education. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Sit with the client [number] minutes [number] times per shift Expression of feelings and concerns in an accepting environment to discuss the client’s feelings about self. can facilitate problem solving. • Answer questions honestly. Promotes the development of a trusting relationship. • Provide feedback to the client about the nurse’s perceptions of Assists the client with reality testing in a safe, trusting relationship. the client’s abilities and appearance by: � Using “I” statements � Using references related to the nurse’s relationship to the client � Describing the client’s behavior in situations � Describing the nurse’s feelings in relationship • Provide positive reinforcement. List here those things that are Positive reinforcement encourages behavior. reinforcing for the client and when they are to be used. Also list here those things that have been identified as nonreinforcers for this client, and include social rewards. • Provide group interaction with [number] persons [number] Disconfirms the client’s sense of aloneness, and assists the client to minutes 3 times a day at [times]. This activity should be gradual experience personal importance to others while enhancing and within the client’s ability—e.g., on admission the client may interpersonal relationship skills. Increasing these competencies tolerate one person for 5 min. If the interactions are brief, the can enhance self-esteem and promote positive orientation. frequency should be high—i.e., 5-min interactions should occur at 30-min intervals. • Protect the client from harm by: Client safety is of primary concern. � Removing all sharp objects from environment � Removing belts and strings from environment � Providing a one-to-one constant interaction if risk for self-harm is high � Checking on the client’s whereabouts every 15 min � Removing glass objects from environment � Removing locks from room and bathroom doors � Providing a shower curtain that will not support weight � Checking to see whether the client swallows medications • In a supportive attitude and manner, reflect back to the client Increases the client’s awareness of negative evaluations of self. negative self-statements he or she makes. • Set achievable goals for the client. Goals that can be accomplished increase the client’s perceptions of power and enhance self-esteem. • Provide activities that the client can accomplish and that the Activities the client finds demeaning could reinforce the client’s client values. negative self-evaluation. Accomplishment of valued tasks provides positive reinforcement and enhances self-esteem. (continued) Copyright © 2002 F.A. Davis Company 512 SELF-PERCEPTION AND SELF-CONCEPT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide verbal reinforcement for achievement of steps toward Positive reinforcement encourages behavior while enhancing a goal. self-esteem. • Have the client develop a list of strengths and potentials. Promotes positive orientation and hope. • Define the client’s lack of goal achievement or failures as simple Promotes positive orientation. mistakes that are bound to occur when one attempts something new—e.g., learning comes with mistakes, or if one does not make mistakes one does not learn. • Make necessary items available for the client to groom self. Physical grooming can facilitate positive self-esteem by encouraging positive feedback from others. • Spend [number] minutes at [time] assisting the client with Presence of the nurse can serve as a positive reinforcement. Positive grooming, providing necessary assistance, and providing reinforcement encourages behavior while enhancing self-esteem. positive reinforcement for accomplishments. • Reflect back to the client those statements that discount the Raises the client’s awareness of this behavior, which facilitates positive evaluations of others. change. • Focus the client’s attention on the here and now. Past happenings are difficult for the nurse to provide feedback on. • Present the client with opportunities to make decision about Promotes the client’s sense of control. care, and record these decisions in the chart. • Develop with the client alternative coping strategies. Promotes the client’s sense of control, and enhances opportunities for positive outcome when stressful events are encountered. • Practice new coping behavior with client [number] minutes at Behavioral rehearsal provides opportunities for feedback and [times]. modeling of new behaviors from the nurse. • Place the client in a therapy group for [number] minutes once a Facilitates the client’s awareness of others’ thoughts about day where the focus is mutual sharing of feelings and support themselves and him or her. of each other. • Identify with the client those situations that are perceived as Facilitates developing alternative coping behavior. most threatening to self-esteem. • Assist the client in identifying alternative methods of coping Increases the client’s opportunities for success, and each success with the identified situations. These should be developed by enhances self-esteem. the client and listed here. • Role-play with the client once per day for 45 min those Behavioral rehearsal provides opportunities for feedback and high-risk situations that were identified and the alternative modeling of new behaviors from the nurse. coping methods. • Establish an appointment with the client and significant others Support system understanding facilitates the maintenance of new to discuss their perceptions of the client’s situation (the time of behaviors after discharge.69 this and follow-up appointments should be listed here). • Discuss with the client current behavior and reactions of others Provides opportunities for feedback on new behaviors in a safe, to this behavior. trusting environment. • Provide the client with [number] minutes of assertive skills Teaches clients they have a right to their feelings, beliefs, and training [number] times per week. This could be provided in a opinions, and provides them with the skills to express themselves group or individual context. effectively.37 • Practice with the client [number] minutes twice a day making Promotes the development of a positive orientation. positive “I” statements. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient in developing self-care skills needed for Enhances perception of control over the situation. managing the current illness.70 • Assist the patient in identifying his or her unique abilities, and Increases recognition of successes that come from the use of relate the benefits you as a nurse receive from your interactions personal strengths. with the patient.70 • Review the patient’s current abilities and how they may require Increases perception of functional ability in preferred life roles. role modification.70 • Assist with personal grooming needs, such as removal of excess Attention to personal appearance can have a positive influence on facial hair and use of cosmetics, where applicable.71 self-esteem and thus perception of the individual. Copyright © 2002 F.A. Davis Company SELF ESTEEM, CHRONIC LOW, SITUATIONAL LOW,

AND RISK FOR SITUATIONAL LOW 513 Home Health ACTIONS/INTERVENTIONS RATIONALES • Involve the client and family in planning and implementing Family involvement improves effectiveness of implementation. strategies to reduce and cope with disturbance in self-esteem: � Family conference: Discuss perceptions of the client’s situations and identify realistic strategies. � Mutual goal setting: Establish goals and identify roles of each family member—e.g., provide safe environment, assist with grooming, or focus on here and now. � Communication. • Assist the client and family in lifestyle adjustments that may be Lifestyle changes require long-term changes in behavior. Such required72: changes in behavior require support. � Obtaining and providing accurate information � Clarifying misconceptions � Maintaining safe environment � Encouraging appropriate self-care without encouraging dependence or expecting unrealistic independence � Providing opportunity for expressing feelings � Realistic goal-setting � Providing sense of mastery and accomplishable goals in secure environment � Maintaining the treatment plan of the health care professionals guiding therapy � Relaxation techniques: Yoga, biofeedback, hypnosis, breathing techniques, or imagery � Altering roles • Consult with or refer to assistive resources as indicated. Utilization of existing services is efficient use of resources. Psychiatric nurse clinician and support groups can enhance the treatment plan. Copyright © 2002 F.A. Davis Company 514 SELF-PERCEPTION AND SELF-CONCEPT PATTERN Self-Esteem, Chronic Low, Situational Low, and Risk for Situational Low FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient list X number of positive self-aspects? Yes No Record list here as data. Reassess using initial assessment factors. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., cannot list more than two positive self-statements. Did evaluation demonstrate Listed four negative self-statements. a new problem had arisen? Yes Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company SELF-MUTILATION, RISK FOR AND ACTUAL 515 Self-Mutilation, Risk for and Actual B. Self-Mutilation 1. Cuts or scratches on body DEFINITIONS33 2. Picking at wounds 3. Self-inflicted burns (e.g., eraser or cigarette) Risk for Self-Mutilation Risk for deliberate self-injurious behav- 4. Ingestion or inhalation of harmful substances or object ior causing tissue damage with the intent of causing nonfatal injury 5. Biting to attain relief of tension. 6. Abrading Self-Mutilation Deliberate self-injurious behavior causing tissue 7. Severing damage with the intent of causing nonfatal injury to attain relief of 8. Insertion of object(s) into body orifices tension. 9. Hitting 10. Constricting a body part NANDA TAXONOMY: DOMAIN 11—SAFETY/ RELATED FACTORS33 PROTECTION; CLASS 3—VIOLENCE NIC: DOMAIN 3—BEHAVIOR; CLASS O—BEHAVIOR A. Risk for Self-Mutilation THERAPY The risk factors also serve as the related factors. B. Self-Mutilation NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; 1. Psychotic state (command hallucination) CLASS O—SELF-CONTROL 2. Inability to express tension verbally 3. Childhood sexual abuse DEFINING CHARACTERISTICS33 4. Violence between parental figures 5. Family divorce A. Risk for Self-Mutilation (Risk Factors) 6. Family alcoholism 1. Psychotic state (command hallucination) 7. Family history of self-destructive behavior 2. Inability to express tension verbally 8. Adolescence 3. Childhood sexual abuse 9. Peers who self-mutilate 4. Violence between parental figures 10. Isolation from peers 5. Family divorce 11. Perfectionism 6. Family alcoholism 12. Substance abuse 7. Family history of self-destructive behavior 13. Eating disorders 8. Adolescence 14. Sexual identity crisis 9. Peers who self-mutilate 15. Low or unstable self-esteem 10. Isolation from peers 16. Low or unstable body image 11. Perfectionism 17. Labile behavior (mood swings) 12. Substance abuse 18. History of inability to plan solutions or see long-term con- 13. Eating disorders sequences 14. Sexual identity crisis 19. Use of manipulation to obtain nurturing relationship with 15. Low or unstable self-esteem others 16. Low or unstable body image 20. Chaotic or disturbed interpersonal relationships 17. Labile behavior (mood swings) 21. Emotionally disturbed and/or battered children 18. History of inability to plan solutions or see long-term con- 22. Feels threatened with actual or potential loss of signifi- sequences cant relationship, for example, loss of parent or parental 19. Use of manipulation to obtain nurturing relationship with relationship others 23. Experiences dissociation or depersonalization 20. Chaotic or disturbed interpersonal relationships 24. Experiences mounting tension that is intolerable 21. Emotionally disturbed and/or battered children 25. Impulsivity 22. Feels threatened with actual or potential loss of significant 26. Inadequate coping relationship 27. Experiences irresistible urge to cut or damage self 23. Loss of parent or parental relationship 28. Needs quick reduction of stress 24. Experiences dissociation or depersonalization 29. Childhood illness or surgery 25. Experiences mounting tension that is intolerable 30. Foster, group, or institutional care 26. Impulsivity 31. Incarceration 27. Inadequate coping 32. Character disorder 28. Experiences irresistible urge to cut or damage self 33. Borderline personality disorders 29. Needs quick reduction of stress 34. Developmentally delayed and autistic persons 30. Childhood illness or surgery 35. History of self-injurious behavior 31. Foster, group, or institutional care 36. Feeling of depression, rejection, self-hatred, separation anx- 32. Incarceration iety, guilt, and depersonalization 33. Character disorder 37. Poor parent-adolescent communication 34. Borderline personality disorders 38. Lack of family confidant 35. Loss of control over problem-solving situation 36. Developmentally delayed and autistic persons RELATED CLINICAL CONCERNS 37. History of self-injurious behavior 38. Feeling of depression, rejection, self-hatred, separation 1. Borderline personality disorder anxiety, guilt, and depersonalization 2. Organic mental disorders Copyright © 2002 F.A. Davis Company 516 SELF-PERCEPTION AND SELF-CONCEPT PATTERN 3. Autism 6. Multiple personality disorder 4. Schizophrenia 7. Sexual masochism 5. Major depression 8. Affective disorder or mania HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Risk for Violence This diagnosis is very similar to coping. These could be companion diagnoses, the Risk for Self-Mutilation. However, self- with priority being given to the self-mutilation mutilation speaks only to the intent to injure self problem to decrease the life-threatening aspects and specifically exempts suicide. before working with the client to increase coping Ineffective Individual Coping Certainly self- abilities. mutilation would be indicative of ineffective EXPECTED OUTCOME TARGET DATES Will demonstrate no self-mutilation attempts by [date]. Initially progress should be evaluated on a daily basis because of the danger involved for the patient. After stabilization has been demon- strated, the target date could be moved to 5- to 7-day intervals. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health NOTE: Should this diagnosis be made on an adult health patient, immediately refer him or her to a mental health practitioner. See Psychiatric Health nursing actions. Child Health NOTE: Refer patient to a mental health practitioner. See Psychiatric Health nursing actions related to this diagnosis. Women’s Health The nursing actions for the woman with this diagnosis would be the same as those given for the mental health patient. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Sit with the client [number] minutes [number] times per shift at Promotes the development of a trusting relationship, while [times] to assess the client’s mood, distress, needs, and feelings. providing a nonintrusive manner.73 • Place the client on a frequent observation schedule. Note that Client safety is of primary importance. Increased attention may schedule here. This observation should take place in a inadvertently reinforce injury if it occurs in relation to self-injury nonintrusive manner. episodes.73 • Remove from the environment any object that could be used to Client safety is of primary importance. harm self. • Use one-to-one observation to protect the client during periods Physical and chemical restraints have been demonstrated to of risk for self-harming behavior. escalate behavior. At times clients may escalate their behavior to be placed in restraints.74 • Develop a baseline assessment of the self-injury patterns. This Provides baseline information on which to base criteria for should include frequency of behavior, type of behavior, factors behavioral change. Provides positive reinforcement. related to self-harm, and effects of self-harm on the client and other clients. Note this information here. • Answer the client’s questions honestly. Promotes the development of a trusting relationship. • Reframe the client’s self-harming behavior as habitual behavior Promotes a positive orientation, and supports the client’s that can be changed as any habit. While doing this, do not strengths.75 diminish the client’s experience of pain and discomfort. • Identify, with the client, goals that are reasonable. Note those Assists the client in gaining internal control of problematic goals here—e.g., the client will contact staff when feeling need behaviors.75 Achieving goals provides reinforcement of positive to harm self. behavior and enhances self-esteem. (continued) Copyright © 2002 F.A. Davis Company SELF-MUTILATION, RISK FOR AND ACTUAL 517 (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide positive verbal reinforcement for positive behavior Positive reinforcement encourages behavior and enhances change. self-esteem. • Have the client develop a list of “feel-good” reinforcers. Note Promotes the client’s sense of control, while supporting a positive those reinforcers here.74 orientation. • Provide feel-good reinforcers according to the reinforcement Provides consistency in behavioral rewards. Positive reinforcement plan developed. Note the plan here. encourages behavior and enhances self-esteem. • Identify with the client those situations and feelings that trigger Promotes the client’s perception of control by pairing self-injurious self-injury.74 behavior to specific situations and decreasing cognitive exaggerations.76 • Identify with the client strategies that can be utilized to cope Promotes the client’s sense of control, and assists the client with with these situations. Note the identified strategies here. cognitive preparation for coping with these situations.76 • Select one identified strategy and spend 30 min a day at [times] Behavioral rehearsal provides opportunities for feedback and practicing this with the client. This could be in the form of a modeling from the nurse. role-play. Note here the person responsible for this practice. • Meet with the client just prior to and after trigger situations to Promotes the client’s sense of control, and provides an opportunity assist with planning coping strategies and processing outcome for the nurse to provide positive reinforcement for adaptive coping to revise plans for future situations.74 mechanisms. • Initiate the client’s coping strategy or provide distraction, such Provides opportunity for the client to practice new behaviors in a as physical activity, when the client identifies that the urge to supportive environment where positive feedback can be provided. harm himself or herself is strong. Acknowledge that the Promotes the client’s sense of control, and enhances self-esteem. distraction will not increase comfort as much as self-harm Promotes positive orientation. would at the present time, but the feelings of mastery will be satisfying.75 • Identify, with the client, areas of social skill deficits, and Enhances interpersonal skills by providing the client with more develop a plan for improving these areas. This could include adaptive ways of achieving interpersonal goals. assertiveness training, communication skills training, and/or relaxation training to reduce anxiety in trigger situations. Note plan and schedule for implementation here. This should be a progressive plan with rewards for accomplishment of each step.74–76 • Develop a schedule for the client to attend group therapies. Provides an opportunity for the client to practice interpersonal Note this schedule here. skills in a supportive environment and to observe peers modeling interpersonal skills. • Meet with the client and the client’s support system to plan coping strategies that can be used at home. Assist system in obtaining resources necessary to implement this plan. • In the event that self-mutilation does occur, provide the Prevents loss of function and further injury. necessary first aid in a matter-of-fact manner. � Avoid elaborate focusing on the injury. Prevents the development of secondary gains from self-injury.77 � Sit with the client for [number] minutes to discuss the Supports the development of appropriate methods of coping with feelings that preceded the act. feelings. Gerontic Health The nursing actions for the gerontic patient with this diagnosis would be the same as those given for the mental health patient. Home Health See Psychiatric Health nursing actions for additional interventions. ACTIONS/INTERVENTIONS RATIONALES • Monitor for factors contributing to risk for self-mutilation. Provides database for early recognition and intervention. • Involve the client and family in planning, implementing, and Family involvement enhances effectiveness of interventions. promoting reduction or elimination of risk for self-mutilation: � Family conference: Discuss perspective of each family member. � Mutual goal setting: Develop short- and long-term goals with evaluative criteria. Tasks and roles of each family member should be specified. � Communication: Open, direct, reality-oriented communication. (continued) Copyright © 2002 F.A. Davis

Company 518 SELF-PERCEPTION AND SELF-CONCEPT PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Assist the client and family in lifestyle adjustments that may Adjustments in lifestyle require long-term behavioral changes. be required: Such changes are enhanced by education and support. � Development and use of support networks � Provision of safe environment � Protection of client from harm � Long-term care necessity • Consult with or refer to assistive resources such as caregiver Utilization of existing services is efficient use of resources. A support groups as needed. psychiatric nurse clinician, support group, and mental health–mental retardation expert can enhance the treatment plan. Copyright © 2002 F.A. Davis Company SELF-MUTILATION, RISK FOR AND ACTUAL 519 Self-Mutilation, Risk for and Actual FLOWCHART EVALUATION: EXPECTED OUTCOME Has the patient made any attempts of self-mutilation? No Yes Record data, e.g., has made Reassess using initial assessment factors. no threats of or attempts at self-mutilation since day 2 of admission; making positive self-statements, attending group, and actively participating. Record RESOLVED (may wish to use CONTINUE until patient No Is diagnosis validated? discharged). Delete nursing diagnosis, expected outcome, target date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., is making self- mutilation threats daily; has made Did evaluation show another three self-mutilation attempts since problem had arisen? Yes admission. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company CHAPTER 9 Role-Relationship Pattern 1. CAREGIVER ROLE STRAIN, RISK FOR 7. RELOCATION STRESS SYNDROME, AND ACTUAL 526 RISK FOR AND ACTUAL 570 2. FAMILY PROCESSES, INTERRUPTED, 8. ROLE PERFORMANCE, AND FAMILY PROCESSES, INEFFECTIVE 574 DYSFUNCTIONAL: 9. SOCIAL INTERACTION, ALCOHOLISM 534 IMPAIRED 580 3. GRIEVING, ANTICIPATORY 544 10. SOCIAL ISOLATION 585 4. GRIEVING, DYSFUNCTIONAL 551 11. SORROW, CHRONIC 591 5. PARENT, INFANT, AND CHILD 12. VERBAL COMMUNICATION, ATTACHMENT, IMPAIRED, RISK IMPAIRED 596 FOR 557 13. VIOLENCE, SELF-DIRECTED 6. PARENTING, IMPAIRED, RISK FOR AND OTHER-DIRECTED, AND ACTUAL, AND PARENTAL ROLE RISK FOR 602 CONFLICT 561 Pattern Description 5. Is the client making verbal threats against others? a. Yes (Risk for Violence) The role-relationship pattern is concerned with how a person feels he b. No or she is performing the expected behavior delineated by the self and 6. Is the client exhibiting increased motor activity? others. Each of us has several roles we fulfill during our daily life, and a. Yes (Risk for Violence) with these roles come related responsibilities. Included in our roles b. No are family, work, and social relationships. Disruption in these roles, 7. Can the patient speak English? relationships, and responsibilities can lead a patient to seek assistance a. Yes from the health care system. Likewise, satisfaction with the roles, re- b. No (Impaired Verbal Communication) lationships, and responsibilities is a patient strength that can be used 8. Does the patient demonstrate any difficulty in talking? in planning care for other health problem areas. a. Yes (Impaired Verbal Communication) b. No 9. Does the client verbalize difficulty with social situations? Pattern Assessment a. Yes (Impaired Social Interaction) 1. Is the client exhibiting distress over a potential loss? b. No a. Yes (Anticipatory Grieving) 10. Does the client indicate strained relationships with his or her b. No family or others? 2. Is the client denying a potential loss? a. Yes (Impaired Social Interaction) a. Yes (Anticipatory Grieving) b. No b. No 11. Does the patient have family or significant others visiting or calling? 3. Is the client exhibiting distress over an actual loss? a. Yes a. Yes (Dysfunctional Grieving) b. No (Social Isolation) b. No 12. Is the patient uncommunicative, withdrawn, or not making 4. Is the client denying an actual loss? eye contact? a. Yes (Dysfunctional Grieving) a. Yes (Social Isolation) b. No b. No 520 Copyright © 2002 F.A. Davis Company CONCEPTUAL INFORMATION 521 13. Does the client indicate that admission might impact role (fam- 31. Does the patient appear depressed following a change in living ily, work, or leisure)? environments? a. Yes (Ineffective Role Performance) a. Yes (Risk for Relocation Stress Syndrome) b. No b. No 14. Does the family or do significant others verbalize that admis- 32. Does the patient facing a change in a living environment have sion might impact the patient’s role (family, work, or leisure)? a good support system? a. Yes (Ineffective Role Performance) a. Yes b. No b. No (Risk for Relocation Stress Syndrome) 15. Does the child show signs or symptoms of physical or emo- 33. Does the patient express concern over his or her recent move? tional abuse? a. Yes (Risk for Relocation Stress Syndrome) a. Yes (Impaired Parenting) b. No b. No 16. Do the parents indicate difficulty in controlling the child? a. Yes (Impaired Parenting) Conceptual Information b. No 17. Do the parents demonstrate attachment behaviors? The social connotation for role performance and relationships is a a. Yes major premise for the intended use of this pattern. A role is a com- b. No (Risk for Impaired Parenting, Risk for Impaired Parent, prehensive pattern of behavior that is socially recognized and that Infant, and Child Attachment) provides a means of identifying and placing an individual in a so- 18. Do the parents make negative comments about the child? ciety. Role is the interaction point between the individual and soci- a. Yes (Risk for Impaired Parenting) ety. It also serves as a means of coping with recurrent situations. b. No The term “role” is a borrowed theatrical noun that emphasizes the 19. Does the family demonstrate capability to meet the child’s distinction of the actor and the part. A role remains relatively sta- physical needs? ble even though there may be a variety of persons occupying the a. Yes position or role; however, the expectations of the script, other play- b. No (Interrupted Family Processes) ers, and the audience all influence role enaction.1 The importance 20. Does the family demonstrate capability to meet the child’s of each of these factors varies with the context. In our personal emotional needs? roles, the script is equivalent to the societal “norms,” and our audi- a. Yes ence can be real or imagined. Uniqueness of style may exist within b. No (Interrupted Family Processes) the boundaries of the role as determined by society. 21. Does a family member exhibit signs and symptoms of alco- Because our roles are such an integral part of our lives, we sel- holism? dom analyze them until they become a problem to our internal or a. Yes (Dysfunctional Family Processes: Alcoholism) external adaptation to life’s demands. Roles that are often associated b. No with stages of development serve as society’s guides for meaningful 22. Do the parents express concern about ability to meet the child’s and satisfying relationships in life by facilitating an orderly method physical or emotional needs? for transferring knowledge, responsibility, and authority from one a. Yes (Parental Role Conflict) generation to the next. b. No During the childhood years, an individual will have numerous 23. Are the parents frequently questioning decisions about the contacts with different individuals who have different sets of val- child’s care? ues. The child learns to internalize the values of those significant in a. Yes (Parental Role Conflict) his or her life as personal goals are actualized. When the goals are b. No realistic, consistent, and attainable, the individual is assisted in de- 24. Was the infant premature? veloping a sense of self-esteem as these various roles are mastered. a. Yes (Risk for Impaired Parent, Infant, and Child Attachment) Each new role carries with it the potential for gratification and in- b. No creased ego identity if the role is acquired. If the role is not mas- 25. Do the parents express anxiety regarding the parental role? tered, poor self-esteem and role confusion may ensue. The poten- a. Yes (Risk for Impaired Parent, Infant, and Child Attachment) tial for successful role mastery is diminished with multiple role b. No demands and the absence of suitable role models. Additionally, role 26. Has the patient recently received a diagnosis related to a acquisition depends on adequate patterns of cognitive-perceptual chronic physical or mental condition? ability and a healthy sense of self. a. Yes (Chronic Sorrow) Although all roles are learned within the context of one’s culture, b. No specific roles are delineated in two ways: acquired and achieved. 27. Is the patient verbally expressing sadness? Acquired roles are those roles with variables over which the individ- a. Yes (Chronic Sorrow) ual has no choice, such as gender or race. Role achievement allows b. No for some choice by the individual with the result of purposefully 28. Is the patient in the role of primary caregiver for another person? earning a role, such as choosing to become a professional nurse. a. Yes (Risk for Caregiver Role Strain, Caregiver Role Strain) Many roles are not clearly defined as being either acquired or b. No achieved but rather are a combination of the two. Roles are not mu- 29. Does the patient verbally express difficulty in or concerns tually exclusive, but are interdependent. The roles an individual as- about caregiving role? sumes usually blend well; however, the roles that a person achieves a. Yes (Caregiver Role Stress) or acquires may not always make for a harmonious blend. Role con- b. No flicts may occur at the most internalized personal level to a gener- 30. Has the patient recently moved from one living site to another? alized societal level. a. Yes (Risk for Relocation Stress Syndrome) Roles may be influenced by a multitude of factors, including eco- b. No nomics, family dynamics, changing roles of institutions, and gender Copyright © 2002 F.A. Davis Company 522 ROLE-RELATIONSHIP PATTERN role expectations. Roles can be mediated through role-playing skills Husband and wife Economic specialization and cooperation, and self-conceptions. It is hoped that with the increased demands on sexual cohabitation; joint responsibility for support, care, the individual, society will continue to value human dignity with re- and upbringing of children; well-defined reciprocal rights spect for life itself. Roles should allow for self-actualization. with respect to property, divorce, and spheres of authority One of the more recent eclectic theories of personality develop- Father and son Economic cooperation in masculine activities ment encompassing role theory is that of symbolic interaction. In this under leadership of the father; obligation of material support orientation, social interaction has symbolic meaning to the partici- vested in father during childhood of son and in son during pants in relation to the roles assigned by society. (For further re- old age of father; responsibility of father for instruction and lated conceptual information, refer to Chapter 8, Self-Perception discipline of son; duty of obedience and respect on part of and Self-Concept Pattern.) son; tempered by some measure of comradeship Symbolic interaction encompasses the roles assumed by humans Mother and daughter Relationship parallel to that between fa- in their constant interaction with other humans, communicating ther and son, but with more emphasis on child care and eco- symbolically in almost all they do. This interaction has meaning to nomic cooperation and less on authority and material sup- both the giver and the receiver of the action, thus requiring both port (However, strong relationships in the development of persons to interact symbolically with themselves as they interact mothering skills and parenting techniques lead to obligations with each other. Symbolic interaction involves interpretation, that of emotional support and caretaking activities vested in the is, ascertaining the meaning of the actions or remarks of the other mother during the childhood of daughter and in daughter person, and definition, that is, conveying indication to another per- during old age of mother.) son as to how he or she is to act. Human association consists of a Father and daughter Responsibility of father for protection and process of such interpretation and definition. Through this process, material support prior to marriage of daughter; economic co- the participants fit their own acts to the ongoing acts of one another operation, instruction, and discipline appreciably less promi- and guide others in doing so.2 nent than in father-son relationship; playfulness common in To explore further how relationships develop, a brief overview of infancy of daughter, but normally yields to a measure of re- kinship is offered. A

kinship system is a structured system of rela- serve with the development of a strong incest taboo tionships in which individuals are bound one to another by com- Mother and son Relationship parallel to mother and daughter plex, interlocking relationships. These relationships are commonly but with more emphasis on financial and emotional support referred to as families. It is not so much the family form in which in later life of mother one lives as how that family form functions that defines whether or Elder and younger brother Relationship of playmates, devel- not there is a cohesive family structure: oping into that of comrades; economic cooperation under leadership of elder; moderate responsibility of elder for in- An ideal family environment consists of a family that has many rou- struction and discipline of younger tines and traditions, provides for quality time between adults and Elder and younger sister Relationship parallel to that between children, has regular contact with relatives and neighbors, lives in a elder and younger brother, but with more emphasis on phys- supportive and safe neighborhood, has contact with the work world ical care of the younger sister and has adult members who model a harmonious and problem- solving relationship. (pp. 505–506)3 Brother and sister Early relationship of playmates, varying with relative age; gradual development of an incest taboo, The 1980s saw great change in family structures with an explo- commonly coupled with some measure of reserve; moderate sion of individualized living arrangements and lifestyles requiring economic cooperation; partial assumption of parental role, new definitions of the “family.”3–6 Fewer nuclear families consist- especially by the elder sibling ing of husband, wife, and children exist today, and this is no longer the only acceptable form for family life. The following are some of The nurse must exercise great caution in maintaining sensitivity the different family forms identified in today’s society.3–6 to the individual meaning attached to various roles and the way in which these roles are perceived and assumed. With the current so- Nuclear family Husband, wife, and children living in a com- cietal and economic changes, the individual’s roles are being im- mon household, sanctioned by marriage pacted on a daily basis even without the added stress of a health Nuclear dyad Husband and wife alone; childless or children problem. have left home Single-parent family One head of household, mother or fa- Developmental Considerations ther, as a result of divorce, abandonment, or separation Single adult alone Either by choice, divorce, or death of a NEONATE AND INFANT spouse Three-generation family Three or more generations in a single The newborn period is especially critical for the development of the household first attachment that is so vital for all future human relationships. Kin network Nuclear households or unmarried members liv- Attachment behavior includes crying, smiling, clinging, following, ing in close geographic proximity and cuddling. The infant is dependent on its mother and father for Institutional family Children in orphanages or residential basic needs of survival. This is often demanding and requires par- schools ents to place self-needs secondary to the needs of the infant. This Homosexual family Homosexual couples with or without makes for a potential role-relationship alteration. children Although dependent on others, the infant is an active participant in role-relationship pattern development from conception on. The Despite the differences in family forms and cultural differences, infant is capable of influencing the interactions of those caring for primary relationships within various family structures reveal him or her. Reciprocal interactions also influence the maternal- markedly similar characteristics in all societies. These relationships paternal-infant relationship. Positive interactions will be greatly in- were described in 19497 and still exist in the various family forms fluenced by infant-initiated behavior as well as maternal-paternal cited today: responses and the reciprocal interaction of all involved. The state of Copyright © 2002 F.A. Davis Company DEVELOPMENTAL CONSIDERATIONS 523 the infant as well as the state of the parent interacting with the in- ten, it is because of crying. The attempt to quiet the infant can take fant must be considered as critical. the form of lashing out for those individuals unable to deal with the It is important to note that any alteration in health status of usual role-relationship patterns. The infant is unable to defend him- the mother, the neonate, or both has the potential of interfering self or herself, and therefore is to be protected by reporting of any with the establishment of the maternal-infant relationship. This suspected abusive or negligent behavior. At particular risk would be may not necessarily be the case, but it is often critical that the po- infants with feeding or digestive disorders, premature or small-for- tential risk be acknowledged early so that residual, secondary prob- gestational-age infants who require feedings every 2 hours, or others lems can be prevented with appropriate nursing intervention. It is perceived as “demanding” or “irritable.” Also at risk would be infants also important to keep in mind that the infant is taking in all situ- who are born with congenital anomalies or disfigurements. ational experiences and that as learning occurs through interaction with the environment, a gradual evolution of role-relationship pat- TODDLER AND PRESCHOOLER terns occurs. By approximately 12 months of age, the infant shows fear of be- The toddler has an increasing sense of identity and knows himself ing left alone and will search for the parents with his or her eyes. or herself as a separate person. The toddler treats other children as The infant will avoid and reject strangers. There is an obvious in- if they were objects and gradually becomes involved in parallel creasing interest in pleasing the parent. In protest, the infant cries, play, which then leads to a more interactive play with peers. The screams, and searches for the parent. In despair, the infant is list- sharing of possessions is not yet to be expected for toddlers. The less, withdrawn, and disinterested with the environment. In de- toddler begins to formulate a sense of right and wrong, with the tachment or resignation, a superficial “adjustment” occurs in which ability to conform to some social demand, as exemplified by the ca- the infant appears interested in surroundings, happy, and friendly pacity for self-toileting. It is reasonable that a toddler would begin for short periods of time. The infant is emotionally changeable from to work through problems of family relations with other children crying to laughing with a beginning awareness of separation from while playing. the environment. Still, the infant uses the mother as a safe haven The preschool child talks and plays with an imaginary playmate from which to explore the world. The infant will have a favorite toy, as a projection. What is offered may be what the child views as bad blanket, or other object that serves to comfort him or her in times in himself or herself. The preschooler may have some friends of the of stress. (Sucking behavior may also serve to calm the infant, and same sex, and opportunities for socialization serve critical func- eventually the infant will develop self-initiated ways of dealing with tions. The preschool child lives in the “here and now” and is capa- the stressors of life, such as thumbsucking versus the actual taking ble of internalizing more and more of society’s norms. There is a of formula or milk.) sense or morality and conscience by this age. A strong sense of fam- The infant receives cues from significant others and primary ily exists for the preschooler. caregivers regarding grief responses such as crying, with a prefer- The toddler may be unusually dependent on the mother, objects ence for the mother. Depending on age and situational status, the of security, and routines. He or she is capable of magical thinking infant may protest by crying for the mother. In a weakened state, and may believe in animation of inanimate objects, such as believ- the infant may make little response of preference for caregivers. ing an x-ray machine is really a mean monster. Toddlers may According to family structure, the neonate or infant will adapt to be fearful of seeing blood. These fears may be unrelated to actual usual socialization routines within reasonable limits. Actual isola- situations. tion for the infant would occur perhaps if the primary caregiver The preschooler may be critical of himself or herself and may could not exercise usual role-taking behavior for socialization. If blame himself or herself for a situation, with some attempt at view- this behavior is arrested for marked periods of time, there is a po- ing the current situation as punishment for previous behavior or tential for developmental delays secondary to the lack of appropri- thoughts. He or she will tolerate brief separation from parents in ate social stimulation. usual functioning. Play or puppet therapy that is appropriate to the The newborn period is especially critical for the development of situation will help the preschooler in expressing feelings. the neonate’s first attachment for future human relationships. Dur- The toddler must have room to safely explore, with a sense of au- ing this period, the infant must depend on others for his or her care tonomy evolving in the ideal situation. If social isolation limits these and basic needs. This is often a demanding situation for parents, who opportunities, the toddler will be limited in role-relationship expo- must sacrifice their own needs to best meet the needs of the infant. sure. This will often result in either social isolation or a form of forced The infant is dependent on others for care ranging from required precocious role-taking in which the toddler is perceived as being able food for physical growth to appropriate sensory and social stimula- to satisfy the companionship needs of adults. The toddler may mis- tion. In the absence of the stability usually afforded by the family in interpret socialization opportunities as abandonment or punishment, its usual functioning pattern, the infant may be at risk for failure to so short intervals of parallel play with one peer, to begin with, would thrive or developmental delay. Ultimately, rather than developing a be appropriate. Toddlers who are denied opportunities for peer in- sense of trust and a feeling that the world is a place in which one’s teraction would be at risk for role-relationship problems. needs are met, the infant will doubt and mistrust others. This in turn The child of the preschool age group may experience alteration places the infant at risk for an abnormal pattern of development. in socialization attempts if overpowered by peers, if there are too Crying serves as the primitive verbal communication for the many rigid or unrealistic rules, or if the situation places the child in neonate and infant. As the infant begins to understand and respond a situation that presents values greatly different from those of the to the spoken word, the world should be symbolized as comforting child and his or her family. If the child at this age experiences pro- and safe. With time, basic attempts at verbalization are noted in im- longed social isolation or rejection, there could be marked poten- itation of what is heard. There is a correlation between parental tial for difficulty in forming future relationships. If things do not go speech stimulation and the actual development of speech in young well in his or her socialization, the child at this age may blame him- children, suggesting a positive effect for early stimulation. Echolalia self or herself. (the often pathologic repetition of what is said by other people as if The toddler will seek out opportunities to explore and interact echoing them) and attempts at making speech are most critical to with the environment, provided there is a safe haven to return to as note during this time. represented by the family. When this facilitative factor is not pres- The infant may be the recipient of violent behavior, and, all too of- ent, the toddler may regress and become dependent on primary Copyright © 2002 F.A. Davis Company 524 ROLE-RELATIONSHIP PATTERN caregivers or others or may manifest frustration via extremes in de- This child is at risk of social isolation if a situation is different from manding behavior. The child’s subsequent development may also previous socialization opportunities. He or she may experience value be affected by family process alteration. conflict and

question the rules. He or she may also be afraid to ex- The preschool child is able to verbalize concerns regarding press desires or concerns regarding socialization needs for fear of changes in family process but is unable to comprehend dynamics. It punishment. Peer involvement is a most vital component of assisting is critical to attempt to view the altered process through the eyes of the school-ager to formulate views of acceptable social behavior. the preschooler who could blame himself or herself for the change or The school-ager may try to assume the role of a parent if the dys- crisis, or who may think magically and have fears that may be unre- function of the family relates to the parent of the same sex. This may lated to the situation. Subsequent development may be altered by be healthy with appropriate acknowledgment of limitations. At this family process dysfunction, with regression often occurring. age, the child is concerned with what other friends may think about At this age, it is important to stress the need for ritualistic be- the family, with some stigma attached in certain cultures to divorce, havior as a means of mastering the environment with adequate an- homosexuality, and altered lifestyles. It would be critical for the ticipatory safety. This period allows for knowing “self ” as a separate school-ager to have a close friend who might share the cultural entity. The toddler is capable of attempting to conform to social de- views of his or her own family to best endure the altered family mands but lacks ability of self-control. process. The importance of setting limits must be stressed with regard to Allowance for increasing interests outside the home should be safety and disciplinary management. At this age, the child begins to made with sensitivity to parental approval or disapproval. The child resist parental authority. Methods of dealing with differences or may rebel against parental authority in an attempt to be like peers. rules from one setting to another must be simple and appropriate Confidence in self and a general sense of well-being will promote to the situation. adequacy in communication development. The child of this age For the toddler, this time can prove frustrating, with a need to be continues to learn vocabulary and takes pride in his or her ability understood despite a limited vocabulary. Jargon and gestures may to demonstrate appropriate use of words. At this age, jokes and rid- be misinterpreted, with resultant frustration for the child and the dles serve as a means of encouraging peer interaction with speech. parent. Patience and understanding go far with a child of this age. Reading is a leisure activity for the school-age child. Pictures and the telling of stories serve as means of enhancing The child will usually enjoy school and consider peer interaction speech as well as instilling an appreciation for reading and speech. an enjoyable part of life. In instances in which the child feels infe- Feelings come to be expressed by the spoken word also. The child rior, there may be a risk for violence or abusive behavior as a cover- is able to refer to self as “I,” “me,” or by name. up for poor self-image or low self-esteem. Often there will be re- By preschool age, the child is able to count to 10, is able to de- lated role-relationship alterations as well. The family serves as a fine at least one word, and may name four or five colors. Speech means of valuing the interaction, which should foster the appro- now serves as a part of socialization in play with peers. Wants priate enjoyment of friendships. At risk would be those children should be expressed freely as the child broadens his or her contact with learning disabilities or handicaps, parental conflicts, or related with persons other than primary family members. The preschooler role-relationship alteration. enjoys stories and television programs and attempts to tell stories of his or her own creation. ADOLESCENT If the toddler is unable to fulfill the expectations of parents or caregivers who demand unrealistic behavior, there is risk of abuse. Vacillation between dependence and independence is a common Especially noteworthy would be a desire for the young toddler to occurrence for the adolescent who is attempting to establish a sense be capable of self-toileting behavior when in fact such is not possi- of identity. The adolescent questions traditional values, especially ble. This places the toddler in a target population for abuse also. At those of parents. There is a gradual trend to independent function- this age, the toddler may be unable to express hostility or anger in ing that allows the adolescent to assume roles of adulthood, in- the verbal mode, and so a common occurrence may be temper cluding the development of intensive relationships with members tantrums. At risk for violence would be the toddler who resists of the opposite sex. parental authority in discipline and cannot meet demands of the The adolescent will be constantly weighing self-identity versus parents. perceived identity expressed via peers. He or she may be fearful of expressing true feelings or concern for fear of rejection by peers, SCHOOL-AGE CHILD parents, or significant others. Isolation from peers places the ado- lescent at risk for altered self-identity as well as altered role- Learning social roles as male or female is a major task for the school- relationship patterns. age child, with a preference for spending time with friends of the The adolescent is able to assist within the family during times of same sex rather than the family. The school-ager is capable of role- altered process. It is important to stress that in more and more dual- taking and values cooperation and fair play. There may be a strict career or single-parent families, young adolescents spend more and moralism of “black and white” with no gray areas noted. The more time alone. Nonetheless, adolescents should still have oppor- school-ager enjoys simple household chores, likes a reward system, tunities for peer interaction and socialization according to the fam- and has the capacity for expressing feelings. Fear of disability and ily’s needs. concern for missing school are typical concerns for this age group. There may be marked vacillations, as the adolescent strives to Illness may impose separation from the peer group. Although in- find self-identity, with dependence and independence issues. Even dependent of parents in health, the school-ager may require close more marked rebellion against parental wishes may be manifest at parental relationship in illness or crisis. Loss of control and fear of this time as peer approval is sought. mutilation and death are real concerns. The school-age child may Any factors that may interfere with usual speech patterns may fear disgracing parents if loss of control such as crying occurs. He prove especially difficult for the adolescent. Bracing of teeth may be or she is aware of the severity of his or her prognosis and may even common, with the potential for self-image alteration. Also, the deal with reality better than parents or adults might. The school- eruption of 12-year molars could prove painful, as might the pos- age child may use art as a means of expressing his or her feelings. sible impaction of wisdom teeth later. Expressed wit is valued in Copyright © 2002 F.A. Davis Company DEVELOPMENTAL CONSIDERATIONS 525 this age group, as might be special colloquial expressions to qual- MIDDLE-AGE ADULT ify group or peer identity. Difficulty in expression of self may prove most difficult for this individual. Respect for times of reflection and Middle age, or middlescence, is often considered the most produc- estrangement should be maintained. tive years of an individual. Persons in this age group are usually se- The adolescent may be caught in a crossfire of strife for inde- cure in a profession or career, are in the middle of raising a family, pendence versus dependence. For this group, it is paramount that and often must assume responsibility for aging parents. self-control be attained to develop the meaningful relationships so As biophysical changes occur, there is a concurrent adaptation of critical for appropriate role-relationship patterns. Often those ado- the cognitive and physical activities of the individual. The body lescents who have not acquired appropriate socialization skills re- ages in varying stages or degrees, and young middle-age adults usu- sort to drugs or alcohol as a means of feeling better and escaping ally retain the body structure and activity level they established as the reality of life. This may also foster loss of control as reality is dis- young adults. Middle-age adults with more sedentary lifestyles torted. In many instances, there may be related juvenile delin- must establish exercise programs to retain their youthful figures. quency, with resultant records of lawbreaking. The greatest changes facing both men and women during this time Additionally, any adolescent who is assuming a role that stresses are those associated with the climacteric and the loss of reproduc- or negates the usual development of self-identity would be at risk tive capabilities. These biologic and physical changes can affect sex- for violence as a means of coping. An example of this would be two ual lifestyles either positively or negatively, depending on the per- young teenagers attempting to parent when they themselves still ception and orientation of the individual. require parenting. Most middle-age adults function well and learn to gradually ac- cept the changes of aging, and with proper nutrition, exercise, and YOUNG ADULT a healthy lifestyle, they can experience excellent health and a pro- ductive middlescence. Middle-age people usually begin to face Although biophysical and cognitive skills reach their peak during more accidents, illness, and death; they begin to deal with their own the adult years, the young adult is still in a period of growth and de- aging process and death, as well as that of their parents. There is of- velopment. Striving for achievement of an education, job security, ten a role reversal, with the middle-age adult assuming the role of meaningful intimate relationships with others, and establishment of parent. a family are the primary focuses of the young adult. Although young This is the time of life when individuals usually review their adults usually have achieved independence, they find themselves goals and aspirations, sometimes to find that they did not reach learning socially relevant behavior and settling into specific acquired the potential they once dreamed. Most middle-age adults begin to roles within a chosen profession or occupation. They begin to adopt feel that there is not enough time to accomplish all they want to some of the values of the group to which they belong and to assume accomplish, and they begin to adjust to the fact that they may not assured roles such as marriage and parenting. reach all the goals they set in their youth. This can result in a loss Cognitively, young adults have reached their peak level of intel- of self-esteem, or it can be a motivation to develop previously un- lectual efficiency, and they are able to think abstractly and to syn- tapped reservoirs, which can lead to self-actualization and per- thesize and integrate their ideas, experiences, and knowledge. Think- sonal satisfaction. ing for the adult usually involves reasoning, taking into consideration past experiences, education, and the possible outcomes of a situation OLDER ADULT more realistically and less egocentrically than the adolescent. Young adulthood is still a time of great adjustment. The individ- With aging, individuals may have fewer demands placed on them, ual is expected to look at self in relation to society, learning how to thus leaving more time and fewer potential opportunities for role deal with personal needs and desires as opposed to the needs and performance. This may also be a time when one is able to fulfill vol- desires of others, and managing the economic and physical needs of unteer roles and those of choice versus those of demand. A critical life. Sexual activity focuses toward the development of a single inti- factor may be the freedom one feels as basic needs are met. If health mate, meaningful relationship and the establishment of a family. In is satisfactory and one has children or grandchildren to enjoy, fi- developing the role of parenting, the young adult often falls back on nancial stability, and the ability

to pursue fulfillment via role en- the parenting patterns and behavior of his or her own parents. gagement, this experience would be self-actualizing. On the other The young adult begins to assume the responsibility of provid- hand, if one’s health fails, few meaningful family supports exist, and ing for a family. Most young adults are members of dual-career fam- financial needs arise, self-actualizing role performance is potentially ilies and thus face the stresses of multiple roles. Many of these threatened. young adults become single parents, and the stresses of multiple re- The older adult must deal with decreasing function with resul- sponsibilities and roles are greater both at home and at work. Just tant decreasing socialization potential. This is a time for retrospec- as during adolescence, the negation of development of self-identity tion and pondering the past, with sincere concerns regarding the can lead to crises, role strain, conflict, and often failure in the young future and death. In some instances, full functional level is possi- adult. ble, whereas for others life is lived vicariously. Elder role-modeling As the adult acquires full role responsibility, there may be diffi- opportunities, with respect for those who have lived life, still exist culties related to role diffusion, role confusion, role strain, or re- in many cultures. For these individuals, the aging process is wel- lated assumption of appropriate roles. Also, the ultimate develop- comed and enjoyed as the fullest potential is actualized for role- mental need for assumption of accountability for self may be relationship patterning, namely the generation of values to the unresolved. There may be a greater likelihood for the various de- young in society. In those instances where aging is accompanied by mands of society on male and female roles to be experienced at this loss in whatever form, the potential exists for the individual to be- time as women assume the multiple roles of wife, mother, worker, come dependent. This dependency may range from a minor form housekeeper, and so on, just as men also have assumed more and to a major form of total dependence on others. The onset of de- more roles that were formerly assumed by females. This challenge pendency may be gradual or sudden. In either instance, the nurse also brings the potential for growth and fulfillment in self-actualizing must recognize the impact of the loss for the patient according to individuals. the values of the patient and family. Copyright © 2002 F.A. Davis Company 526 ROLE-RELATIONSHIP PATTERN b. Grief or uncertainty regarding changed relationship with APPLICABLE NURSING DIAGNOSES the care receiver 4. Family processes a. Family conflict Caregiver Role Strain, Risk for and Actual b. Concerns about marriage DEFINITIONS8 RELATED FACTORS8 Risk for Caregiver Role Strain Caregiver is vulnerable for felt dif- ficulty in performing the family caregiver role. A. Risk for Caregiver Role Strain (Risk Factors) Caregiver Role Strain Difficulty in performing the family caregiver 1. Pathophysiologic role. a. Illness severity of the care receiver b. Addiction or codependency NANDA TAXONOMY: DOMAIN 7—ROLE c. Premature birth or congenital defect RELATIONSHIPS; CLASS 1—CAREGIVING ROLES d. Discharge of family member with significant home care needs NIC: DOMAIN 5—FAMILY; CLASS X—LIFE SPAN CARE e. Caregiver health impairment NOC: DOMAIN VI—FAMILY HEALTH; f. Unpredictable illness course or instability in the care re- CLASS W—FAMILY CAREGIVER STATUS ceiver’s health g. Caregiver is female DEFINING CHARACTERISTICS8 h. Psychological or cognitive problems in care receiver 2. Developmental A. Risk for Caregiver Role Strain a. Caregiver is not developmentally ready for caregiver role, The risk factors also serve as the defining characteristics. for example, a young adult needing to provide care for B. Caregiver Role Strain middle-age parent 1. Caregiving activities b. Developmental delay or retardation of the care receiver or a. Difficulty in performing or completing required tasks caregiver b. Preoccupation with care routine 3. Psychological c. Apprehension about the future regarding the care re- a. Marginal family adaptation or dysfunction prior to the ceiver’s health and the caregiver’s ability to provide care caregiving situation d. Apprehension about the care receiver’s care when the b. Marginal caregiver’s coping patterns caregiver becomes ill or dies c. Past history of poor relationship between the caregiver e. Apprehension about possible institutionalization of the and the care receiver care receiver d. Caregiver is spouse f. Dysfunctional changes in the caregiver’s activities e. Care receiver exhibiting deviant or bizarre behavior 2. Caregiver’s health status 4. Situational a. Physical a. Presence of abuse or violence (1) Gastrointestinal upset, for example, mild stomach b. Presence of situational stressors that normally affect fam- cramps, vomiting, diarrhea, and recurrent gastric ilies, such as significant loss, disaster or crisis, poverty or ulcer episodes economic vulnerability, major life events (2) Weight change c. Duration of caregiving required (3) Rash d. Inadequate physical environment for providing care, for (4) Hypertension example, housing, transportation, community services, or (5) Cardiovascular disease equipment (6) Diabetes e. Family or caregiver isolation (7) Fatigue f. Lack of respite and recreation for the caregiver (8) Headaches g. Inexperience with caregiving b. Emotional h. Caregiver’s competing role commitments (1) Impaired individual coping i. Complexity or amount of caregiving tasks (2) Feeling depressed B. Caregiver Role Strain (3) Anger 1. Care receiver health status (4) Somatization a. Illness severity (5) Increased nervousness b. Illness chronicity (6) Increased emotional lability c. Increasing care needs or dependency (7) Impatience d. Unpredictability of illness course (8) Lack of time to meet personal needs e. Instability of the care receiver’s health (9) Frustration f. Problem behaviors (10) Disturbed sleep g. Psychological or cognitive problems (11) Stress h. Addiction or codependency c. Socioeconomic 2. Caregiving activities (1) Withdraws from social life a. Amount of activities (2) Changes in leisure activities b. Complexity of activities (3) Low work productivity c. 24-hour care responsibilities (4) Refuses career advancement d. Ongoing changes in activities 3. Caregiver–care receiver relationship e. Discharge of family members to home with significant a. Difficulty watching the care receiver go through the illness care needs Copyright © 2002 F.A. Davis Company CAREGIVER ROLE STRAIN, RISK FOR AND ACTUAL 527 f. Years of caregiving b. Inadequate equipment for providing care g. Unpredictability of care situation c. Inadequate transportation 3. Caregiver health status d. Inadequate community resources, for example, respite a. Physical problems services and recreational resources b. Psychological or cognitive problems e. Insufficient finances c. Addiction or codependency f. Lack of support d. Marginal coping patterns g. Caregiver is not developmentally ready for caregiver role e. Unrealistic expectations of self h. Inexperience with caregiving f. Inability to fulfill one’s own or other’s expectations i. Insufficient time 4. Socioeconomic j. Emotional strength a. Isolation from others k. Physical energy b. Competing role commitments l. Assistance and support (formal and informal) c. Alienation from family, friends, and coworkers m. Lack of caregiver privacy d. Insufficient recreation n. Lack of knowledge or difficulty in accessing community 5. Caregiver–care receiver relationship resources a. History of poor relationship b. Pressure of abuse or violence RELATED CLINICAL CONCERNS c. Unrealistic expectations of the caregiver by the care receiver d. Mental status of elder inhibiting conversation 1. Any chronic, debilitating illness, for example, Alzheimer’s dis- 6. Family processes ease, cancer, or rheumatoid arthritis a. History of marginal family coping 2. Severe mental retardation b. History of family dysfunction 3. Chemical abuse 7. Resources 4. Closed head injury a. Inadequate physical environment for providing care, for 5. Schizophrenia example, housing, temperature, and safety 6. Personality disorders HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Ineffective Individual Coping This diagnosis and adjusting to his or her own illness or health Caregiver Role Strain are very close; however, the problem, not adjustment to someone else’s illness differentiating factor is whether or not the or health problem. individual is involved in a caregiver role. If Compromised or Disabled Family Coping These significant caregiving is a part of the individual’s diagnoses could be companion diagnoses to role, then initial interventions should be directed Caregiver Role Strain. If the family cannot adapt to toward resolving the problems within the a change in a family member’s condition and caregiving role. assigns the caregiver role to just one family Impaired Adjustment Certainly needing to assume member, then both Compromised or Disabled a caregiving role would require some adjustment. Family Coping and Caregiver Role Strain are likely However, this diagnosis relates to an individual to develop. EXPECTED OUTCOME TARGET DATES The caregiver will implement a plan to reduce strain by [date]. A target date of 5 days would be the earliest date to begin evalua- tion of progress toward meeting the expected outcome. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Encourage the patient to talk about caregiver role by active Decreases anxiety when allowed to ventilate positive and negative listening, reflection, open-ended questions, accepting his or feelings in nonthreatening, empathetic environment. her feelings for 15 min twice a day at [times]. • Teach stress management techniques such as relaxation, meditation, or deep breathing. (continued) Copyright © 2002 F.A. Davis Company 528 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Have the patient return-demonstrate techniques for 5 min every Relieves stress, identifies alternative coping strategies, and 4 h while awake at [times]. decreases depression. • Identify community support groups such as Mother’s Day Out, Provides alternatives for coping and resources to support in daycare centers, housekeeping services, home health aides, short-term and long-term problems. hospice, or respite care prior to discharge. Also, cooperative arrangement could be made with friends and neighbors for release time from care activities. • Encourage family conferences to discuss role expectations, role Opens communication and promotes cooperative problem solving. conflict, role strain, and role negotiation for 1 h every other day. • Refer to psychiatric nurse specialist as needed (see Psychiatric Collaboration promotes holistic health care. Interventions may Health nursing actions). require expertise of specialist. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for contributing factors with a focus on high-risk Unrealistic demands of parenting or care provision increase the populations: likelihood of role strain. � Excessive demands exist secondary to a child requiring extensive care, e.g., several small children in family with one child requiring extensive assistance with physical or mental problems � A patient who has a total self-care deficit � Caregiver indicates inability to carry out usual routines • Schedule a daily conference with the caregiver of at least 30 min. Allows identification of current perception of role strain by encouraging ventilation of feelings. Provides a teaching opportunity. Assists in identification of referrals that are needed. • Explore with the parent or caregiver, during conference, options Support from others serves as a means of preventing further available to assist with the demands of the situation. Encourage demise of desired role-taking while also allowing for long-term the caregiver to provide time for self on a daily basis through needs. Time for self will enhance coping abilities and, ultimately, such means as seeking outside help—e.g., visiting nurse, self-esteem. housekeeping assistance, respite care, institutionalization such as temporary per day or, if appropriate and desired, permanent. • Identify, during conference, community resources that are Provides long-term support and information. Encourages sharing available, especially parenting support groups. of concerns with others in the same situation. • Schedule family conference, as needed, to focus on the family’s Assists in delineating roles for each family member. Assists in willingness to provide assistance in caregiving. providing relief for the primary caregiver on a more regular basis. • Determine, via an ongoing assessment, any unresolved guilt Unresolved conflict increases the likelihood of little change in regarding role demands, “less-than-perfect child,” or related behavior. aspects of situation (see Dysfunctional Grieving). • Assist the caregiver and significant other(s) to explore, during Expectations may be unrealistic. Clarification of expectations and conference, inevitabilities and realities associated with the care reality assist in problem solving. situation. • Preserve the effective functioning of the caregiver through The likelihood of secondary and tertiary alterations for the teaching and support in conferences. caregiver increase when primary needs of rest and own physical self are not met. Women’s Health ACTIONS/INTERVENTIONS RATIONALES NEW MOTHER OR PARENT ROLE • Assist the new mother in developing realistic plans for infant Provides time for assessment and planning for home care. Affords care from hospital. Have the mother review plans for self-care opportunity to teach and give realistic feedback regarding the and plans for care of the infant in the

home. impact a newborn makes on former lifestyle. (continued) Copyright © 2002 F.A. Davis Company CAREGIVER ROLE STRAIN, RISK FOR AND ACTUAL 529 (continued) ACTIONS/INTERVENTIONS RATIONALES • Include significant other in plans for care of the new mother and infant after discharge from the hospital. Encourage discussion by the mother and significant other of various role changes in the family that will occur with the new infant’s being incorporated into the household—e.g., sibling’s role, wife’s role, husband’s role, or grandparent’s role.9 • Encourage discussion of the “new” role of being a mother and father, as well as being husband and wife. • Assist with development of plan to save time, such as Assists in reducing fatigue, which is a significant contributor to the learning to sleep when the infant sleeps, turning telephone development of caregiver role strain. off when trying to rest, or putting sign on front door when sleeping.10 • Identify areas in which the significant other can assist the new mother and help reduce fatigue—e.g., if breastfeeding, let dad get the infant, change the diaper, and bring the infant to the mother for feeding during the night.10,11 • Plan meals for the family before leaving for the hospital, cook them, and freeze them, so that meals can be prepared easily during the first few weeks at home.10 TEEN PARENTING NOTE: The nursing actions for the teenage parent will be the same as those in the previous section with the following additions: • Refer the young couple or teenager to young parents’ groups in Provides long-term support and a source of information.11 the community for social and personal support. • Give the young couple telephone hot lines they can call for assistance and support—e.g., hospital nursery, young parent services, or the YWCA. • Assist the young parent to get into or stay in school by giving Promotes long-range planning, and reduces the likelihood of references for childcare. strain for the young parent. • Encourage the young couple to express their feelings about the new responsibilities they face. PARENT TO YOUR PARENTS NOTE: Approximately 80 percent of women will become the primary care providers for their elderly parents. These interventions and rationales can also apply to spouse and/or other family members. • Provide supportive atmosphere for discussion of situation in Sharing responsibilities of elderly parents assists the entire family order to: to lead better lives. Many women have entire burden of elderly � Identify specific concerns and needs. parents while trying to maintain jobs and their own families. Often � Explore the inevitabilities and realities of the situation. they will not speak of this; therefore, the nurse must patiently � Identify possible resources in the community (financial interview the women. assistance, personal support, social work, or day care). � Identify methods by which the family members and siblings can share responsibilities. � Establish ties from the primary caretaker to other family members to provide relief for each other. � Identify methods of sharing expenses associated with housing (keeping parent[s] in own home, nursing home or extended care, or assisted living). � Assist with development of plan to provide supervision for parent while working (neighbors of parents, family members, day care, or home aide assistant). • Provide instructions to both the woman and spouse (significant Ensures that both parties have the same instructions or other) about provision of needed care. information about care needed. • Provide telephone number where the caregiver can reach Provides a resource to answer questions and give reassurance. clinical, professional assistance night or day. (continued) Copyright © 2002 F.A. Davis Company 530 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Discuss with the caregiver possible lifestyle changes that will Most caregivers are not professional health care providers and occur: have to understand the need to plan their daily schedules to � Sleeplessness (worried about hearing if needed) incorporate the time required to provide needed care.12 � Arranging time needed for work and other family members’ needs NOTE: Resources for caregivers: Abundant resources exist in bookstores and on the Internet for caregivers. Additionally, most local hospitals and outpatient facilities host support group meetings for caregivers. Here’s a short list of resources to help nurses, patients, and caregivers alike sharpen their skills: • Alzheimer’s Association, (800) 677-1116, has a great World Wide Web site at http://www.alz.org, with a host of resources for caregivers. • Caregiver Network, Inc., is a Canadian resource dedicated to making caregivers’ lives easier and hosts extensive caregiver links to other World Wide Web sites, including “Ask a Professional” link at http://www.caregiver.on.ca/. • Eldercare Locator (800) 677-1116 • Eldercare Navigator features a caregiver state-by-state resources listing, a caregiver newsletter, advice column and other links at http://www.mindspring.com//~eldercare/elderweb • Senior Net has a library of caregiving resources at http://wwwseniornet.com/. • The Caregiver’s Handbook is distributed both on the World Wide Web at http://wwwbiostat.wustl.edu/ALZHEIMER/ care.html and through its producer, the Caregiver Education and Support Services Division of the San Diego County Mental Health Services office, (619) 692-8702. • Today’s Caregiver, (800) 829-2734, a magazine written by and for caregivers, features a caregiver’s bill of rights among other useful resources at http://www.caregiver.com/. Psychiatric Health NOTE: For information related to the caregivers of those clients with a medical diagnosis of demen- tia, refer to Gerontic Health. As used in this discussion, “caregiver” can mean one person or an ex- tended family system. ACTIONS/INTERVENTIONS RATIONALES • Spend [number] minutes [number] times per week interacting Promotes the development of a trusting relationship. with the primary caregiver. • Provide a role model for effective communication by: Family problem solving is improved when the family members � Seeking clarification can effectively communicate with one another and the health care � Demonstrating respect for individual family members and team.13 the family system � Listening to expression of thoughts and feelings � Setting clear limits � Being consistent • Include the caregiver in weekly treatment planning meetings Assists in providing information to the caregiving system so they with the client. Note here the time for this meeting and persons can better cope with the uncertainty of a psychiatric diagnosis.13,14 responsible for providing the information. • Provide the family with opportunities to provide the care and Provides the family with a sense of helpfulness and control.14 support they identify as important. Note here the care the family is going to provide, with the assistance they need to complete these activities. • Spend [number] minutes [number] times per week educating Provides the caregiver with an increased understanding of the the primary caregiver about the client’s diagnosis. Provide both diagnosis, and assists in the development of a home care plan. written and verbal information. When anxiety is high, caregivers may have difficulty remembering information provided only in verbal form. Increases the stability in the living environment by decreasing the caregiver’s anxiety. (continued) Copyright © 2002 F.A. Davis Company CAREGIVER ROLE STRAIN, RISK FOR AND ACTUAL 531 (continued) ACTIONS/INTERVENTIONS RATIONALES • Communicate understanding of the difficulty of the caregiver Promotes the development of a trusting relationship, and assists role by: the caregiver in the process of working through feelings related to � Answering questions honestly the client. � Providing time to interact with the caregiver when he or she visits � Inquiring about the caregiver’s self-care activities � Encouraging the caregiver to use the time the client is in the hospital to rest and meet personal needs � Providing time for the caregiver to express feelings related to the client and the hospitalization � Commend the family on their competencies and strengths, Provides caregivers an opportunity to change their self-view, e.g., comment on what the caregiver has said or done that is which opens them up to viewing the problem differently, and effective and useful. move toward solutions that are more effective.15 • Normalize the caregiver’s feelings of guilt and/or ambivalence by Promotes a positive orientation, and enhances self-esteem. informing him or her that these are normal feelings for anyone who assumes the level of responsibility that he or she has assumed. • Have the caregiver identify areas where he or she feels a need Promotes the caregiver’s sense of control, and provides positive for support on a daily basis, and assist him or her in networking reinforcement when he or she can accomplish the task, which community resources to meet these needs. This should be a enhances self-esteem. process that allows the nurse to teach the caregiver the skills necessary to accomplish this networking on his or her own after discharge. • Spend [number] minutes [number] times per week discussing Gives permission to the caregiver to care for self. Promotes the his or her self-care activities. This could include planning time caregiver’s strengths. away from the client, inviting friends to visit, going for a walk, or arranging to get uninterrupted sleep. Inform the caregiver that if he or she does not care for himself or herself, he or she will eventually not have the energy to care for the client. A specific plan should be developed and noted here. • Before the client is discharged, meet with the client and Anxiety can decrease an individual’s ability to process information caregiver to: during hospitalization. A specific coping plan provides direction � Review information about the diagnosis and hospital course. during times of crisis and prevents the reliance on ineffective � Review special treatments the client is to receive. patterns of coping. These actions increase the caregiver’s repertoire � Explain the client’s medications. of strategies to deal with the problems.16 � Anticipate problems that may arise after discharge. • A specific plan should be developed for coping with anticipated problems. This plan should be written down and given to both the client and the caregiver. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for signs of increasing strain in the caregiver, such as The stresses of caregiving have a negative effect on the caregiver’s an increase in episodes of illness. immune system.17 • Assist the caregiver in discussing feelings about caregiving. For Provides opportunity for ventilation of feelings about caregiving, example, encourage sharing by use of statements such as “Often which assists in reducing stress. people in your situation say they feel angry, helpless, guilty, or depressed.” • Determine the caregiver’s knowledge of support services in the Assists in identifying actual or potential resources based on the community, such as adult daycare, respite services, or family individual’s current knowledge of services. Expands options support groups. available to the caregiver. • Discuss with the caregiver stress management techniques such as imagery, deep breathing, or exercise. What has been tried? How helpful was it? • Encourage the caregiver to use a journal to evaluate stresses, Provides database to use in planning interventions to reduce stress. prioritizing stresses and noting his or her usual response. Are there specific times, days, or circumstances when stress is especially high? (continued) Copyright © 2002 F.A. Davis Company 532 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • If needed, consult with social services for increased support in Highlights attention to caregiver. Realistic planning serves to home care. reduce stress. • Discuss with the caregiver, prior to patient discharge, his or her plan for maintaining self-health and coping abilities.18 Home Health See Psychiatric Health section for additional interventions. ACTIONS/INTERVENTIONS RATIONALES • Consult with and/or refer the patient to assistive resources, such Utilization of existing services is an efficient use of resources. as caregiver support groups, as needed. • Provide respite care for the client to allow the caregiver rest as To allow for caregiver physical and emotional rest, which finances allow. promotes the best possible care for the client. • Educate all family members about critical care issues for the Knowledge helps promote a sense of control and order, as well client, and encourage the primary caregiver to delegate as more appropriate delegation of tasks. Delegation promotes caregiving responsibilities as appropriate. caregiver physical and emotional rest, which enhances client care. • Help the caregiver identify positive outcomes related to Positive feelings can balance negative feelings and provide a sense caregiving (e.g., increased relationship intimacy and feeling of purpose. valued in the relationship) to balance negative feelings. • Provide written documentation of caregiving responsibilities as To assist the caregiver in obtaining time away from work if needed needed for the caregiver’s employers. to provide care. Copyright © 2002 F.A. Davis Company CAREGIVER ROLE STRAIN, RISK

FOR AND ACTUAL 533 Caregiver Role Strain, Risk for and Actual FLOWCHART EVALUATION: EXPECTED OUTCOME Has the caregiver implemented a plan to reduce strain? Yes No Record data, e.g., is taking Reassess using initial assessment factors. husband to adult day care 2 days per week; neighbor is staying with husband one night a week while she goes to play bingo; states, “everything is much better.” Record RESOLVED. Delete No Is diagnosis validated? nursing diagnosis, expected outcome, target date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., stated, “I just don’t see any help anywhere. Guess it’s just Did evaluation show another my burden.” Record CONTINUE and problem had arisen? Yes change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 534 ROLE-RELATIONSHIP PATTERN Family Processes, Interrupted, and Family q. Triangulating family relationships r. Patterns of rejection Processes, Dysfunctional: Alcoholism 2. Behavioral DEFINITIONS8 a. Refusal to get help, or inability to accept and receive help appropriately Interrupted Family Processes Change in family relationships b. Inadequate understanding or knowledge of alco- and/or functioning. holism c. Ineffective problem-solving skills Dysfunctional Family Processes: Alcoholism Psychosocial, d. Loss of control of drinking spiritual, and physiologic functions of the family unit are chroni- e. Manipulation cally disorganized, which leads to conflict, denial of problems, re- f. Rationalization or denial of problems sistance to change, ineffective problem solving, and a series of self- g. Blaming perpetuating crises. h. Inability to meet emotional needs of its members i. Alcohol abuse NANDA TAXONOMY: DOMAIN 7—ROLE j. Broken promises RELATIONSHIPS; CLASS 2—FAMILY RELATIONSHIPS k. Criticizing l. Dependency NIC: DOMAIN 5—FAMILY; CLASS X—LIFE m. Impaired communication SPAN CARE n. Difficulty with intimate relationships o. Enabling to maintain alcoholic drinking pattern NOC: DOMAIN VI—FAMILY HEALTH; CLASS X— p. Inappropriate expression of anger FAMILY WELL-BEING q. Isolation r. Inability to meet spiritual needs of its members DEFINING CHARACTERISTICS8 s. Inability to express or accept wide range of feelings t. Inability to deal constructively with traumatic experi- A. Interrupted Family Processes ences 1. Changes in power alliances u. Inability to adapt to change 2. Changes in assigned tasks v. Immaturity 3. Changes in effectiveness in completing assigned tasks w. Harsh self-judgment 4. Changes in mutual support x. Lying 5. Changes in availability for effective responsiveness and in- y. Lack of dealing with conflict timacy z. Lack of reliability 6. Changes in patterns and rituals aa. Nicotine addiction 7. Changes in participation in problem solving bb. Orientation toward tension relief rather than achieve- 8. Changes in participation in decision making ment of goals 9. Changes in communication patterns cc. Seeking approval and affirmation 10. Changes in availability for emotional support dd. Difficulty having fun 11. Changes in satisfaction with family ee. Agitation 12. Changes in stress-reduction behaviors ff. Chaos 13. Changes in expression of conflict with and/or isolation from gg. Contradictory, paradoxical communication community resources hh. Diminished physical contact 14. Changes in somatic complaints ii. Disturbances in academic performance in children 15. Changes in expressions of conflict within family jj. Disturbances in concentration B. Dysfunctional Family Processes: Alcoholism kk. Escalating conflict 1. Roles and relationships ll. Failure to accomplish current or past developmental a. Inconsistent parenting or low perception of parental tasks, or difficulty with life cycle transitions support mm. Family special occasions are alcohol-centered b. Ineffective spouse communication or marital problems nn. Controlling communications or power struggles c. Intimacy dysfunction oo. Self-blaming d. Deterioration in family relationships or disturbed fam- pp. Stress-related physical illnesses ily dynamics qq. Substance abuse other than alcohol e. Altered role function or disruption of family roles rr. Unresolved grief f. Closed communication systems ss. Verbal abuse of spouse or parent g. Chronic family problems 3. Feelings h. Family denial a. Insecurity i. Lack of cohesiveness b. Lingering resentment j. Neglected obligations c. Mistrust k. Lack of skills necessary for relationships d. Rejection l. Reduced ability of family members to relate to each e. Feelings of responsibility for alcoholic’s behavior other for mutual growth and maturation f. Shame or embarrassment m. Family unable to meet security needs of its members g. Unhappiness n. Disrupted family rituals h. Powerlessness o. Economic problems i. Anger or suppressed rage p. Family does not demonstrate respect for individuality j. Anxiety, tension, or distress and autonomy of its members k. Emotional isolation or loneliness Copyright © 2002 F.A. Davis Company FAMILY PROCESSES, INTERRUPTED, AND FAMILY PROCESSES, DYSFUNCTIONAL: ALCOHOLISM 535 l. Frustration 4. Inadequate coping skills m. Guilt 5. Family history of alcoholism, resistance to treatment n. Hopelessness 6. Biochemical influences o. Hurt 7. Addictive personality p. Decreased self-esteem or feelings of worthlessness q. Repressed emotions RELATED CLINICAL CONCERNS r. Vulnerability s. Hostility 1. Surgery t. Lack of identity 2. Trauma u. Fear 3. Mental retardation v. Loss 4. Chronic illness w. Emotional control by others 5. Alcoholism x. Misunderstood 6. Chemical Abuse y. Moodiness z. Abandonment aa. Being different from other people HAVE YOU SELECTED bb. Being unloved cc. Confused love and pity THE CORRECT DIAGNOSIS? dd. Confusion ee. Failure Compromised or Disabled Family Coping ff. Depression This diagnosis has a history of destructive gg. Dissatisfaction patterns of behavior. For the diagnosis of Interrupted Family Processes to be applicable, there would be evidence that the RELATED FACTORS8 usual adequacy in coping is altered in A. Interrupted Family Processes relation to a specific crisis. 1. Power shift of family members 2. Family role shifts 3. Shift in health status of a family member EXPECTED OUTCOME 4. Developmental transition and/or crisis 5. Situation transition and/or crisis Will describe specific plan to cope with [specific stressor] by [date]. 6. Informal or formal interaction with community 7. Modification in family social status TARGET DATES 8. Modification in family finances B. Dysfunctional Family Processes: Alcoholism Five to 7 days would be the earliest acceptable target date. Even af- 1. Abuse of alcohol ter the expected outcome has initially been met, there may be other 2. Genetic predisposition precipitating events that will again alter family processes; therefore, 3. Lack of problem-solving skills a long-term date should be designated. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Monitor interaction styles, communication patterns, and role Baseline information about family dynamics can assist the nurse behaviors in the family.19 with planning and developing family interventions. • Promote a trusting therapeutic relationship during interaction Provides comfort, and aids in crisis resolution. with the patient and family by being empathetic, actively listening, accepting feelings and attitudes, and being nonjudgmental. • Promote open, honest communications among the family Promotes verbalization of feelings and shared understanding of members by facilitating group interaction. Encourage the patient problems. Assists the family to acknowledge and accept the and family to express feelings regarding current family process problem. Promotes a common definition of the problem, and by spending [specific time] each shift, while awake, for this assists in identifying ways to cope with the problem. purpose. • Determine the family’s level of recognition of problems within Level of recognition may serve as an indicator of the family’s the family unit associated with the patient’s alcoholism. acceptance or denial of problems. • Allow the family to grieve by providing time, giving permission, Assists in crisis intervention, and provides extra coping and referring them to clergy and/or bereavement group. mechanisms. (continued) Copyright © 2002 F.A. Davis Company 536 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Support efforts of the family to deal with previously identified Family may already be involved in therapy for previously identified problems within the family unit associated with the patient’s family unit problems. Hospitalization can cause regression and/or alcoholism. intensification of problems. • Monitor readiness to learn; then teach the family about the Provides knowledge base to assist in problem solving. Decreases precipitating situation, its implications, and the expected anxiety. response to treatment. • Allow the family members to participate in patient care as possible. • Help the family to identify its strengths and weaknesses in Identifies existing resources for crisis resolution and areas to dealing with the situation during family conference. strengthen. Provides positive feedback for strengths that already exist. • Help the family organize to continue usual family activities. Decreases sense of overwhelming loss of everything. Adds stability to activities. • Refer the family to a health professional or organization If family is not already involved in therapy, it is essential to specializing in substance abuse. provide resources for treatment or rehabilitation following discharge from the hospital. Provides long-term support and effective use of already available resources. • See Psychiatric Health nursing actions for more detailed Collaboration promotes more holistic care; many need specific interventions. interventions by a specialist. Child Health NOTE: Depending on the age of the infant or child, there may be a range of possible needs represented in the context of the family—all interventions should be developmentally appropriate. Include all children in family counseling as applicable. ACTIONS/INTERVENTIONS RATIONALES • Promote sibling participation in the patient’s hospitalization and Inclusion of sibling(s) fosters a sense of family concern, and need plans for discharge, e.g., allowing visitation during game time. for support is met for all involved. Undue prolonged separations increase stress for the sibling(s) and family relationships. • Provide for cultural preferences when possible, including diet, Attention to preferences demonstrates valuing and sensitivity for religious needs, and plans for health care. the family. • Provide reinforcement to appropriately value caretaking Reinforcement of desired behaviors serves to offer positive behavior. learning, with increased likelihood of compliance. • Advocate on the infant’s or child’s behalf to best offer The infant, child, or adolescent may be unable to look after management of alcohol or substance abuse impact on current self-interests, and when this is so, it is legally and morally or future development. mandated that the client have an advocate. • Determine the child’s or adolescent’s feelings of the family per Assists in anxiety reduction, and values input of all individual ventilation about same for 30 min each shift. family members. Also, data may be known for best treatment. Women’s Health ACTIONS/INTERVENTIONS RATIONALES NEW PARENTS • Assist the patient and significant others in establishing realistic Assist the family with role changes during a normal, but often goals related to changes in role due to newborn, e.g., sharing of unexpected, amount of role change event. Provides basis for tasks or parenting skills. planning necessary changes. • Provide positive reinforcement for parenting tasks. Provides motivation, and enhances likelihood of effective parenting. • Assist the parents in identifying infant behavior patterns and Assists in reducing stress, and promotes positive parenting. understanding how they allow the infant to communicate with them, e.g., crying or fussing. • Assist the patient in verbalizing her perceptions of the infant’s Provides database that allows more effective teaching and planning growth and development, individual and family needs, and the for effective parenting. stresses of being a new parent. • Identify support groups, e.g., formal groups, such as Mother’s Day Promotes planning, and allows early intervention for potential Out, and informal groups, such as parenting groups, family, stress areas. or friends. • Encourage open communication between the mother and father on household tasks, discipline, fears, and anxieties, e.g., less-than-perfect baby. (continued) Copyright © 2002 F.A. Davis Company FAMILY PROCESSES, INTERRUPTED, AND FAMILY PROCESSES, DYSFUNCTIONAL: ALCOHOLISM 537 (continued) ACTIONS/INTERVENTIONS RATIONALES • Help develop a plan for sharing household tasks and child Reduces stress-provoking events. caretaking activities: � Bathing � Feeding � Care of siblings � Quality time with older children • Allow older children to assist with newborn care (even the smallest child can do this with parental supervision): � Bringing a diaper to the parent � Pushing the baby in stroller � Holding the baby (while sitting on couch is best) • Follow up with home visits after discharge from hospital to Provides long-term support. physically monitor the infant, monitor family interactions, provide support, and provide referrals to the proper agencies. • Teach and reinforce methods of caring for and coping with the Provides measures and preplanning to cope with potential emotional and physiologic needs of the infant, siblings, parents, stressful events. and other relatives such as grandparents. PARENT TO YOUR PARENTS • Assist the client and family to establish realistic goals related to increasing responsibilities in caring for elderly

parents, e.g., sharing of tasks, time, and resources (financial and emotional). • Assist in identifying resources in the community: � Daycare for the elderly � Church groups � YWCAs � Professional help in the home, such as home health aides • Assist in exploring and identifying need for care of elderly parent outside of home, e.g., assisted living or skilled nursing care. ALCOHOLISM NOTE: Interventions under Adult Health and Psychiatric Health will apply here, in addition to the following: Perinatal • Check your state’s laws. Because of the widespread drug use in this country, some states have mandatory screening for drug use during the perinatal period.20,21 • Screen clients for chemical use during pregnancy by means of interview at first visit. Provide a relaxed, secure atmosphere for the client when trying to obtain a substance-abuse history. Include the following in your questions: � Use of nonprescription drugs � Use of coffee � Use of cigarettes � Use of alcohol � Use of prescription drugs � Use of recreational drugs, such as marijuana � Use of multiple drugs � Problems encountered in trying to abstain from drug use • Assure the client of acceptance for her and her family but not for self-destructive behaviors.22 • Support and praise the client for health-seeking behaviors.22 • Thoroughly assess the woman and fetus who present with complications related to substance abuse in order to provide the best physiologic support for her and her fetal well-being. • Obtain sample for toxicology screening: � Maternal or neonatal urine toxicology screen (continued) Copyright © 2002 F.A. Davis Company 538 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Meconium and maternal or neonatal hair samples Because of slow growth of hair and meconium produced by the second trimester, these methods provide the best analysis of long-term data on drug use.22 • Collaborate with physician to provide appropriate pain control Women with narcotic dependency problems have a high tolerance during labor. to analgesics and usually have a low pain threshold.22 • Notify neonatal personnel of the patient’s labor and history of substance abuse. • Support and guide maternal-infant interactions in order to encourage maternal-infant attachment. For the addicted infant, see Child Health. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Provide a role model for effective communication by: Communication skills provide a framework for effective problem � Seeking clarification solving. � Demonstrating respect for individual family members and the family system � Listening to expression of thoughts and feelings � Setting clear limits � Being consistent � Communicating with the individual being addressed in a clear manner � Encouraging sharing of information among appropriate system subgroups • Demonstrate an understanding of the complexity of system Outcome improves when psychosocial problems are treated from problems by: a systems perspective.15 � Not taking sides in family disagreements � Providing alternative explanations of behavior that recognize the contributions of all persons involved with the problem, including health care providers as appropriate � Requesting the perspective of multiple family members on a problem or stressor • Include all family members in the first interview. Provides opportunity to assess all family members’ perception of the problem and in identification of problem-solving strategies that are acceptable to more family members. • Have each member provide his or her perspective to the current Assists the family in defining a problem that can be resolved. For difficulties. example, rather than defining the problem as “We don’t love each other any more,” the problem can be defined as “We do not spend time together in family activities.” This definition evolves from the family’s description of what they mean by the more general problem description. • Assist the family in developing behavioral short-term goals by: Setting achievable goals increases the opportunities for success, � Asking what they would see happening in the family if the which increases the motivation to continue to work toward situation improved problem resolution. � Having them break the problem into several parts that combine to form the identified stressor � Asking them what they could do in a week to improve the situation (should include a response from each family member) • Maintain the nurse’s role of facilitator of family communication Maintains a context that enhances and supports the family’s by: problem-solving skills. � Having family members discuss possible solutions among themselves � Having each family member talk about how he or she might contribute to both the problem and the problem’s resolution • Provide the family with the information necessary for appropriate problem solving. (continued) Copyright © 2002 F.A. Davis Company FAMILY PROCESSES, INTERRUPTED, AND FAMILY PROCESSES, DYSFUNCTIONAL: ALCOHOLISM 539 (continued) ACTIONS/INTERVENTIONS RATIONALES • During each meeting with the family, provide positive Promotes the family’s positive opinions of themselves, which comments about the family’s strengths and competencies. opens them up to viewing the problem differently and developing more effective problem solving.15 • Answer all questions in an open, direct manner. Promotes a trusting relationship. • Support the expression of affect by: Promotes communication among family members, while � Having family members share feelings with one another developing a positive expectational set. � Normalizing the expression of emotion—e.g., “Most persons experience anger after they have experienced a loss.” � Providing a private environment for this expression • Maintain and support functional family role—e.g., allow the Provides positive reinforcement for functional interactions, and parents private time alone, allow the children to visit parents, serves to encourage this behavior while enhancing self-esteem. and encourage the presenting of problems to the “family leader.” • Schedule a time with the family to discuss how the current situation affects family roles and possible changes that may be necessary. • Have the family identify those systems in the community that Promotes and develops the family’s strengths. could support them during this time, and assist the family in contacting these systems. Note here the systems to be contacted as well as how they will assist the family. • Provide positive verbal reinforcement for the family’s Positive reinforcement encourages behavior and enhances accomplishments. self-esteem. • Assist the family in identifying patterns of interaction that Facilitates the development of more appropriate coping behaviors. interfere with successful problem resolution—e.g., the husband frequently asks his wife closed-ended questions, which discourages her from sharing her ideas; the children interrupt the parents when their level of conflict increases to a certain level; or the wife walks out of the room when the husband brings up issues related to finances. • Assist the family in planning fun activities together. This could Families in crisis often limit their emotional experience. include time to play together, exercise together, or engage in a shared project. • Teach the family methods of anxiety reduction, establish a Relaxation response inhibits the activation of the autonomic practice schedule and a schedule for discussing how this nervous system’s fight-or-flight response. Repeated practice of a method could be used on a daily basis in the family. The behavior internalizes and personalizes the behavior. selected method along with the schedule for discussion and practice should be listed here. • Include the family in discussions related to planning care and Support system involvement in problem solving increases the sharing information about the client’s condition. opportunities for a more positive outcome. • Assist the family in developing a specific plan when the client is Promotes the client’s sense of control. Planned coping strategies scheduled for a pass or discharge. Note that plan here, with the facilitate the enactment of new behaviors when stress is assistance needed from the nursing staff for implementation. experienced. This increases the opportunities for successful coping and enhances self-esteem. ALCOHOL • Promote a trusting therapeutic relationship during interaction Provides comfort, and aids in the development of a context that with the client and family by being empathetic, listening supports expressions of emotions and risking change.23 actively, accepting feelings and attitudes, and being nonjudgmental. • Spend time in the initial interactions with the family discussing Assists the family in viewing the problem as outside of themselves, the influence the problem or illness has on their lives and the objectifying the problem rather than the person, thus making it influence they have on the problem. easier for the family to see the problem as something they can influence. Assists the family in developing a different perspective of the problem.15 • Establish a therapeutic relationship with whatever part of the Working with the nonalcoholic spouse and family members can family system initiates treatment. facilitate the entry of the alcoholic family member into treatment.24 • Promote open, honest communications among the family Promotes verbalization of feelings and shared understanding of members by facilitating group interaction. Promote the problems. Assists the family to acknowledge and accept the expression of feelings regarding current family process by problem. Promotes a common definition of the problem, and spending [specific time] each shift, while awake, for this assists in identifying ways to cope. purpose. (continued) Copyright © 2002 F.A. Davis Company 540 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Schedule the family for psychoeducational groups that explore Family involvement in early treatment improves outcome.24 basic information, family responses to alcoholism, family roles in intervention, and codependence. Included topics should be: � Basic disease concepts � Family control behaviors � Anger � Threats � Covering up for alcoholic or enabling � Personal responsibility � Self-care � Healthy communication • Provide a role model for effective communication by: Communication skills provide a framework for effective problem � Seeking clarification solving. � Demonstrating respect for individual family members and the family system � Listening to expression of thoughts and feelings � Setting clear limits � Being consistent � Communicating clearly with the individual being addressed • Demonstrate an understanding for the complexity of system Outcome improves when family communication problems are problems by: addressed.24 � Not taking sides in family disagreements � Providing alternative explanations of behavior that recognize the contributions of all persons involved with the problem � Requesting the perspective of multiple family members on a problem or stressor • Assist the family in defining a problem that can be resolved. For example, rather than defining the problem as “I want him to be more responsible around the house,” try “I would like him to take responsibility for paying the bills by the first of the month.” • Assist the family in developing behavioral short-term goals by: Setting achievable goals increases the opportunities for success, � Asking what they would see happening in the family if the which increases the motivation to continue to work toward situation improved problem resolution. � Having them break the problem into several parts that can bring to fore the identified stressor � Asking them what they could do in a week to improve the situation • Maintain the nurse’s role of facilitator of family communication Maintains a context that enhances and supports the family’s by : problem-solving skills. � Having family members discuss possible solutions among themselves � Having each family member take responsibility for his or her own actions and not accept responsibility for others • Support the expression of affect: Expression of affect is one of the most difficult areas for these � Have family members share feelings with one another. families. Promotes learning positive ways of communicating � Normalize the expressions of emotion—for example, “Most among family members, while developing a positive expectational families experience anger as part of the recovery process.” set.25 � Provide a private environment for this expression. • Schedule time with the family to discuss how the current situation affects family roles and possible changes that may be necessary. Note that schedule here with responsible person. • Maintain and support functional family roles; for example, Provides positive reinforcement for functional interactions, and allow the parents private time alone, or allow the children to serves to encourage this behavior while enhancing self-esteem. visit parents. • Have the family identify those systems in the community that Promotes and develops the family’s strengths, and provides could support them in recovery, and assist them in contacting support systems for behavior changes. these systems (Alcoholics Anonymous, Al-Anon, Al-Ateen). Note here the systems to be contacted and person responsible for this activity. (continued) Copyright © 2002 F.A. Davis Company FAMILY PROCESSES, INTERRUPTED, AND FAMILY PROCESSES, DYSFUNCTIONAL: ALCOHOLISM 541 (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide positive verbal reinforcement for the family’s Positive reinforcement encourages

behavior and enhances accomplishments. self-esteem. • Assist the family in planning fun activities together. This could Families in crisis often limit emotional experiences. include time to play together, exercise together, or engage in a shared project. • Teach the family methods of anxiety reduction; establish a Relaxation response inhibits the activation of the autonomic practice schedule and a schedule for discussing how this nervous system’s fight-or-flight response. Repeated practice of a method could be used on a daily basis in the family. The behavior internalizes and personalizes the behavior. selected method along with the schedule for discussion and practice should be listed here. • Assist the family in developing a specific plan when the client is Promotes the client’s sense of control. Planned coping strategies scheduled for a pass or discharge. Note that plan here, including facilitate the enactment of new behaviors when stress is the assistance needed from the nursing staff for implementation. experienced. This increases the opportunities foe successful coping, and enhances self-esteem. Gerontic Health NOTE: The nursing actions for the gerontic patient with this diagnosis would be the same as those given in Adult Health and Psychiatric Health. The prevalence of alcoholism in older adults is report- edly lower than in the general population; however, this may be due to the lack of age-specific screen- ing instruments.26 In older adults, there may be late-onset alcoholism due to an increase in the stresses associated with aging. Such things as the loss of a spouse, changes in health, and retirement may pre- cipitate alcohol abuse.27 Some researchers advocate programs that are connected to aging service pro- grams, such as senior programs, to assist the older alcoholic and his or her family in dealing with ag- ing issues as well as alcoholism.28 Home Health See Psychiatric Health nursing actions for detailed psychosocial interventions. ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family appropriate information regarding Basic knowledge that contributes to successful family functioning. the care of family members: � Discipline strategies appropriate for developmental level � Normal growth and development � Expected family life cycles, e.g., childrearing or grandparenting � Coping strategies for family growth � Care of health deviations � Developing and using support networks � Safe environment for family members � Anticipatory guidance regarding growth and development, discipline, family functioning, responses to illness, role changes, etc. • Involve the client and family in planning and implementing Family involvement enhances effectiveness of intervention. strategies to decrease or prevent alterations in family process: � Family conference to ascertain perspective of members on current situation and to identify strategies to improve situation � Mutual goal setting to identify realistic goals with evaluation criteria and specific activities for each family member � Encouragement of clear, consistent, and honest communication with positive feedback � Distribution of family tasks so that all members are involved in maintaining family based on developmental capacity • Assist the client and family in lifestyle adjustments that may be Permanent changes in behavior and family roles require support. required: � Separation or divorce � Temporary stay in community shelter � Family therapy � Communication of feelings � Stress reduction � Identification of potential for violence (continued) Copyright © 2002 F.A. Davis Company 542 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Providing safe environment � Therapeutic use of anger � Seeking and providing support for family members � Coping with catastrophic or chronic illness � Requirements for redistributing family tasks � Changing role functions and relationships � Financial concerns • Consult with or refer to assistive resources as required. Utilization of existing services is efficient use of resources. Support groups, psychiatric nurse clinicians, and teachers can enhance the treatment plan. Copyright © 2002 F.A. Davis Company FAMILY PROCESSES, INTERRUPTED, AND FAMILY PROCESSES, DYSFUNCTIONAL: ALCOHOLISM 543 Family Processes, Interrupted, and Family Processes, Dysfunctional: Alcoholism FLOWCHART EVALUATION: EXPECTED OUTCOME Interview the family as a group and individually. Can each describe a plan to cope with the identified stressor? Yes No Record data, e.g., all helped Reassess using initial assessment factors. to design plan; plan is written and posted on refrigerator as a reminder; all have verbally indicated understanding of and commitment to plan. Record RESOLVED. Delete nursing diagnosis, expected No Is diagnosis validated? outcome, target date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., have ideas for plan but have not mutually agreed Did evaluation show another on a plan. Record CONTINUE and problem had arisen? Yes change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 544 ROLE-RELATIONSHIP PATTERN Grieving, Anticipatory 7. Potential loss of significant object; for example, people, posses- sions, job, status, home, ideals, parts and processes of the body DEFINITION8 8. Denial of the significance of the loss 9. Bargaining Intellectual and emotional responses and behaviors by which indi- 10. Alterations in: viduals, families, or communities work through the process of a. Eating habits modifying self-concept based on the perception of potential loss. b. Sleep patterns c. Dream patterns NANDA TAXONOMY: DOMAIN 9—COPING/STRESS d. Activity level TOLERANCE; CLASS 2—COPING RESPONSES e. Libido 11. Difficulty taking on new or different roles NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING 12. Resolution of grief prior to the reality of loss ASSISTANCE RELATED FACTORS8 NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; CLASS N— PSYCHOSOCIAL ADAPTATION To be developed. DEFINING CHARACTERISTICS8 RELATED CLINICAL CONCERNS 1. Expression of distress at potential loss 1. Cancer 2. Sorrow 2. Amputation 3. Guilt 3. Spinal cord injury 4. Denial of potential loss 4. Birth defects 5. Anger 5. Any diagnosis that the family has been told has a terminal 6. Altered communication patterns prognosis HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Disturbed Sensory Perception This diagnosis is Anxiety and Fear may arise as parallel diagnoses identified according to the patient’s change in with Anticipatory Grieving. capacity to exercise judgment or think critically Ineffective Individual Coping This is the with appropriate sensory-perceptual functioning. appropriate diagnosis if the individual is not This may well be related to Anticipatory Grieving. making the necessary adaptations to deal with the Anxiety or Fear Anxiety is the response the threatened loss. This diagnosis can be a individual has to a threat that is for the most part companion diagnosis to Anticipatory Grieving. unidentified. Fear is the response made by an Spiritual Distress When faced with a devastating individual to an identified threat. When the patient loss, the client may well express Spiritual Distress. is faced with the thought of death, loss of a limb, This quite often is a companion diagnosis to loss of functioning, loss of a loved one, and so on, Anticipatory Grieving. EXPECTED OUTCOME TARGET DATES Will identify at least two support systems by [date]. A target date ranging from 2 to 4 days would be appropriate in eval- uating progress toward achievement of the expected outcome. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health For this diagnosis, the Psychiatric Health nursing actions serve as the generic actions. Please see those actions. Child Health ACTIONS/INTERVENTIONS RATIONALES • Spend at least 30 min every 8 h (or as situation dictates) to A structured discussion places value on the importance of grieving address specific anticipated loss by: and provides critical data for the plan of care. � Encouraging the patient and family to express perception of current situation (may be facilitated by age and developmentally appropriate intervention such as drawing, play, or puppet therapy) (continued) Copyright © 2002 F.A. Davis Company GRIEVING, ANTICIPATORY 545 (continued) ACTIONS/INTERVENTIONS RATIONALES � Providing active listening in a quiet, private environment � Offering clarification of procedures, treatment, or plans for the patient and family � Revising plan of care to honor preferences when possible � Discussing and identifying impact of anticipated loss • Collaborate with appropriate health care professional members Appropriate collaboration and coordination of efforts results in to meet needs of the patient and family in realistically more holistic versus fragmented care at a time of special need. A anticipating loss. sense of support remains long after the event itself. • Encourage the patient and family to realistically develop coping Fostering coping strategies provides an opportunity for growth strategies to best prepare for anticipated loss through: with minimal support from others, thereby increasing � Engaging in diversional activities of choice empowerment for the family. � Reminiscing of times spent with loved one or associated with anticipated loss � Identification of support groups • Encourage optimal function for as long as possible, with Participation in usual daily activities provides a sense of normalcy identification of need for proper attention to rest, diet, and despite impending loss and provides validation of life. health of all family members at this time of stress. • Promote parental and sibling participation in care of the infant Maintenance of family input and participation in care offers or child according to situation: continuation of the family unit at a time when unity can serve to � Feedings and selection of menu positively influence daily coping for all. � Comfort measures such as holding the child or giving backrubs � Diversional activities, quiet games, or stories � Decisions regarding life-support measures and resuscitation • Reassure the infant or child that he or she is loved and cared for, Reassurance lessens the likelihood of guilt while demonstrating with ample opportunities to answer questions regarding specific there is no need for assignment of blame to any member of the anticipated loss whether related to self or others. According to family. age and developmental status, provide reassurance that cause for situation is not the patient’s own doing. • Remember that hearing is one of the last of the senses to remain Speaking can serve to reassure the child of worth; urge caution in functional. Exercise opportunities for loved ones and staff to conversations that indicate the child cannot hear. continue to address the patient even though the patient may be unable to answer or respond. • Provide for appropriate safety and maintenance related to Standard practice requires safety maintenance. Special attention physiologic care of the patient. is required when the infant or child is comatose or cannot respond regarding sensations, especially for pressure areas, heat, or cold. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Obtain a thorough obstetric history, including previous Provides essential database needed to plan for effective occurrences of fetal demise. interventions. • Ascertain whether there were any problems conceiving this pregnancy or any attempts to terminate this pregnancy. • Assess and record the mother’s perception of cessation of fetal movements. • Monitor and record fetal activity or lack of activity. • Inform the mother and significant others of antepartal testing and why it is being ordered, and explain results: � Nonstress testing � Oxytocin (Pitocin) challenge test � Ultrasound • Be considerate and honest in keeping the patient and significant Promotes trusting relationship, and provides support during a other(s) informed. Share information as soon as it becomes very difficult time. available. • Allow the mother and family to express feelings and begin Provides support and care to the patient and family, who are grieving process. unable to begin real grieving because death is not yet real to them while they are going through a “normal” birthing process. (continued) Copyright © 2002 F.A. Davis Company 546 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • With collaboration of physician, facilitate necessary laboratory tests and procedures, e.g., blood tests such as complete blood count, type, and crossmatch; disseminated intravascular coagulation (DIC) screening and coagulation studies; real-time or obstetric ultrasound; or amniotomy. • Provide emotional support for the couple during labor and birth process. • Closely monitor physiologic process of labor. • Explain the procedure of induction of labor and the use of In instances where fetal death has been ascertained, labor is Pitocin, IVs, and the uterine contraction pattern. induced to prevent further complications. • Watch for nausea, vomiting, and diarrhea. • Provide comfort measures: analgesics, tranquilizers, and medications for side effects, or prostaglandins as ordered. • Change the patient’s position at least every 2 h on [odd/even] hour. • Observe for full bladder. Record intake and output every 8 h. • Provide ice chips for dry mouth, and lip balm or petroleum jelly for dry lips. • Monitor vital signs every 2–4 h at [times]. • Utilize breathing and relaxation

techniques with the patient for comfort. • Inform physician of the mother’s wishes for use of anesthetic for birth, e.g., awake and aware, sedated, or asleep. • Prepare the infant for viewing by the mother and significant Initiates the grieving process in a supportive environment. others: Demonstrates respect for and understanding of the family’s � Clean the infant as much as possible. emotional state. � Use clothing to hide gross defects, such as a hat for head defects and a T-shirt or diapers for trunk defects. � Wrap in soft, clean baby blanket (allow the mother to unwrap the infant if she desires). • Provide private, quiet place and time for the parents and Provides essential support for the family during time of grief. family to: Provides reality by letting the parents hold the infant. � See and hold the infant � Take pictures • Provide a certificate with footprints, handprints, lock of hair, armbands, date and time of birth, weight of the infant, and name of the infant. • Ask the client whether she has a faith community. Asking about a faith community is less threatening than using the term religion. The client is more likely to respond. • Contact religious or cultural leader as requested by the mother or significant other. Provide for religious practices such as baptism. • Provide references to supportive groups within community, such as Resolve with Sharing or Parents of Miscarried Children. • Explain need for autopsy or genetic testing of the infant. • In instances of infertility, assist in realistic planning for future: Provides database that can be used in assisting the couple to cope � Possible extensive testing with situation and initiate realistic planning for the future. � Fear � Economics � Uncertainty � Embarrassment � Surgical procedures � Feelings of inadequacy � Life without children � Adoption Copyright © 2002 F.A. Davis Company GRIEVING, ANTICIPATORY 547 Psychiatric Health NOTE: It may take clients anywhere from 6 months to a year or more to grieve a loss. This should be taken into consideration when developing evaluation dates. In a short-stay hospitalization, a reason - able set of goals would be to assist the client system in beginning a healthy grieving process. It is also important to note the anniversary date because grief reaction can be experienced past the 1-year pe - riod noted here. ACTIONS/INTERVENTIONS RATIONALES • Assign the client a primary care nurse, and inform client of this Promotes the development of a trusting relationship. decision. This nurse must have a degree of comfort in discussing issues related to loss and grief. • Primary nurse will spend 30 min once a shift with the client Promotes the development of a trusting relationship, and provides discussing his or her perceptions of the current situation. a supportive environment for the expression of feelings, which These discussions could include: facilitates a healthy resolution of the loss. � His or her perceptions of the loss � His or her values or beliefs about the lost “object” � Client’s past experiences with loss and how these were resolved � Client’s perceptions of the support system and possible support system responses to the loss • Primary nurse will schedule 30-min interactions with the client and support system to assist them in discussing issues related to the loss and answering any question they might have (note time and date of this interaction here). • Primary nurse will discuss with the client and family role Anticipatory planning facilitates adaptation. adjustments and other anticipated changes related to the loss. • If necessary after the first interaction, primary nurse will schedule follow-up visits with the client and his or her support system (note schedule for these interactions here). • Spend [number] minutes (this should begin as 5-min times and Promotes the development of a trusting relationship and the can increase to 10 min as client needs and unit staffing permit) client’s sense of control. with the client each hour. If the client does not desire to talk during this time, it can be used to give a massage (backrub) or sit with the client in silence. Inform the client of these times, and let him or her know if for some reason this schedule has to be altered and develop a new time for the visit. Inform the client that the purpose of this time is for him or her to use as he or she sees fit. The nurse should be seated during this time if he or she is not providing a massage. • Provide positive verbal and nonverbal reinforcement to Positive reinforcement encourages the behavior and enhances expressions of grief from both the client and the support system. self-esteem. This would include remaining with the client when he or she is expressing strong emotions. • Once the client and the support system are discussing the loss, Facilitates healthy resolution of the loss. assist them in scheduling time when they can be alone with the client. • Answer questions in an open, honest manner. Promotes the development of a trusting relationship, and promotes the client’s sense of control. • If the client expresses anger toward the staff and this anger Expression of anger is a normal part of the grieving process, and it appears to be unrelated to the situation, accept it as part of the is “safer” to be angry with members of the health care team than grieving process and support the client in its expression by: with the family. � Not responding in a defensive manner � Recognizing the feelings that are being expressed—e.g., “It sounds like you are very angry right now,” or “It can be very frustrating to be in a situation where you feel you have little control.” • Recognize that the stages of grief progress at individual rates Supports the client’s perception of control and strengths. and in various patterns. Do not “force” a client through stages or express expectations about what the “normal” next step should be. (continued) Copyright © 2002 F.A. Davis Company 548 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • If the client is in denial related to the loss, allow this to happen, Serves as a way of the client’s protecting self from information he and provide the client with information about the loss at the or she is not ready to cope with. As coping behaviors are client’s pace. If the client does not remember information given strengthened, the client will be able to accept and respond to this before, simply provide the information again. information. • Allow the client and the support system to participate in Promotes the client’s sense of control, and enhances his or her decisions related to nursing care. Those areas in which client strengths. decision making is to be encouraged should be noted here along with the client’s decisions. • Normalize the client’s and support system’s experience of grief Promotes the client’s sense of control, and promotes a positive by telling the client that his or her experience is normal and by orientation, which enhances self-esteem. discussing with him or her potential future responses to loss. • Recognize that this is an emotionally painful time for the client Encourages expression of feelings, and facilitates progression and the support system, and share this understanding with the through the grieving process. client system. • Assist the client in obtaining the spiritual support needed. • Monitor the use of sedatives and tranquilizers. Consult with Extensive use of these medications may delay the grieving process. physician if overuse is suspected. • Monitor the client system’s use of alcohol and nonprescription These are symptoms of ineffective coping and interfere with the drugs as a coping method. Refer to Ineffective Individual normal grieving process. Coping (Chap. 11) if this is identified as a problem. • Have the client and the support system develop a list of Promotes the client’s strengths concerns and problems, and assist them in determining those they have the ability to change and those they do not. . • When they have a list of workable problems, have the client Facilitates creative problem solving by assisting the family to system list all of the solutions they can think of for a problem; break the “more-of-the-same” problem-solving set. encourage them to include those solutions they think are impossible or just fantasy solutions. Do this one problem at a time. • After solutions have been generated, assist the client in Promotes the development of creative problem solutions. evaluating solutions generated. Solutions can be combined, eliminated, or altered. From this list the best solution is selected. It is important that the solution selected is the client’s solution. • Assist the client in developing a plan for implementing this Planned coping strategies facilitate the enactment of new behaviors solution. Note here any assistance needed from the nursing staff. when the client is experiencing stress. • Observe the client for signs and symptoms of dysfunctional Early intervention promotes positive outcome. grieving. • Monitor the client’s nutritional pattern, and refer to appropriate Nutritional status impacts the individual’s ability to cope. nursing diagnoses if a problem is identified. • Develop an exercise plan for the client. Consult with physical Exercise increases the production of endorphins, which contribute therapist as needed. Develop a reward schedule for the to feelings of well-being. accomplishment of this plan. Note schedule for plan here. This can also include the support system. • Provide assistance for the support system by: Support system reactions can impact the client. � Having them develop a schedule for rest periods � Providing snacks for them and scheduling periods of high nursing involvement with the client at a time when support persons can obtain meals (This can reassure the support person that the client will not be alone while he or she is gone.) � Assisting the support system in finding cafeteria and transportation � Suggesting that support persons rest or walk outside or around hospital while the client is napping � Helping support persons discuss with the client their feelings Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Provide information to the patient regarding what is occurring This intervention is viewed by survivors as especially helpful and expected or anticipated changes. during the dying process.29 (continued) Copyright © 2002 F.A. Davis Company GRIEVING, ANTICIPATORY 549 (continued) ACTIONS/INTERVENTIONS RATIONALES • Discuss, with the individual, the grieving process, what can be Provides information on common responses to loss and what anticipated, and how each person grieves in his or her own way. emotions are commonly experienced by grieving people. Promotes grieving process, and reassures survivor that he or she is coping well. Home Health See Psychiatric Health nursing actions for detailed interventions. ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family appropriate monitoring of signs and Provides database for early recognition and intervention. symptoms of anticipatory grief: � Crying, sadness � Alterations in eating and sleeping patterns � Developmental regression � Alterations in concentration � Expressions of distress at loss � Denial of loss � Expressions of guilt � Labile affect � Grieving beyond expected time � Preoccupation with loss � Hallucinations � Violence toward self or others � Delusions � Prolonged isolation • Involve the client and family in planning and implementing Family involvement in planning enhances effectiveness of plan. strategies to reduce or cope with anticipatory grieving: � Family conference: Develop list of concerns and problems; identify those concerns that family can control. � Mutual goal setting: Set short-term realistic goals and evaluation criteria. Specify role of each member. � Communication: Discuss loss in supportive environment. • Assist the client and family in lifestyle adjustments that may be Permanent changes in behavior and lifestyle are facilitated by required: knowledge and support. � Providing realistic hope � Identifying expected grief pattern in response to loss � Recognizing variety of accepted expressions of grief � Developing and using support networks � Communicating feelings � Providing a safe environment � Therapeutic use of denial � Identifying suicidal potential or potential for violence � Therapeutic use of anger � Exploring meaning of situation � Stress reduction � Promoting expression of grief � Decision making for future � Promoting family cohesiveness • Assist the client and family to set criteria to help them determine Provides data for early intervention. when intervention of health care professional is required—e.g., if the client

is threat to self or others, or if the client is unable to perform activities of daily living. • Consult and/or refer to assistive resources as indicated. Utilization of existing services is efficient use of resources. Self-help groups, religious counselor, or psychiatric nurse clinician can enhance the treatment plan. Copyright © 2002 F.A. Davis Company 550 ROLE-RELATIONSHIP PATTERN Grieving, Anticipatory FLOWCHART EVALUATION: EXPECTED OUTCOME Has the patient identified at least two support systems? Yes No Record data, e.g., has identified Reassess using initial assessment factors. support systems of in-laws, sister, longtime family friend, church pastor, and Sunday School teacher; all have been in to visit and indicated willingness to be of assistance; all have attended session with nurse thanatologist. Record RESOLVED. No Is diagnosis validated? Delete nursing diagnosis, expected outcome, target date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., stated, “Can’t think of any support systems; we have no Did evaluation show another relatives here.” Record CONTINUE and problem had arisen? Yes change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company GRIEVING, DYSFUNCTIONAL 551 Grieving, Dysfunctional 11. Alterations in: a. Eating habits DEFINITION8 b. Sleep patterns c. Dream patterns Extended, unsuccessful use of intellectual and emotional responses d. Activity level by which individuals, families, or communities attempt to work e. Libido through the process of modifying self-concept based on the percep- f. Concentration and/or pursuit of tasks tion of loss. 12. Developmental regression 13. Expression of guilt NANDA TAXONOMY: DOMAIN 9—COPING/STRESS 14. Repetitive use of ineffectual behaviors associated with attempts TOLERANCE; CLASS 2—COPING RESPONSES to reinvest in relationships 15. Prolonged interference with life functioning NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING 16. Onset or exacerbation of somatic or psychosomatic responses ASSISTANCE 17. Anger NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; CLASS N— PSYCHOSOCIAL ADAPTATION RELATED FACTORS8 DEFINING CHARACTERISTICS8 1. Actual or perceived object loss, for example, people, possessions, job, status, home, ideals, or parts and processes of the body 1. Sadness 2. Crying RELATED CLINICAL CONCERNS 3. Reliving of past experiences with little or no reduction (dimin- ishment) of intensity of the grief 1. Cancer 4. Labile affect 2. Amputation 5. Expression of unresolved issues 3. Spinal cord injury 6. Interference with life functioning 4. Birth defects 7. Verbal expression of distress at loss 5. Any diagnosis that the family has been told has a terminal 8. Idealization of lost object, for example, people, possessions, prognosis job, status, home, ideals, parts and processes of the body 6. Sudden infant death syndrome (SIDS) 9. Difficulty in expressing loss 7. Stillbirth 10. Denial of loss 8. Infertility HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Disturbed Sensory Perception This diagnosis is Ineffective Individual Coping This can be an identified according to the patient’s change in appropriate diagnosis if the individual is not capacity to exercise judgment or think critically with making the necessary adaptations to deal with appropriate sensory-perceptual functioning. This crises in his or her life; however, if a real loss has may well be related to Dysfunctional Grieving. occurred, the most appropriate diagnosis is Anxiety or Fear Anxiety is the response the Dysfunctional Grieving. individual has to a threat that is for the most part Spiritual Distress When faced with a devastating unidentified. Fear is the response made by an loss, the client may well express Spiritual Distress. individual to an identified threat. When the patient This quite often is a companion diagnosis to has experienced a loss, it is not a threat but an Dysfunctional Grieving. actual event. Therefore, the diagnoses of Anxiety and Fear would not be appropriate. EXPECTED OUTCOME TARGET DATES Will identify at least [number] ways to appropriately cope with grief Grief work should begin within 1 to 2 days after the nurse has in- by [date]. tervened; the complete process of grief may take several years. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health For this diagnosis, the Psychiatric Health nursing actions serve as the generic actions. Please see Psychiatric Health nursing actions. Copyright © 2002 F.A. Davis Company 552 ROLE-RELATIONSHIP PATTERN Child Health NOTE: It is difficult to make general assumptions as to how each child views death, but according to previous patterns of behavior, including communication, it would be necessary to allow for develop- mental patterns previously attained. In young children, there may be manifestations of obsessive, rit- ualistic behavior related to the loss or activities surrounding loss. For example, if a loved one died, young children may think that if they fall asleep they may also die. In the event of grieving, regardless of the precipitating event, the child must be allowed to respond in keeping with developmental ca- pacity. At times when the child is in danger of self-injury or injuring others, the risk for violence must be considered. ACTIONS/INTERVENTIONS RATIONALES • Provide opportunities for expression of feelings related to loss or Expression of feelings helps deal with sense of loss and provides a grief according to developmental capacity, e.g., puppets or play database for intervention. Expression of grief reduces uncontrolled therapy for toddlers. outbursts. • In the event of a family member’s death, offer support in Provides database for more accurate intervention in dealing with understanding the deceased family member’s relationship to the loss. patient and status for the family, with special attention to siblings and their reactions. Identify impact grief has for family dynamics via monitoring of family dynamics. • Allow for cultural and religious input in plan of care, especially Demonstrates valuing of these beliefs to the family, and decreases related to care of the dying patient and care of the patient at stress for the family. time of death. • Collaborate with professionals and paraprofessionals to aid in Collaboration offers the most comprehensive plan of care and resolution of grief according to family preferences. avoids fragmentation of care. • Identify support groups to assist in resolution of grief, such as Support groups offer validation of feelings and a sense of hope as Compassionate Friends Organization. similar concerns are shared. • Assist the family members in identification of coping strategies Provides for support during the adjustments that are required needed for resultant role-relationship changes. because of the loss of a loved one. • Assist the family members to resolve feelings of loss via Reminiscing and valuing past experiences will offer an reminiscing about loved one, positive aspects of situation, or opportunity to project the impact for the present and future. personal growth potential presented. Remember that behavior often serves as the most effective communication for the child or young toddler. . • Allow the family members time and space to face reality of Time and readiness promote the willingness to discuss feelings situation and ponder meaning of loss for self and the family. after the major emotional shock has diminished. • Direct the family to appropriate resources regarding positive A sense of fulfillment may be derived from the sharing of time, methods of acknowledging loved one through memorials or talent, or money in honor of the loved one. This affords some related processes. sense of resolve of the guilt or emptiness associated with the loss. • Assist in referral to appropriate resources for funeral planning In times of emotional duress, objective decisions may be difficult. and arrangements if needed. Providing assistance will offer empowerment and a sense of coping. • In the event of SIDS, provide an opportunity, through a scheduled conference, for verbalization of: � How the infant’s death occurred � Police investigation � Sense of guilt � Feelings of powerlessness � Questions � Anger � Disbelief � Fears for future pregnancies and birth • Identify the impact the death or grief has on other family Provides the essential database that can assist in planning that will members, the relationship of the couple, and the couple’s offset the development of dysfunctional grieving. attitude toward having other children. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Schedule a 30-min daily conference with the couple and focus on: Initiates expression of emotions that allows gradual transference � Expression of grief, anger, guilt, or frustration through the grief process. Allows Clarification of issues related to � Exploring expectations regarding children, e.g., the couple’s a pregnancy that has not resulted in a healthy infant. expectations, relatives’ expectations, and society’s expectations (continued) Copyright © 2002 F.A. Davis Company GRIEVING, DYSFUNCTIONAL 553 (continued) ACTIONS/INTERVENTIONS RATIONALES � Providing factual information (on whichever diagnosis is appropriate) regarding SIDS, stillbirth, or abortion � Encouraging the couple to honestly share feelings with each other • During conference, encourage couple to ask questions through open-ended questions, reflection, etc. • Monitor, during hospitalization, for signs and symptoms of Provides the database necessary to permit early intervention and depression, anger, frustration, and impending crisis. prevention of more serious problems during this crisis. • Encourage the couple to seek professional help, as necessary, to Fetal demise, SIDS, the decision to have an abortion, and the like deal with continued concerns, such as their sexual relationship, all have long-term effects; therefore, long-term support will be conflicts, anxieties, parenting, and coping mechanisms that can required. be used to deal with the loss of fertility. • Assist the couple, through teaching and provision of written Avoids unrealistic expectations regarding grief resolution. information, to realize that grief may not be resolved for more than a year. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Monitor source of the interference with the grieving process. Early recognition and intervention can facilitate the grieving process. • Monitor the client’s use of medications and the effects this may Sedatives and tranquilizers may delay the grieving process. have on the grieving process. Consult with physician regarding necessary alterations in this area. • Assign a primary care nurse to the client. Facilitates the development of a trusting relationship. • Provide a calm, reassuring environment. Excessive environmental stimuli can increase the client’s confusion and disorganization. • When the client is demonstrating an emotional response to the Encourages appropriate expression of feelings. grief, provide privacy and remain with the client during this time. • Primary nurse will spend 15 min twice a day with the client at Facilitates the development of a trusting relationship. Rituals are [times]. These interactions should begin as nonconfrontational most helpful in situations where there is confusion because of interactions with the client. The goal is to develop a trusting incompatible demands.14 relationship so the client can later discuss issues related to the grieving process. If the client and support system do not identify rituals that would facilitate the grieving process, assist them in developing rituals as appropriate. Note here the rituals and any assistance needed in completing the ritual. • Monitor level of dysfunction, and assist the client with activities Facilitates the development of a trusting relationship. of daily living as necessary. Note type and amount of assistance here. • Monitor nutritional status, and refer to Imbalanced Nutrition Alterations in nutrition can impact coping abilities, or diminished (Chap. 3) for detailed care plan. coping abilities can lead to alterations in nutrition. • Monitor significant others’ response to the client, and have Support system understanding facilitates the maintenance of new primary nurse set a schedule to meet with them and the client behaviors after discharge. every other day to answer questions and facilitate discussion between the client and the support system. Note schedule for these meetings here. • Provide the spiritual support that the client indicates is necessary. Clients may find answers to their questions about life and loss Note here the type of assistance needed from the nursing staff. through spiritual expression. • Allow the client to express anger, and assure him or her that you Violent behavior can evolve from unexpressed anger. Appropriate will not allow harm to come to anyone during this expression. expression of anger promotes the client’s sense of control and enhances self-esteem. • Provide the client with punching bags and other physical activity Assists the client in developing appropriate coping behaviors that assists with the expression of anger. Note tools preferred by enhancing self-esteem. this client here. Note the specific activities that assist this client with this expression here. • Remind the staff and support system that the client’s expressions Support system understanding facilitates the maintenance of new of anger at this point should not be

taken personally even though behaviors after discharge. they may be directed at these persons. (continued) Copyright © 2002 F.A. Davis Company 554 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Answer questions directly and honestly. Promotes the development of a trusting relationship. • Provide time and opportunity for the client to participate in Rituals provide clarity and direction for the grieving process. appropriate religious rituals. Note here assistance needed from nursing staff. • Sit with the client and listen attentively while he or she is talking The presence of the nurse provides positive reinforcement. Positive about the lost object. reinforcement encourages the behavior. • When the client’s verbal interactions increase with the primary Provides opportunities for peer feedback and for peer assistance nurse to the level that group interactions are possible, schedule for problem solving. the client to participate in a group that allows expression of feelings and feedback from peers. Note schedule of group here. • Assign the client appropriate tasks in unit activities. Note type Successful accomplishment of tasks enhances self-esteem. of tasks assigned here. These should be based on the client’s level of functioning and should be at a level that the client can accomplish. Note type of tasks to be assigned to the client here. • If delusions, hallucinations, phobias, or depression are present, refer to Ineffective Individual Coping (Chap. 11) and Disturbed Thought Process (Chap. 7). Some persons in active functional grief may experience hallucinations of the lost person. Tell them that this is common and subsides as their grief is resolved. • Primary nurse will engage the client and the support system in Planned coping strategies facilitate the enactment of new behaviors planning for lifestyle changes that might result from the loss. when the client is experiencing stress, which enhances self-esteem. Note schedule for these interactions here, along with the specific goals. Gerontic Health The nursing actions for the gerontic patient with this diagnosis are the same as those given in Psychiatric Health. Home Health See Psychiatric Health nursing actions for detailed interventions. ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family appropriate monitoring of signs and Provides database for early recognition and intervention. symptoms of dysfunctional grief: � Crying or sadness � Alterations in eating and sleeping patterns � Developmental regression � Alterations in concentration � Expressions of distress at loss � Denial of loss � Expressions of guilt � Labile affect � Grieving beyond expected time � Preoccupation with loss � Hallucinations � Violence toward self or others � Delusions � Prolonged isolation • Involve the client and family in planning and implementing Family involvement in designing the plan of care enhances the strategies to reduce or cope with dysfunctional grieving: effectiveness of the interventions. � Family conference: Identify concerns. � Mutual goal setting: Set realistic goals with evaluation criteria. Specify activities for each family member. � Communication: Provide open and honest communication with positive feedback. Recognize that anger is common and should not be taken personally. • Assist the client and family in lifestyle adjustments that may be Dysfunctional grieving can be a chronic condition. Permanent required: changes in behavior and family roles require support. � Providing realistic hope � Identifying expected grief pattern in response to loss (continued) Copyright © 2002 F.A. Davis Company GRIEVING, DYSFUNCTIONAL 555 (continued) ACTIONS/INTERVENTIONS RATIONALES � Recognizing a variety of accepted expressions of grief � Developing and using support networks � Communicating feelings � Providing a safe environment � Therapeutic use of denial � Identifying suicidal potential or potential for violence � Therapeutic use of anger � Exploring meaning of situation � Stress reduction � Promoting expression of grief � Promoting family cohesiveness • Assist the client and family to set criteria to help them Provides for early recognition and intervention. determine when intervention of health care professional is required—e.g., prolonged inability to complete activities of daily living, or threat to self or others. • Consult with or refer to assistive resources as indicated. Psychiatric nurse clinician and support groups can enhance the treatment plan. Copyright © 2002 F.A. Davis Company 556 ROLE-RELATIONSHIP PATTERN Grieving, Dysfunctional FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient identify at least X number of ways to cope with grief? Yes No Record data, e.g., has joined Reassess using initial assessment factors. Compassionate Friends and attended two sessions; has identified two support systems. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., stated, “I don’t want to cope—I just want to die, too”; family Did evaluation show another reports is drinking more alcohol. problem had arisen? Yes Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company PARENT, INFANT, AND CHILD ATTACHMENT, IMPAIRED, RISK FOR 557 Parent, Infant, and Child Attachment, RELATED CLINICAL CONCERNS Impaired, Risk for 1. Premature infant 2. Chronically ill child DEFINITION8 3. Chronically ill parent Disruption of the interactive process between parent or significant 4. Mental retardation other and infant that fosters the development of a protective and nurturing reciprocal relationship. HAVE YOU SELECTED NANDA TAXONOMY: DOMAIN 7—ROLE THE CORRECT DIAGNOSIS? RELATIONSHIPS; CLASS 2—FAMILY RELATIONSHIPS NIC: DOMAIN 5—FAMILY; CLASS Z— Interrupted Family Processes This diagnosis CHILDREARING CARE is an actual diagnosis and would be used if there were an actual problem with NOC: DOMAIN 3—PSYCHOSOCIAL HEALTH; attachment. CLASS P—SOCIAL INTERACTION Impaired Parenting Again, this is an actual diagnosis. Risk for Impaired Parenting occurs RISK FACTORS8 beyond the attachment phase. 1. Physical barriers 2. Anxiety associated with the parent role 3. Substance abuse EXPECTED OUTCOME 4. Premature infant, ill infant, or child who is unable to effectively ini- tiate parental contact as a result of altered behavioral organization Will show [number] percent decrease in risk factors by [date]. 5. Lack of privacy 6. Inability of parents to meet personal needs TARGET DATES 7. Separation This diagnosis will require time periods that are longer than those RELATED FACTORS8 for other diagnoses to reduce the risk factors. An appropriate initial target date would be 5 to 7 days. The risk factors also serve as the related factors. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Make arrangement, when possible, for the patient to interact with Gives opportunity to practice parenting skills and obtain feedback the infant or child. Accompany the patient to cafeteria, chapel, or in a supportive environment. visitors’ lounge. Provide protection for the infant or child. Provide privacy, but remain close at hand during parent-child interactions. • Encourage the patient with substance-abuse problem to seek Provides long-term support and assistance. counseling, treatment, and support groups; initiate referrals as needed. • Encourage time line planning to provide time for care of the Helps the patient not to get overwhelmed with activities needed to infant or child as well as time for self. care for the infant or child. • Encourage the patient to trade skills or barter for babysitting Provides time for self. Can increase the patient’s self-esteem respite. knowing that he or she has skills that can be traded. • Allow the patient to talk about anxiety with parenting. Teach Provides alternate strategies for coping. stress management and alternate coping strategies. • Have child health clinical nurse specialist or pediatric nurse Provides knowledge base, and helps the patient know that some practitioner teach parenting skills and growth and development of the things he or she is experiencing are normal. of premature infant. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for factors regarding the infant that contribute to or A thorough assessment of reciprocal behaviors will serve as a guide influence maternal or paternal or parent or infant reciprocity: to specific needs of parental-infant dyad. (continued) Copyright © 2002 F.A. Davis Company 558 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Inability to send cues for needs � Inability of the mother or father to attend to cues � Inability of the mother or father to comfort the infant � Mismatch of temperament of the infant to the mother or father � Parental verbalization of feelings about the infant less than ideal for appropriate bonding • Explore actual parent-infant interactions and note strengths and deficits. • Identify behaviors so unsafe as to suggest separation of the infant Safety and legal needs will help protect the infant in an unsafe from the parent, e.g., physical or emotional abuse. (Involve Child relationship. Protective Services according to protocols for location; hotline available nationally.) • Offer role modeling and parenting teaching modules at readiness Often new parenting roles must be acquired as there may be no of the parents and when deemed suitable to do so: suitable role modeling in the parent’s own childhood. � Normal growth and development � Special care for the infant • When the parents must be absent, maintain communication that Trust and sincerity will support the parents in this demanding role. is consistent with ideally the same few individuals to maintain long-term relationship. • Involve appropriate support services as indicated in a timely Support during time of need will enable the parents to be near the manner (e.g., Ronald McDonald House for lodging and local infant as much as possible. social services agencies). • Ensure appropriate counseling and follow-up for all members Long-term goals are best established during acute phase of crisis. as may be deemed essential. Women’s Health ACTIONS/INTERVENTIONS RATIONALES PREGNANCY • Encourage the expectant parents to discuss their perceptions Allows expectant parents to progress through pregnancy in a and expectations of the pregnancy. satisfactory and satisfying manner. Provides knowledge base, and helps the parents know that what they are experiencing is normal. • Provide a nonthreatening atmosphere to encourage the parents to discuss their fears and concerns. • Assist the parents to dispel myths about birth, postpartum period, and early parenthood. • Assist the parents to plan for changes in financial requirements of pregnancy, birth, and early parenthood. • Encourage the parents to talk to the fetus, spend time together feeling the fetus move, etc. • Encourage attendance in various classes that can assist in the transition to parenthood. • Assist the parents in identifying community resources available to expectant and new parents. PARENTHOOD30,31 • Encourage the new parents to touch, talk to, and observe the Allows expectant parents to progress through pregnancy in a newborn as soon as possible (immediately is best). satisfactory and satisfying manner. Provides knowledge base, and helps the parents know that what they are experiencing is normal. • Encourage comparison of newborn characteristics to fantasized newborn. Psychiatric Health This diagnosis is more appropriate under Child Health. Gerontic Health This diagnosis is not appropriate to use with gerontic clients. Copyright © 2002 F.A. Davis Company PARENT, INFANT, AND CHILD ATTACHMENT, IMPAIRED, RISK FOR 559 Home Health ACTIONS/INTERVENTIONS RATIONALES • Involve the client and family in planning and implementing Family involvement enhances effectiveness of intervention. strategies to decrease or prevent alterations in attachment: � Identify family strengths and weaknesses. � Design strategies to support strengths and correct weaknesses. � Provide safe environment. • Teach parenting strategies and techniques to enhance Parenting is learned behavior. parent-child interactions. � Appropriate stimulation for the child � Consistent approach to parenting • Consult with or refer to community resources as required. Provides efficient use of existing resources. Copyright © 2002 F.A. Davis Company 560 ROLE-RELATIONSHIP PATTERN Parent, Infant, and Child Attachment, Impaired, Risk for FLOWCHART EVALUATION: EXPECTED OUTCOME Have the parents shown the stated decrease in risk factors? Yes No Record data, e.g., state “Have Reassess using initial assessment factors. arranged better schedule for work and infant care.” “Now know how to care for baby.” Risk factors now reduced to one—lack of privacy (live with husband’s parents). Record RESOLVED. Delete No Is diagnosis validated? nursing diagnosis, expected outcome, target date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., still expressing concerns about personal needs, lack Did evaluation show another of experience in caring for a baby. problem had arisen? Yes “Scared about baby being too early.” Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company

PARENTING, IMPAIRED, RISK FOR AND ACTUAL, AND PARENTAL ROLE CONFLICT 561 Parenting, Impaired, Risk for and Actual, c. Lack of knowledge about parenting skills d. Poor communication skills and Parental Role Conflict e. Preference for physical punishment f. Inability to recognize and act on infant care DEFINITIONS8 g. Low cognitive functioning Risk For Impaired Parenting Risk for inability of the primary h. Lack of knowledge about child health maintenance caretaker to create, maintain, or regain an environment that pro- i. Lack of knowledge about child development motes the optimum growth and development of a child.* j. Lack of cognitive readiness for parenthood 3. Physiologic Impaired Parenting Inability of the primary caretaker to create, a. Physical illness maintain, or regain an environment that promotes the optimum 4. Infant or Child growth and development of a child.* a. Multiple births Parental Role Conflict Parent experience of role confusion and b. Handicapping condition or developmental delay conflict in response to crisis. c. Illness d. Altered perceptual abilities e. Lack of goodness of fit (temperament) with parental ex- NANDA TAXONOMY: DOMAIN 7—ROLE pectations RELATIONSHIPS; CLASS 1—CAREGIVING ROLES, f. Unplanned or unwanted child AND CLASS 3—ROLE PERFORMANCE g. Premature birth NIC: DOMAIN 5—FAMILY; CLASS Z— h. Not gender desired CHILDBEARING CARE i. Difficult temperament j. Attention deficit hyperactivity disorder NOC: DOMAIN VI—FAMILY HEALTH; CLASS X— k. Prolonged separation from parent FAMILY WELL-BEING l. Separation from parent at birth 5. Psychological a. Separation from infant or child DEFINING CHARACTERISTICS8 b. High number of or closely spaced children c. Disability A. Risk for Impaired Parenting (Risk Factors) d. Sleep deprivation or disruption 1. Social e. Difficult labor and/or delivery a. Marital conflict and/or declining satisfaction f. Young ages, especially adolescent b. History of being abused g. Depression c. Poor problem-solving skills h. History of mental illness d. Role strain or overload i. Lack of, or late, prenatal care e. Social isolation j. History of substance abuse or dependence f. Legal difficulties B. Impaired Parenting g. Lack of access to resources 1. Infant or child h. Lack of value of parenthood a. Poor academic performance i. Relocation b. Frequent illness j. Poverty c. Runaway k. Poor home environment d. Incidence of physical and psychological trauma or abuse l. Lack of family cohesiveness e. Frequent accidents m. Lack of or poor parental role model f. Lack of attachments n. Father of child not involved g. Failure to thrive o. History of being abusive h. Behavioral disorders p. Financial difficulties i. Poor social competence q. Low self-esteem j. Lack of separation anxiety r. Unplanned or unwanted pregnancy k. Poor cognitive development s. Inadequate child care arrangements 2. Parental t. Maladaptive coping strategies a. Inappropriate child care arrangements u. Lack of resources b. Rejection or hostility to child v. Low socioeconomic class c. Statements of inability to meet child’s needs w. Lack of transportation d. Inflexibility to meet needs of child or situation x. Change in family unit e. Poor or inappropriate caretaking skills y. Unemployment or job problems f. Frequently punitive z. Single parent g. Inconsistent care aa. Lack of social support network h. Child abuse bb. Inability to put child’s needs before own i. Inadequate child health maintenance cc. Stress j. Unsafe home environment 2. Knowledge k. Verbalization of inability to control child a. Low educational level or attainment l. Negative statements about child b. Unrealistic expectations of child m. Verbalization of role inadequacy frustration *It is important to state as a preface to this diagnosis that adjustment to n. Abandonment parenting in general is a normal maturational process that elicits nursing o. Insecure or lack of attachment to infant behaviors of prevention of potential problems and health promotion. p. Inconsistent behavior management q. Child neglect Copyright © 2002 F.A. Davis Company 562 ROLE-RELATIONSHIP PATTERN r. Little cuddling d. Limited cognitive functioning s. Maternal-child interaction deficit e. Lack of knowledge about child development t. Poor parent-child interaction f. Inability to recognize and act on infant cues u. Inappropriate visual, tactile, or auditory stimulation g. Low educational level or attainment C. Parental Role Conflict h. Poor communication skills 1. Parent(s) express concerns about changes in parental role, i. Lack of cognitive readiness for parenthood family functioning, family communication, or family health j. Preference for physical punishment 2. Parent(s) express concerns or feelings of inadequacy to pro- 3. Physiologic vide for child’s physical and emotional needs during hospi- a. Physical illness talization or in the home 4. Infant or child 3. Demonstrated disruption in caretaking routines a. Premature birth 4. Expresses concern about perceived loss of control over deci- b. Illness sions relating to his or her child c. Prolonged separation from parent 5. Reluctant to participate in usual caretaking activities even d. Not gender desired with encouragement and support e. Attention deficit hyperactivity disorder 6. Verbalizes and/or demonstrates feelings of guilt, anger, fear, f. Difficult temperament anxiety, and/or frustration about effect of child’s illness on g. Separation from parent at birth family process h. Lack of goodness of fit (temperament) with parental ex- pectations RELATED FACTORS8 i. Unplanned or unwanted child j. Handicapping condition or developmental delay A. Risk for Impaired Parenting k. Multiple births The defining characteristics (risk factors) also serve as the re- l. Altered perceptual abilities lated factors. 5. Psychological B. Impaired Parenting a. History of substance abuse or dependencies 1. Social b. Disability a. Lack of access to resources c. Depression b. Social isolation d. Difficult labor and/or delivery c. Lack of resources e. Young age, especially adolescent d. Poor home environment f. History of mental illness e. Lack of family cohesiveness g. High number or closely spaced pregnancies f. Inadequate child care arrangements h. Sleep deprivation or disruption g. Lack of transportation i. Lack of, or late, prenatal care h. Unemployment or job problems j. Separation from infant or child i. Role strain or overload k. Multiple births j. Marital conflict, declining satisfaction C. Parental Role Conflict k. Lack of value of parenthood 1. Change in marital status l. Change in family unit 2. Home care of a child with special needs (e.g., apnea moni- m. Low socioeconomic class toring, postural drainage, or hyperalimentation) n. Unplanned or unwanted pregnancy 3. Interruptions of family life as a result of home care regimen o. Presence of stress (e.g., financial, legal, recent crisis, and (treatments, caregivers, or lack of respite) cultural move) 4. Specialized care centers policies p. Lack of, or poor, role model 5. Separation from child as a result of chronic illness q. Single parents 6. Intimidation with invasive or restrictive modalities (e.g., iso- r. Lack of social support network lation or intubation) s. Father of child not involved t. History of being abusive RELATED CLINICAL CONCERNS u. Financial difficulties v. Maladaptive coping strategies 1. Birth defect w. Poverty 2. Multiple births x. Poor problem-solving skills 3. Chronically ill child y. Inability to put child’s needs before own 4. Substance abuse z. Low self-esteem 5. Parental chronic illness aa. Relocation 6. Major depressive episode bb. Legal difficulties 7. Manic episode cc. History of being abused 8. Phobic disorders 2. Knowledge 9. Dissociative disorders a. Lack of knowledge about child health maintenance 10. Organic mental disorders b. Lack of knowledge about parenting skills 11. Schizophrenic disorders c. Unrealistic expectations for self, infant, and partner Copyright © 2002 F.A. Davis Company PARENTING, IMPAIRED, RISK FOR AND ACTUAL, AND PARENTAL ROLE CONFLICT 563 HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Interrupted Family Processes This diagnosis Compromised or Disabled Family Coping This indicates dysfunctioning on part of the entire family, diagnosis usually arises from the client’s not just the parents. If the entire family is indicating perspective that his or her primary support is no difficulties dealing with current problems or crises, longer fulfilling this role. If the problem relates to then Interrupted Family Processes is a more correct parents and their child(ren), then one of the diagnosis than one of the Parenting diagnoses, Parenting diagnoses is the most appropriate which related to the parents only. diagnosis. EXPECTED OUTCOME TARGET DATES Will demonstrate appropriate parental role of [specify exactly what, The diagnosis will require a lengthy amount of time to be totally re- e.g., feeding or medication administration] behavior by [date]. solved. However, progress toward resolutions could be evaluated within 7 days. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Provide information relative to normal growth and development Provides knowledge base, and assists the patient to know that of self and the child by sitting and talking with the patient for some of the things he or she is experiencing are normal. 30 min twice a day at [times]. • During conference time, assist the parent to recognize when Prevents a crisis situation. Promotes self-knowledge. stress is becoming distress, e.g., irritability turns to rage and/or verbal or physical abuse, sleeplessness, disturbed thought process, or tunnel perception of situation. • Teach stress management and parenting techniques, e.g., Provides alternative strategies for coping, and provides database relaxation, deep breathing, Mother’s Day Out, safety precautions, needed for dealing with growth and development of the child. or toileting process. • Provide opportunities for the parent to participate in the child’s Gives opportunity to practice parenting skills and obtain feedback care. in supportive environment. • Discuss disciplinary methods other than physical, e.g., Physical discipline can lead to abuse; sends wrong message to the grounding, taking away privileges, positive reinforcement, and child. verbal praise for “good” behavior. • Encourage the patient to allow time for own needs. Own needs must be met to decrease stress and facilitate meeting needs of others. • Encourage use of support groups. Initiate referrals as needed. Provides an outlet for the parents with other parents in similar situations. Provides long-term support and assistance. Child Health ACTIONS/INTERVENTIONS RATIONALES • Review current level of knowledge regarding parenting of the Provides database needed to more accurately plan care. infant or child to include: � Parental perception of the infant or child � Parental views of expected development of the infant or child � Health status of the infant or child � Current needs of the infant or child � Infant or child communication (remember, behaviors reveal much about feelings) � Infant’s or child’s usual responsiveness � Family dynamics, e.g., who offers support for emotional needs or the child’s view of mother and father (continued) Copyright © 2002 F.A. Davis Company 564 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Determine needs for specific health or developmental Needs may be identified with assistance from experts in intervention from other health care providers as needed. multidisciplinary domains. Collaboration is essential to avoid fragmentation of care. • Observe parental readiness, and encourage caretaking in a Provides data needed to plan teaching and to provide supportive atmosphere in the following ways, as applicable: individualization of the plan of care. � Feeding � Bathing � Anticipatory safety measures � Clarification of medical or health maintenance regimen � Play and developmental stimulations for age and capacity � Handling and carriage of the infant or child � Diapering and dressing of the infant or child � Social interaction appropriate for age and capacity � Other specific measures according to the patient’s status and needs • Schedule a daily conference of at least 1 h with the parents, and Provides teaching opportunity. Verbalization reveals thoughts and encourage the parents to verbalize perceived parenting role, data needed to more accurately plan care. both current and desired. • Allow the parents to gradually assume total care of the infant Provides opportunity for practice of needed skills or roles; fosters within hospital setting at least 48 h before dismissal. If more growth and confidence in parenting. time is required to validate appropriate parenting success, collaborate with pediatrician regarding extending the child’s stay for 24 h. • During conference, assist the parents to identify ways of coping Provides growth for parents; provides long-term support. with infant and parental demands to include family, community, and health care professional support. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient, through monthly conferences, in completing Acceptance of pregnancy and working through the tasks of the tasks of pregnancy by encouraging verbalization of: pregnancy provide a strong basis for positive parenthood and � Fears appropriate attachment and bonding. � Mother’s perception of marriage � Mother’s perception of “child within” her � Mother’s perception of the changes in her life as a

result of this birth: (1) Relationship with partner (2) Relationship with other children (3) Effects on career (4) Effects on family • Allow the mother to question pregnancy: “Now” and “Who, me?”31 • Assist the mother in realizing existence of the child by Provides basis for appropriate attachment behaviors and coping encouraging the mother to: skills for transition to maternal role. � Note when the infant moves. � Listen to fetal heart tones during visit to clinic. � Discuss body changes and their relationship to the infant. � Verbalize any questions she may have. • Assist in preparation for birth by: � Encouraging attendance at childbirth education classes � Providing factual information regarding the birthing experience � Involving significant others in preparation for birthing process • Assist the patient in preparing for role transition to parenthood by encouraging: � Economic planning, e.g., physician, hospital, or prenatal testing fees � Social planning, e.g., changes in lifestyle (continued) Copyright © 2002 F.A. Davis Company PARENTING, IMPAIRED, RISK FOR AND ACTUAL, AND PARENTAL ROLE CONFLICT 565 (continued) ACTIONS/INTERVENTIONS RATIONALES • Assist the patient in identifying needs related to the family’s Assists in identifying patients at high risk for the development of acceptance of the newborn: this diagnosis. � Mother’s perceived level of support from family members � Stressors present in the family, e.g., economics, housing, or level of knowledge regarding parenting • Monitor for following behaviors: � Refuses to plan for the infant � No interest in pregnancy or fetal progress � Overly concerned with own weight and appearance � Refuses to gain weight (diets during pregnancy) � Negative comments about “What this baby is doing to me!” POST PARTUM • Assist the patient and significant others in establishing realistic goals for integration of the baby into the family. • Provide positive reinforcement for parenting tasks: Promotes realistic planning for the new baby as well as bonding � Encourage use of birthing room: Labor, delivery, and recovery and attachment. (LDR) room and labor, delivery, recovery, and postpartum (LDRP) rooms—for birth to allow active participation in birth process by both parents. � Allow the mother and partner time with the infant (do not remove to nursery if stable) following delivery. � Provide mother-baby care to allow maximum continuity of mother-infant contact and nursing care. • Assist the parents in identifying different kinds of infant behavior Provides the parents with essential information they need to care and understanding how they allow the infant to communicate for the infant. with them: � Perform gestational age assessment with the parents, and explain significance of findings. � Perform Brazelton neonatal assessment with the parents, and explain significance of findings. � Demonstrate how to hold the infant for maximum communication. � Explain infant reflexes—e.g., rooting or Moro—and the importance of understanding them. • Assist the parents in identifying support systems: � Friends from childbirth classes � Parents and parents-in-law � Siblings � Nurse specialists • Encourage the parents to reminisce about birthing experience. • Assist the patient in identifying needs related to family Provides database needed for planning to offset factors that would functioning: result in ineffective parenting. • Identify negative maternal behavior: � No interest in the new baby � Talks excessively to friends on telephone � Is more interested in TV than in feeding the infant � Refuses to listen to infant teaching � Asks no questions � Extraordinary interest in self-appearance: (1) Severe dieting to gain prepregnancy figure (2) Overutilization of exercise to gain prepregnancy figure � Crying, moodiness � Lack of interest in the family and other children � Failure to perform physical care for the infant � Noncompliance: Breaks appointments with health care providers for self and the infant • Identify negative paternal behavior: � Refusal to support wife by: (1) Not assisting in child care (2) Not sharing household tasks (3) Keeping “his” social contacts and going out while the wife remains at home with the child (continued) Copyright © 2002 F.A. Davis Company 566 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Not providing financial support � Abandonment • Assist the patient in identifying methods of coping with stress Provides long-term support. of newborn in the family: � Seek professional help from nurse specialist, physician (obstetrician or pediatrician), or psychiatrist � Identify support system in the family or among friends � Refer to appropriate community or private agencies Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Monitor the degree to which drugs and alcohol interfere with Early intervention and treatment increase the likelihood of a the parenting process. If this is a factor, discuss a treatment positive outcome. program with the client. • Ask the client who is caring for the children while he or she is Early intervention and treatment increase the likelihood of a hospitalized, and assess his or her level of comfort with this positive outcome. arrangement. If a satisfactory arrangement is not present, refer to social services so arrangements can be made. • Discuss with the client expectations and problem perception. Promotes the client’s sense of control. • Have the client identify support systems, and gain permission to Support system understanding facilitates the maintenance of include these persons in the treatment plan as necessary. This behaviors after discharge. could include spouse, parents, close friends, etc. • If the client desires to maintain parenting role, arrange to have A continuous relationship between the parent and the child is the children visit during hospitalization. Assign a staff member necessary for the normal development of the child.32 to remain with the client during these visits. The staff person can serve as a role model for the client and facilitate communication between the child and the client. Note schedule for these visits here and the staff person responsible for the supervision of these interactions. • Answer the client’s questions in a clear, direct manner. Promotes the development of a trusting relationship. • Spend 15 min twice a day at [times] with the client discussing Promotes the development of a trusting relationship, and provides his or her perception of the parenting role and his or her information abut the client’s worldview that can be utilized in expectations for self and the children. constructing interventions. • Arrange 30 min a day for interaction between the client and one Supports the maintenance of these relationships, and provides member of the support system. A staff member is to be present opportunities for the nurse to do positive role modeling. during these interactions to facilitate communication and focus the discussion on parenting issues. • Provide the client with information on normal growth and Provides information that will assist the client in making development and normal feelings of parents. Provide the client appropriate parenting decisions, enhancing self-esteem. Provides with concrete information about building age-appropriate parents with specific strategies for affirmation of parent and child developmental assets. This could include setting appropriate interactions that support positive child development. boundaries, providing appropriate support, and constructive use of time.33 • Assist the client in developing a plan for disciplining the children. Facilitates the development of positive coping behaviors, and This plan should be based on behavioral interventions, and the promotes a positive expectational set. primary focus should be on positive social rewards.33 • Teach the client ways of interacting with the child that reduce Promotes positive orientation and enhances self-esteem. levels of conflict, e.g., providing the child with limited choices, spending scheduled time with the child, and listening carefully to the child. • Encourage the client to maintain telephone contact with the Assists in maintaining these important relationships to make the children by providing a telephone and establishing a regular transition home easier. time for the client to call home or have the children call the hospital. • Encourage the support system to continue to include the client Assists in maintaining the client’s role functioning, thus enhancing in decisions related to the children by having them bring up self-esteem. these issues in daily visits and by assisting the client and the support system to engage in collaborative decision making regarding these issues. (continued) Copyright © 2002 F.A. Davis Company PARENTING, IMPAIRED, RISK FOR AND ACTUAL, AND PARENTAL ROLE CONFLICT 567 (continued) ACTIONS/INTERVENTIONS RATIONALES • Have the client identify parenting models, and discuss the effect these persons had on their current parenting style. • Observe interaction between the parents to assess for problems Children can be triangled into parental conflicts in an unconscious in the husband-wife relationship that may be expressed in the effort to preserve the marital relationship.34,35 parenting relationship. If this appears to be happening, refer the parents to family therapy. • Have the client develop a list of problem behavior patterns, and Promotes the client’s sense of control, and begins the development then assist him or her in developing a list of alternative behavior of alternative, more adaptive coping behaviors. patterns. For example, Current: When I get frustrated with my child, I spank him with a belt. New: When I get frustrated with my child, I arrange to send him to the neighbors for 30 min while I take a walk around the block to calm down. • Role-play with the client those situations that are identified as Behavioral rehearsal provides opportunities for feedback and being most difficult, and provide opportunities to practice more modeling of new behaviors by the nurse. appropriate behavior. This should be done daily in 30-min time periods. Note schedule for this activity here, list time periods, and list those situations that are to be practiced. It would be useful to include spouse. • Have the client attend group sessions where feelings and thoughts Assists the client to experience personal importance to others, can be expressed to peers and the thoughts and feelings of peers while enhancing interpersonal relationship skills. Increasing these can be heard. Note schedule for the group here. competencies can enhance self-esteem and promote positive orientation. • Assist the client in identifying personal needs and in developing Assists the parents to develop strategies for coping with role strain. a plan for meeting these needs at home; e.g., the parents will exchange babysitting time with neighbors so they can have an evening out once a month. Note this plan here. • Monitor staff attitudes toward the client, and allow them to Negative attitudes of staff can be communicated to the client, express feelings, especially if child abuse is an issue with this decreasing the client’s self-esteem and increasing the client’s client. defensiveness. • Assist the client with grieving separation from the child, and refer to Anticipatory Grieving for detailed nursing actions. • Provide the client with positive verbal support for positive Positive reinforcement encourages behavior and enhances parenting behavior and for progress on behavior change self-esteem. goal—e.g., “You demonstrate a great deal of concern for your child’s welfare,” or “You have taught your child to be very sensitive.” Make sure these comments are honest and fit the client’s awareness of the situation. • Assist the client in developing stress reduction skills by: � Teaching deep muscle relaxation and practicing this with the client 30 min a day at [time]. � Discussing with the client the role physical exercise plays in stress reduction and developing a plan for exercise (note plan and type of exercise here). Have staff member remain with the client during these exercise periods. Note time for these periods here. • When the client’s level of tension or anxiety is rising on the unit, remind him or her of the exercise or relaxation technique, and work through one of these with him or her. • Observe interaction between the parents to monitor for problems Conflict in one part of the family system can impact interactions in in the parental dyad that may be expressed in the parenting other parts of the system. relationship with the children. If this appears to be happening, refer the patient to family therapy. Gerontic Health NOTE: This would be an unusual diagnosis for the gerontic patient, but might develop if the grand- parents had to take grandchildren into their home as a result of a family crisis. In that instance, the nursing actions would be the same as those given in Adult Health and Child Health. Copyright © 2002 F.A. Davis Company 568 ROLE-RELATIONSHIP PATTERN Home Health ACTIONS/INTERVENTIONS RATIONALES • Act as role model through use of positive behaviors

when Role modeling provides example for parenting skills. interacting with the child and parents. • Report child abuse and neglect to the appropriate authorities. Meets legal requirements and provides for intervention. • Teach the client and family appropriate information regarding Knowledge is necessary to provide appropriate child care. the care and discipline of children: � Cultural norms � Normal growth and development � Anticipatory guidance regarding psychosocial, cognitive, and physical needs for children and parents � Expected family life cycles � Development and use of support networks � Safe environment for family members � Nurturing environment for family members � Special needs of the child requiring invasive or restrictive treatments • Involve the client and family in planning and implementing Involvement of the family in planning enhances the effectiveness strategies to decrease or prevent alterations (risk for or actual) of the interventions. in parenting: � Family conference: Identify each member’s perspective of the situation. � Mutual goal setting: Develop short-term, realistic goals with evaluation criteria. � Communication: Use open, honest communication with positive feedback. � Distribution of family tasks: Tasks are performed by all family members as developmentally and physically appropriate. � Promoting the parent’s self-esteem: Provide positive support of existing positive parenting skills. • Assist the client and family in lifestyle adjustments that may be Long-term behavioral changes require support. required: � Development of parenting skills � Use of support network � Establishment of realistic expectations of the children and spouse • Refer to appropriate assistive resources. Support groups, family therapist, school nurse, and teachers can enhance the treatment plan. Copyright © 2002 F.A. Davis Company PARENTING, IMPAIRED, RISK FOR AND ACTUAL, AND PARENTAL ROLE CONFLICT 569 Parenting, Impaired, Risk for and Actual, and Parental Role Conflict FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient accurately return-demonstrate the specified parental role behavior? Yes No Record data, e.g., accurately Reassess using initial assessment factors. return-demonstrated medication administration X 3. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., indicates still feels “unsure” re the child’s diabetic Did evaluation show another exchange diet. Record CONTINUE and problem had arisen? Yes change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 570 ROLE-RELATIONSHIP PATTERN Relocation Stress Syndrome, Risk for 3. Anxiety, for example, separation 4. Sleep disturbance and Actual 5. Withdrawal DEFINITION8 6. Anger 7. Loss of identity, self-worth, or self-esteem Risk for Relocation Stress Syndrome Risk for physiologic and/or 8. Increased verbalization of needs, unwillingness to move, or psychosocial disturbances pending a transfer from one environment concern over relocation to another. 9. Increased physical symptoms or illness, for example, gas- trointestinal disturbance or weight change Relocation Stress Syndrome Physiologic and/or psychosocial 10. Dependency disturbances following a transfer from one environment to another. 11. Insecurity 12. Pessimism NANDA TAXONOMY: DOMAIN 9—COPING/STRESS 13. Frustration TOLERANCE; CLASS 1—POST-TRAUMA RESPONSES 14. Worry 15. Fear NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING ASSISTANCE RELATED FACTORS8 NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; A. Risk for Relocation Stress Syndrome (Risk Factors) CLASS N—PSYCHOSOCIAL CHANGE The risk factors also serve as the related factors. B. Relocation Stress Syndrome DEFINING CHARACTERISTICS8 1. Unpredictability of experiences 2. Temporary or permanent move A. Risk for Relocation Stress Syndrome (Risk Factors) 3. Voluntary or involuntary move 1. Decreased psychosocial or physical health status 4. Past, concurrent, or recent losses 2. Feelings of powerlessness 5. Feelings of powerlessness 3. Lack of adequate support system or group 6. Lack of adequate support system or group 4. Moderate competence, for example, alert enough to expe- 7. Lack of predeparture counseling rience changes 8. Passive coping 5. Lack of predeparture counseling 9. Impaired psychosocial health 6. Moderate to high degree of environmental change (e.g., 10. Decreased health status physical, ethnic, or cultural) 11. Isolation from family and/or friends 7. Passive coping 12. Language barrier 8. Past, current, or recent losses 9. Temporary and/or permanent moves RELATED CLINICAL CONCERNS 10. Unpredictability of experience 11. Voluntary or involuntary move 1. Any diagnosis that would require transfer of the patient to a B. Relocation Stress Syndrome long-term care facility 1. Aloneness, alienation, or loneliness 2. A chronic disease that would require the older adult to move in 2. Depression with his or her children HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Ineffective Individual Coping This diagnosis and resolving the problems associated with relocation Relocation Stress Syndrome do sound similar in of the patient. some ways; however, the differentiating factor Impaired Adjustment Certainly any move, is whether or not the individual is being or whether for an ill or healthy individual, would recently has been involved in a transfer from require some adjustment. However, this diagnosis one care setting to another. If such a transfer relates to an individual’s adjusting to his or her is being considered or has occurred, initial own illness or health problem, not adjustment to a interventions should be directed toward change in the health care setting. EXPECTED OUTCOME TARGET DATES The patient will verbalize increased satisfaction with new environ- An initial target date of 7 days would be reasonable to assess for ment by [date]. progress toward meeting the expected outcome. Copyright © 2002 F.A. Davis Company RELOCATION STRESS SYNDROME, RISK FOR AND ACTUAL 571 NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Encourage verbalization of feelings, both positive and negative, Brings feelings out into the open, and clarifies emotions and by actively listening, using reflection, asking open-ended makes them easier to cope with. questions, etc., about relocation. Schedule 30 min twice a day at [times] to focus on this topic. • Determine any previous experience with relocation and the Provides understanding of problem and information to further strategies used to cope with the experience during discussions develop interventions. Determines previously used coping with the patient. strategies, which ones were successful or unsuccessful, and what alternative strategies may be tried. • Allow the patient to control, to the extent possible, his or her Increases self-confidence, and decreases feeling of powerlessness. environment. • Provide consistency in daily care, such as same primary nurse, Provides security, thus facilitating adjustment. same daily routines, and same environment. • Explain all procedures prior to implementation. Decreases anxiety. • Teach stress management techniques such as relaxation, Decreases anxiety so that energy can be used to implement meditation, deep breathing, exercise, or diversional activities. effective coping strategies. Have the patient return-demonstrate technique for 15 min twice a day at [times]. • Consult with other health care professionals as necessary. Collaboration promotes care that incorporates physiologic and psychosocial interventions that may be needed as a result of relocation stress. • Help the patient maintain former relationships by providing Decreases feelings of isolation and depression. letter-writing materials or a telephone. • Provide the patient with a list of organizations and community Assists the patient to develop new relationship and may hasten services available for newcomers, e.g., Welcome Wagon, senior adjustment. citizens’ groups, churches, or singles’ groups. Child Health ACTIONS/INTERVENTIONS RATIONALES • Assess, to the degree possible, the emotional stability of the Adaptability to change is determined to a large degree by patient and family (can use Chess-Thomas Temperament temperament and previous coping. Scale36). • Schedule a family conference of at least 1 h daily and focus on: Provides support to cope with changes caused by relocation. � Feelings of the patient and family regarding move � Aspects of relocation that are problematic, e.g., school or friends � Identification of potential benefits and growth the relocation might offer • Encourage plans for maintaining desired relationships despite physical move, e.g., letter, telephone calls, or visits. Women’s Health The nursing actions for a woman with this nursing diagnosis are the same as those found in Adult Health and Gerontic Health. Psychiatric Health In addition to those interventions identified under Adult Health and Gerontic Health, the following in- terventions apply. ACTIONS/INTERVENTIONS RATIONALES • Assess the client’s cognitive resources. Nursing interventions should be adapted to the client’s cognitive abilities.37 (continued) Copyright © 2002 F.A. Davis Company 572 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Arrange to have objects familiar to the client in the environment. Familiar objects decrease anxiety and increase the sense of control This could include photographs, clothing, furniture, or other while helping to reestablish personal space. significant personal items. • Provide the client with a sense of personal space by labeling Facilitates the reestablishment of a personal space. room, having him or her seated at the same place at mealtimes, and assisting him or her in the protection of this space and his or her belongings. Note those adaptations here. • Involve the client in the decision to change location. This is Promotes a sense of personal control, and facilitates the adjusted to fit the client’s cognitive abilities, and the degree to psychological and emotional preparation for the move. which the client is involved should be noted here. • Sit with the client [number] minutes each day to discuss the Facilitates adjustment to the new milieu.35 move and memories of the former home. Having a picture of the former residence may facilitate this. Note person responsible for this discussion here. • Provide sensory adaptive devices such as hearing aids and Facilitates orientation to the environment, and promotes sense of eyeglasses. Note those devices needed by this client here. control. Promotes safety in the new environment. Gerontic Health NOTE: These actions apply to the patient entering an acute care facility. ACTIONS/INTERVENTIONS RATIONALES • Identify whether the patient is at risk for relocation syndrome. Early identification of patients at risk can mean earlier intervention In older adults, this may include those with no confidant (social and a possible decrease in the negative consequences of relocation. support), those who perceive themselves as worriers, those in poor health, and those with low self-esteem.38 • Assist the patient in realistic perception of event: What has May assist in accepting need for relocation. occurred, reasons for transfer based on physical needs, changed health status. • Provide supportive care as the situation requires, such as Allows responses that are tailored to the individual’s expressed answering questions regarding the routines in the hospital or needs. expected course of treatment. • Discuss possible occurrence of syndrome with significant others. Provides anticipatory information that avoids undue stress on the family. • Discuss with the patient and significant others the patient’s Provides database to build on prior to discharge from acute care usual coping skills. facility. • Discuss transfer with the patient and family. Provides time to question and to promote positive adjustment to the change in location. • If not returning to prehospitalization location, discuss with the Allows time for ventilation of feelings related to the relocation. patient his or her proposed plans, reasons for transfer, and the patient’s response to proposal. Home Health See Psychiatric Health for additional interventions. ACTIONS/INTERVENTIONS RATIONALES • Assist the client or caregiver to make the new environment as Enhances the client’s sense of security and comfort. much like the previous environment as possible: � Similar schedules and routines � Decorations from previous environment � Significant items such as blankets, artwork, and music � Foods served should be as familiar as possible. • Educate the client or caregiver as far in advance as possible of Promotes a sense of control, and avoids unpleasant surprises. necessary changes in location, and tell them what to expect. • When the change in location involves separation from significant Enhances the client’s sense of security and comfort. others, help the client or caregiver to obtain items that may increase the client’s comfort: � Photographs of loved ones � Letters and cards from loved ones � Videotapes and/or audiotapes of loved ones Copyright © 2002 F.A. Davis Company RELOCATION STRESS SYNDROME, RISK FOR AND ACTUAL 573 Relocation Stress Syndrome, Risk for and Actual FLOWCHART EVALUATION: EXPECTED OUTCOME Interview the patient. Compare number of positive and negative comments today with number made on day of admission. Is the patient indicating increased satisfaction? Yes No Record data, e.g., states has Reassess using initial assessment factors. found some people to play bridge; likes exercise program here and independence allowed; “It’s really not bad at all; I’m having a good time.” Record RESOLVED. Delete nursing diagnosis,

expected No Is diagnosis validated? outcome, target date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., stated, “still don’t like this place; I can’t sleep, the food Did evaluation show another doesn’t agree with me; I just want to go problem had arisen? Yes home.” Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 574 ROLE-RELATIONSHIP PATTERN Role Performance, Ineffective g. Inadequate support system h. Inadequate role socialization, for example, role model, ex- DEFINITION8 pectations, and responsibilities i. Low social economic status Patterns of behavior and self-expression that do not match the en- j. Stress and conflict vironmental context, norms, and expectations.* k. Domestic violence l. Lack of resources NANDA TAXONOMY: DOMAIN 7—ROLE 2. Knowledge RELATIONSHIPS; CLASS 3—ROLE PERFORMANCE a. Inadequate role preparation, for example, role transition, NIC: DOMAIN 5—FAMILY; CLASS X—LIFE SPAN skill rehearsal, and validation CARE b. Lack of knowledge about role, role skills c. Role transition NOC: DOMAIN VI—FAMILY HEALTH; CLASS W— d. Lack of opportunity for role rehearsal FAMILY CAREGIVER STATUS e. Developmental transitions f. Unrealistic role expectations DEFINING CHARACTERISTICS8 g. Education attainment level h. Lack of or inadequate role model 1. Change in self-perception of role 3. Physiologic 2. Role denial a. Inadequate or inappropriate linkage with health care system 3. Inadequate external support for role enactment b. Substance abuse 4. Inadequate adaptation to change or transition c. Mental illness 5. System conflict d. Body image alteration 6. Change in usual patterns of responsibility e. Physical illness 7. Discrimination f. Cognitive defects 8. Domestic violence g. Health alterations, for example, physical health, body image, 9. Harassment self-esteem, mental health, psychosocial health, cognition, 10. Uncertainty learning style, or neurologic health 11. Altered role perception h. Depression 12. Role strain i. Low self-esteem 13. Inadequate self-management j. Pain 14. Role ambivalence k. Fatigue 15. Pessimistic attitude 16. Inadequate motivation 17. Inadequate confidence RELATED CLINICAL CONCERNS 18. Inadequate role competency and skills 1. Any major surgery 19. Inadequate knowledge 2. Any chronic disease 20. Inappropriate developmental expectations 3. Any condition resulting in hemiplegia, paraplegia, or quadriplegia 21. Role conflict 4. Chemical abuse 22. Role confusion 5. Cancer 23. Powerlessness 24. Inadequate coping 25. Anxiety or depression 26. Role overload 27. Change in other’s perceptions of role HAVE YOU SELECTED 28. Change in capacity to resume role THE CORRECT DIAGNOSIS? 29. Role dissatisfaction 30. Inadequate opportunities for role enactment Social Isolation This diagnosis relates to the patient who, because of physical, communicative, or social problems, chooses RELATED FACTORS8 to be alone or perceives that he or she is 1. Social alone and therefore isolated from society. a. Inadequate or inappropriate linkage with the health care sys- This diagnosis deals mainly with the tem individual who cannot or will not perform b. Job schedule demands any role. c. Young age or developmental level Interrupted Family Processes This diagnosis d. Lack of rewards refers to an entire family that must in one e. Poverty way or another alter the processes that go on f. Family conflict within the family. Many times this will involve altered role performances of the individual family members; however, the overall focus is on the alteration within the *There is a typology of roles: socio-personal (friendship, family, marital, parenting, community); home management; intimacy (sexuality, relation- family and not with the individual members ship building); leisure, exercise, or recreation; self-management; socializa- of the family. tion (developmental transitions); community contributor; and religious. Copyright © 2002 F.A. Davis Company ROLE PERFORMANCE, INEFFECTIVE 575 EXPECTED OUTCOME TARGET DATES Will implement plan to offset factors contributing to disturbance in Target dates for this diagnosis will have to be highly individualized role performance by [date]. according to each situation. A minimum target date would be 5 days to allow time to identify impinging factors and methods to cope with those factors. NURSING ACTIONS/INTERACTIONS AND RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Encourage the patient to express his or her perception of role Relieves stress, and helps the patient clarify feelings in a safe responsibilities by active listening, using reflection, asking environment. open-ended questions, accepting the patient’s feelings, and maintaining a nonjudgmental attitude. • Help the patient and significant others realistically negotiate role Facilitates problem solving. Promotes cooperation among involved responsibilities by assisting in the problem-solving process— persons. What is the role? What are its responsibilities? How can responsibilities be shared? What outcomes are expected of the role? Have the patient and significant other(s) meet together for 1 h every other day. • Teach the patient regarding role, e.g., parent, caregiver, or Clarifies misconceptions, and provides realistic role expectations. breadwinner. Allow time for discussion, return-demonstrations, and questioning prior to discharge. • Help the patient identify community resources to assist in role Provides support for short-term and long-term problem solving. responsibilities prior to discharge. • Refer to psychiatric nurse clinician as needed (see Collaboration promotes holistic plan of care, and problem may Psychiatric Health nursing actions for more detailed need specialized interventions. interventions). Child Health ACTIONS/INTERVENTIONS RATIONALES • Determine how the child and parent perceive the expected role Provides essential database necessary to plan care. for the child. • Identify confusion or diffusion of role according to the child’s Problem identification serves to establish common areas to be and parent’s expectations versus actual role. further explored in role performance. • Determine value the child has in the family. The value a child has for each family is critical to expectations for all involved. • Determine the child’s self-perception. One’s self-perception provides insight into how one evaluates his or her own performance. • Identify ways to alleviate role performance alteration according Alleviation of one or more role performance alterations may to actual cause. If child is temporarily unable to participate in prevent further deterioration in role functioning, with a greater certain physical activities, explore other nonphysical ways the appreciation for the value of all roles. child can participate. • Allow for ventilation of feelings by the child via puppetry, art, Feelings are most critical in exploring one’s role performance. or other age-appropriate methods. Schedule at least 30 min Appropriate aids in communication serve to foster focused play or during each 8-h shift, while awake, for this activity. Note times behaviors to reveal thoughts of the child who is unable to express here. himself or herself. • Provide the patient and parents with options to best facilitate Vicarious involvement allows for shared activities and the sense needs for future implications of compromised role of maintaining closeness with the desired groups or person. performance—e.g., shared experiences with peers who have temporarily had to forsake physical activities because of illness. How did they keep up with the team? (continued) Copyright © 2002 F.A. Davis Company 576 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Allow for family time and support for choices to uphold role Shared time of family and friends is important, especially in times needs, e.g., visitation by peers. of role stress, to maintain value of self. • Provide for safety needs of the child and family. Standard care includes safety. The tendency is to relax concerns in times of less stressful activity. • Assist in follow-up plans with appropriate appointments for Arrangements for follow-up promote valuing of follow-up and psychiatric or pediatric care. increase the likelihood for compliance. • Provide support in identification of risk to normal actualization Early identification of primary or secondary risks may prevent or of potential of the child. minimize tertiary risks for the child and family. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Allow the patient to describe her perception of her role as a Provides database to initiate care planning. mother, wife, and working woman. • Identify sources of role stress and strain that contribute to role conflict and fatigue. • Assist in developing a schedule that manages time well, both at home and at work. • Involve significant others in planning methods of reducing role Encourages the patient to identify various roles she is currently stress and strain at home by: fulfilling, and provides support that allows planning of coping � Assisting with child care strategies and techniques. � Assisting with household duties � Sharing carpooling and children’s activities • Encourage the patient to use time at work for “work activities” and time at home for “home activities”—i.e., do not take work home. • Look at possibility of job sharing or part-time employment while the children are at home. • Plan home activities in advance, such as shopping and cooking meals in advance and freezing them for later use. • Encourage division of workload by exchanging childcare activities with friends or other families in the neighborhood. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Sit with the client [number] minutes [number] times per day to Provides information about the client’s perceptions and discuss the client’s feelings about self and role performance. expectations that can be utilized in developing specific interventions. • Answer questions honestly. Promotes the development of a trusting relationship. • Provide feedback to the client about nurse’s perceptions of the Assists the client in realistically evaluating his or her perceptions. client’s abilities and appearance by: � Using “I” statements � Using references related to the nurse’s relationship to the client � Describing the nurse’s feelings in relationship • Provide positive reinforcement. List here those things, including Reinforcement encourages positive behavior and enhances social rewards, that are reinforcing for the client and when they self-esteem. are to be used. Also list those things that have been identified as nonreinforcers for this client. • Provide group interaction with [number] persons [number] Assists the client to experience personal importance to others, minutes 3 times a day at [times]. This activity should be gradual while enhancing interpersonal relationship skills. Increasing these within the client’s ability—e.g., on admission the client may role competences can enhance self-esteem and promote a positive tolerate 1 person for 5 min. If the interactions are brief, the orientation. frequency should be high—e.g., 5-min interactions should occur at 30-min intervals. (continued) Copyright © 2002 F.A. Davis Company ROLE PERFORMANCE, INEFFECTIVE 577 (continued) ACTIONS/INTERVENTIONS RATIONALES • Reflect back to the client negative self-statements made by the This will increase the client’s awareness of these statements and client. This should be done with a supportive attitude in a facilitate the development of alternative cognitive patterns. manner that will increase the client’s awareness of these negative evaluations of self. • Set achievable goals for the client. Achievement of goals provides positive reinforcement that encourages the behavior and enhances self-esteem. • Provide activities that the client can accomplish and that the Accomplishment of valued tasks provides positive reinforcement client values. Care should be taken not to provide tasks that the that encourages behavior and enhances self-esteem. client finds demeaning, which could reinforce the client’s negative self-evaluation. • Provide verbal reinforcement for the achievement of steps Promotes a positive orientation. toward a goal. • Have the client develop a list of his or her strengths and potentials. • Define the client’s lack of goal achievement or failures as simple Promotes a positive orientation. mistakes that are bound to occur when one attempts something new—e.g., learning comes with mistakes; if one does not make mistakes one does not learn. • Define past failures as the client’s best attempts to solve a problem—e.g., if the client had known a better solution, he or she would have used it; one does not set out to fail. • Make necessary items available for the client to groom self. Appropriate grooming improves the client’s self-evaluation. • Spend [number] minutes at [time] assisting the client with The nurse’s presence can provide positive reinforcement, and grooming, providing necessary assistance and positive reinforcement encourages positive behavior. reinforcement for accomplishments. • Focus the client’s attention on the here and now. Past happenings are difficult for the nurse to provide feedback on. • Present the client with opportunities to make decisions about Promotes the client’s sense of control, and enhances self-esteem. care, and record these decisions on the chart. • Develop with the client alternative coping strategies. Promotes the development of more adaptive coping behaviors, and increases the client’s role competence. • Practice new coping behavior with the client [number] minutes Repeated practice of a behavior internalizes

and personalizes the at [time]. behavior. • Discuss with the client ideal versus current perceptions of role Assists the client in a cognitive appraisal of perceptions to performance. eliminate unrealistic or irrational beliefs. • Discuss with the client those factors that are perceived to be Assists the client in cognitive evaluation of perception of role interfering with role performance. performance. • Have the client develop a list of alternatives for resolving Facilitates the development of alternative coping behaviors. interfering factors. This list should be noted here. • Establish an appointment with significant others to discuss their Assists in establishing agreement on the performance of role pairs perceptions of the client’s role performance and their perceptions to decrease role conflict and strain. This is of primary importance of the various roles involved in the identified situations. Date because roles occur in interactions. and time of this meeting should be written here. • Discuss with the client and significant others alterations in role that will facilitate successful performance. Date and time of this meeting should be written here. • Develop a specific list of necessary changes, and provide the client system with a written copy. • Role-play altered role situations with the client system for 1 h Repeated practice of a behavior internalizes and personalizes the once a day at [time]. This would include opportunities for behavior. clients to practice those areas of role performance that may be new or unique. • If the client and client system cannot achieve agreement on the Interactions with the health care system involve role pairs with the problematic role, refer to: role expectations that are present in any social situation. As in any � Psychiatric mental health clinical nurse specialist interaction, there can be differing expectations about role � Family therapist performance, which can lead to role conflict and strain. � Social worker • If problematic roles involve interactions between the client and members of the health care team (nurses, physicians, etc.), request consultation with psychiatric mental health clinical nurse specialist or mental health specialist with experience in the area of resolving system problems, i.e., family therapists or social workers. Copyright © 2002 F.A. Davis Company 578 ROLE-RELATIONSHIP PATTERN Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Discuss with the patient how he or she perceives his or her role Provides opportunity to gain the patient’s exact perspective on performance has altered. situation. Provides database need for most effective planning. • Discuss with the patient potential role modifications or Depending on the patient’s interests and abilities, these measures substitutions, such as foster grandparenting, friendly visitor at would provide an alternate method to achieve role satisfaction. a long-term-care facility, participant in intergenerational programs, or telephone reassurance visitor or caller. Home Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for factors contributing to disturbed role performance. Provides database for early recognition and intervention. • Involve the client and family in planning, implementing, and Family involvement in planning increases the likelihood of promoting reduction or elimination of disturbance in role effective intervention. function: � Family conference: Clarify expected role performance of all family members. � Mutual goal setting: Set realistic goals and evaluation criteria. Identify tasks for each family member. � Communication: Use open, direct communication and provide positive feedback. • Assist the client and family in lifestyle adjustments that may be Long-term behavioral changes require support. required: � Treatment of physical or emotional disability � Stress management � Adjustment to changing role functions and relationships � Development and use of support networks � Requirements for redistribution of family tasks • Consult with assistive resources as indicated. Utilization of existing services is efficient use of resources. Psychiatric nurse clinician, occupational and physical therapists, and support groups can enhance the treatment plan. Copyright © 2002 F.A. Davis Company ROLE PERFORMANCE, INEFFECTIVE 579 Role Performance, Ineffective FLOWCHART EVALUATION: EXPECTED OUTCOME Has the patient indicated a plan to offset contributing factors? Yes No Record data, e.g., has requested Reassess using initial assessment factors. and received orientation to job status change; husband now helping with household chores. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., stated, “I know what’s wrong. I just don’t know Did evaluation show another what to do about it.” Record problem had arisen? Yes CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 580 ROLE-RELATIONSHIP PATTERN Social Interaction, Impaired RELATED FACTORS8 DEFINITION8 1. Knowledge or skill deficit about ways to enhance mutuality 2. Therapeutic isolation Insufficient or excessive quantity or ineffective quality of social ex- 3. Sociocultural dissonance change. 4. Limited physical mobility 5. Environmental barriers NANDA TAXONOMY: DOMAIN 7—ROLE 6. Communication barriers RELATIONSHIPS; CLASS 3—ROLE PERFORMANCE 7. Altered thought process 8. Absence of available significant others or peers NIC: DOMAIN 3—BEHAVIORAL; CLASS Q— 9. Self-concept disturbance COMMUNICATION ENHANCEMENT NOC: DOMAIN III—PSYCHOSOCIAL SKILLS; RELATED CLINICAL CONCERNS CLASS P—SOCIAL INTERACTION 1. Any condition causing paraplegia, hemiplegia, or quadriplegia 2. AIDS DEFINING CHARACTERISTICS8 3. Alzheimer’s disease 4. Cancer of the larynx 1. Verbalized or observed inability to receive or communicate a sat- 5. Mental retardation isfying sense of belonging, caring, interest, or shared history 6. Substance abuse 2. Verbalized or observed discomfort in social situations 7. Communicable disease 3. Observed use of unsuccessful social interaction behaviors 8. Altered physical appearance secondary to disease or trauma 4. Dysfunctional interaction with peers, family, and/or others 9. Psychiatric disorders, for example, major depression, borderline 5. Family report of change of style or pattern of interaction personality disorder, schizoid personality disorder HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Deficient Knowledge This diagnosis, particularly Certainly Impaired Verbal Communication could as related to mutuality, would be the most relate to Impaired Social Interaction and would be appropriate alternate diagnosis if the individual the primary problem that has to be resolved. verbalized or demonstrated an inability to attend Social Isolation This would be the more to significant others’ social actions in the context appropriate diagnosis when the individual is of independent and dependent aspects of their placed in or chooses isolation because of role. physiologic, sociologic, or emotional concerns. Impaired Verbal Communication This would be Further assessment is required to completely the most appropriate diagnosis if the individual is delineate the exact problem when self-isolation is unable to receive or send communication. chosen as the diagnosis. EXPECTED OUTCOME TARGET DATES Will demonstrate (increased/decreased) involvement in social in- Assisting the patient to modify social interactions will require a sig- teractions by [date]. nificant amount of time. A target date ranging between 7 and 10 days would be appropriate for evaluating progress. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Encourage the patient to express how he or she feels or what he Assists the patient to examine social experience and verbalize or she fears in a social situation by scheduling at least 10 min feelings. Encourages therapeutic relationship. twice a day at [times] to focus on this topic. • Evaluate the patient’s communication skills, and help him or Improves communication skills. her to find alternative ones during interactions with the patient. • Help the patient obtain a realistic perception of self by focusing Helps the patient see that no one is perfect, and improves on and enhancing strengths during conferences with the patient. self-concept. (continued) Copyright © 2002 F.A. Davis Company SOCIAL INTERACTION, IMPAIRED 581 (continued) ACTIONS/INTERVENTIONS RATIONALES • Role-play social interactions with the patient. Allow the patient Promotes self-confidence in social situations by allowing practice to choose which social interactions he or she wishes to role-play in a safe environment. for 10 min twice a day at [times]. • Help the patient participate in group interactions; use crutches, Increases social skills by providing social contact. wheelchair, or stretcher to get the patient out of his or her room at least 2 times per shift, while awake, at [times]. • Involve the patient in daily care. Help the patient make decisions Improves self-concepts. Increases motivation. Decreases feeling of about own care. powerlessness. • If the patient is in isolation, spend at least 10 min every hour Avoids feeling of total isolation for the patient. with the patient. • Consult with the patient’s minister, priest, or rabbi as the Provides reinforcement for self-worth. patient desires. • Initiate referrals to support groups prior to discharge. Puts the patient in contact with community groups to interact with the patient to decrease social isolation. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for contributory factors to altered social interaction Provides database needed to plan appropriate care. pattern, e.g., role-play with puppets. • Determine the effect the altered social interaction has on the Provides database needed to accurately plan intervention. child, parent, family, and school. • Develop a plan of care to best meet the child’s potential for Individual family values will dictate the way in which social succeeding with appropriate social interaction—this will be interaction is dealt with. impacted by social class and values. • Determine whether conflict exists between the parent’s and the Conflict may prevent appropriate attention to actual social child’s desired social interaction. interaction, but must be dealt with as it will remain a critical component. This may be true particularly at times of authority issues, e.g., adolescence. • If conflict exists regarding social interaction, deal with this as Values and beliefs may be in conflict, and some resolution of the needed in values or beliefs pattern. problem is essential to prevent further long-term effects. • Assist the child, parents, and family in ventilation of feelings Ventilation of feelings and the opportunity to do so serve to value regarding social interaction impairment, including actual the importance for the patient to help reduce anxiety and initiate consequences of the impairment. problem resolution. • Make referrals as appropriate to professionals best able to assist Referral serves to best deal with problems according to a match of in dealing with problem, e.g., psychiatric nurse clinical needs and resources. specialist, play therapist, or family therapist. • Identify local support groups to appropriately match needs, e.g., Resource groups provide vital support through provision of a parent-child support groups for the handicapped, United common shared sense of concern, coping, and empowerment. Cerebral Palsy Association, or Spina Bifida Association. • If impaired social interaction also relates to school, include Valuing the importance of school and the need to provide the teacher and essential school personnel in plans for resolving the best for the child and family in the development of positive impairment and for best follow-up. social interaction is showing respect for the patient and family. • Identify follow-up appointment needs and ways to monitor Provides reinforcement, and attaches value to follow-up. progress for the child and family—e.g., stickers as incentives to reinforce desired behavior. • Anticipate discrepant or unrealistic parental expectations of the Unrealistic demands or expectations are risk indicators for abuse. child. Monitor for potential abuse of the child according to pattern for this. Women’s Health This nursing diagnosis will pertain to women the same as to any other adult. The reader is referred to the other sections—Adult Health, Child Health, Psychiatric Health, Gerontic Health, and Home Health—for specific nursing actions. Copyright © 2002 F.A. Davis Company 582 ROLE-RELATIONSHIP PATTERN Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • If delusions or hallucinations are present, refer to Disturbed Sensory Perception for detailed interventions. • Assign primary care nurse to the client. Promotes the development of a trusting relationship. • Primary nurse will spend [number] minutes twice a day at Promotes the development of a trusting relationship, and provides [times] with the client. The focus of this interaction will change opportunities for the client to observe the nurse in appropriate as a relationship is developed. Initially the nurse should model interpersonal interactions. for the client how to develop a relationship through his or her behavior in developing this relationship with the client. This modeling should include demonstrating respect for the client; consistency in interaction; congruence between thoughts, feelings, and actions; and empathy. • Have the client identify those persons who are considered Assists the client in reality testing of the belief that he or she is family, friends, and acquaintances. Then have the client note having difficulty with interpersonal relationships. how

many interactions per week occur with each person. Have the client identify his or her thoughts, feelings, and behavior about these interactions. • Provide appropriate confrontation with the client about his or Assists the client in developing alternative coping behaviors that her behavior patterns that inhibit interaction in relationships are adaptive. with the nurse.14 • Observe the client in interactions with others on the unit, and Facilitates the provision of feedback to the client on methods he or identify patterns of behavior that inhibit social interaction. she could use to improve interpersonal effectiveness. • Develop a list of those things the client finds rewarding, and Positive reinforcement encourages behavior. provide these rewards as the client successfully completes progressive steps in treatment plan. • When the client is demonstrating socially inappropriate Continuing the interaction could provide positive reinforcement behavior, keep interactions to a minimum and escort the and encourage inappropriate behavior. client to a place away from activities. • When inappropriate behavior stops, discuss the behavior with Promotes the client’s sense of control, and begins the development the client and develop a list of alternative kinds of behavior for of alternative, more adaptive coping behaviors. Social isolation the client to use in situations where the inappropriate behavior assists in decreasing behaviors. is elicited. Note here those kinds of behavior that are identified as problematic, with the action to be taken if they are demonstrated—e.g., the client will spend time out in seclusion and away from group activity. • Develop a schedule for gradually increasing time of the client in Social interaction can provide positive reinforcement and group activities. For example, the client will spend [number] opportunities for the client to practice new behaviors in a minutes in the group dining hall during mealtimes or will spend supportive environment. [number] minutes in a group game. Note the client’s specific activities here. • Primary nurse will spend 30 min a day with the client exploring thoughts and feelings about social interactions and assisting with reality testing of social interaction—e.g., what others might mean by silence and other nonverbal responses. • Identify with the client areas of social skill deficit, and develop Promotes the client’s sense of control, and begins the development a plan for improving these areas. This could include: of alternative, more adaptive coping behaviors by increasing role � Assertiveness training competence. � Role-playing difficult situations � Teaching the client relaxation techniques to reduce anxiety in social situations (Note here the plan and schedule for implementation. This should be a progressive plan with rewards for accomplishment of each step.) • Consult with occupational therapist if the client needs to learn Increasing behavioral repertoire increases role competence, which specific skills to facilitate social interactions—e.g., cooking skills enhances self-esteem.1 so friends can be invited to dinner, or craft skills so the client can join others in social interactions around these activities. • Include the client in group activities on the unit, and assign the Reinforcement encourages positive behavior and enhances client activities that can be easily accomplished and that will self-esteem. provide positive social reinforcement from other persons involved in the activities. (continued) Copyright © 2002 F.A. Davis Company SOCIAL INTERACTION, IMPAIRED 583 (continued) ACTIONS/INTERVENTIONS RATIONALES • When the client demonstrates tolerance for group interactions, Disconfirms the client’s sense of aloneness, and assists the client to schedule time for the client to participate in a group therapy that experience personal importance to others, while enhancing provides opportunities for feedback about relationship behavior interpersonal relationship skills. Increasing these competencies can from peers and for listening to the thoughts and feelings of peers. enhance self-esteem and promote positive orientation. • Discuss with the support system ways in which they can Support system understanding facilitates the maintenance of new facilitate client interaction. behaviors after discharge. • Have the client identify those activities in the community that Increases the client’s ability to successfully perform these roles, are of interest and would provide opportunities for interaction. which provides positive reinforcement encouraging the behavior List those activities here, and develop a plan for the client to and enhancing self-esteem. develop necessary skills to ensure opportunities for interactional success during these activities, e.g., practice a card game or tennis while in the hospital. • When the client reports problems in an interaction, review his Assists the client with reality testing of his or her perceptions. or her perceptions of the interaction and an evaluation of when the problems began. • Limit amount of time the client can spend alone in room. This Successful accomplishment of a task provides positive should be a gradual alteration and done in steps that can easily be reinforcement and promotes a positive orientation. accomplished by the client. Note specific schedule for the client here. Have staff person remain with the client during these times until client demonstrates an ability to interact with others. • Have referral source make contact with the client before Promotes the development of a trusting relationship while the discharge and schedule a postdischarge meeting. client is in a safe environment. Gerontic Health The nursing actions for the gerontic patient with this diagnosis are the same as those given in Adult Health and Psychiatric Health. Home Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for factors contributing to the impaired social Provides database for early recognition and intervention. interaction, e.g., psychological, physical, economic, or spiritual. • Involve the client and family in planning, implementing, and Family involvement enhances the effectiveness of the interventions. promoting reduction or elimination of Impaired Social Interaction: � Family conference: Identify perspective of each member. Establish consistent rules for behaviors. � Mutual goal setting: Set consistent rules for behavior and provide support for care providers. Identify tasks for each member. • Assist the patient and family in lifestyle adjustments that may Permanent changes in behavior and family roles require support. be required: � Providing safe environment � Development and use of support networks � Change in role functions � Prescribed treatments, e.g., medications or behavioral interventions � Assistance with self-care activities � Possible hospitalization or placement in half-way house � Treatment of drug or alcohol abuse � Development and practice of social skills � Independent living skills � Finances � Stress management � Suicide prevention • Assist the client and family to develop criteria to determine Provides database for early recognition and intervention. when crisis exists and professional intervention is necessary: � Violence � Sudden change in ability to care for self � Hallucinations or delusions • Consult with or refer to assistive resources as indicated. Utilization of existing services is efficient use of resources. Respite care and support groups can enhance the treatment plan. Copyright © 2002 F.A. Davis Company 584 ROLE-RELATIONSHIP PATTERN Social Interaction, Impaired FLOWCHART EVALUATION: EXPECTED OUTCOME Interview the patient. Has social interaction increased or decreased? Yes No Record data, e.g., has joined softball Reassess using initial assessment factors. team and is playing daily in summer; is enrolling in an art class this fall; has joined a local hospital volunteer group; states, “I’m having a good time and meeting some new people.” Record RESOLVED. Delete nursing diagnosis, expected outcome, target No Is diagnosis validated? date, and nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., stated, has “thought about some activities but don’t believe Did evaluation show another I can do it just yet.” Record CONTINUE problem had arisen? Yes and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company SOCIAL ISOLATION 585 Social Isolation 2. Subjective a. Expresses feelings of aloneness imposed by others DEFINITION8 b. Expresses feelings of rejection c. Inadequacy in or absence of significant purpose in life Aloneness experienced by the individual and perceived as imposed d. Inability to meet expectations of others by others and as a negative or threatened state. e. Expresses values acceptable to the subculture but unaccept- able to the dominant cultural group NANDA TAXONOMY: DOMAIN 12—COMFORT; f. Expresses interests inappropriate to the developmental age or CLASS 3—SOCIAL COMFORT stage g. Experiences feelings of difference from others NIC: DOMAIN 3—BEHAVIORAL; CLASS Q— h. Insecurity in public COMMUNICATION ENHANCEMENT NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; RELATED FACTORS8 CLASS P—SOCIAL INTERACTION 1. Alterations in mental status 2. Inability to engage in satisfying personal relationships DEFINING CHARACTERISTICS8 3. Unaccepted social values 4. Unaccepted social behavior 1. Objective 5. Inadequate personal resources a. Absence of supportive significant other(s) (family, friends, 6. Immature interests group) 7. Factors contributing to the absense of personal relationships, for b. Projects hostility in voice or behavior example, delay in accomplishing developmental tasks c. Withdrawn 8. Alterations in physical appearance d. Uncommunicative 9. Altered state of wellness e. Shows behavior unaccepted by dominant cultural group f. Seeks to be alone, or exists in a subculture RELATED CLINICAL CONCERNS g. Repetitive, meaningless actions h. Preoccupation with own thoughts 1. Any condition that has resulted in scarring i. No eye contact 2. Alzheimer’s disease j. Evidence of physical or mental handicap or altered state of 3. AIDS wellness 4. Tuberculosis k. Sad, dull affect 5. Any condition causing impaired mobility l. Inappropriate or immature interests or activities for develop- 6. Psychiatric disorders such as major depression, schizophrenic mental age or stage disorders, paranoid disorders, or conduct disorders HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Deficient Knowledge This diagnosis, particularly as Certainly Impaired Verbal Communication could related to mutuality, would be the most appropriate be related to Impaired Social Interaction and alternate diagnosis if the individual verbalized or would be the primary problem that has to be demonstrated an inability to attend to significant resolved. others’ social actions in the context of independent Impaired Social Interaction Impaired Social and dependent aspects of their role. Interaction can be either too much or too little in Impaired Verbal Communication This would be terms of social activity and is more focused on the the most appropriate diagnosis if the individual is individual’s choice. In Social Isolation, the patient unable to receive or send communication. sees this problem as being caused by others. EXPECTED OUTCOME TARGET DATES Will participate in social activities at least weekly by [date]. A target date range of 2 to 7 days would be acceptable depending on the exact social interaction chosen. Copyright © 2002 F.A. Davis Company 586 ROLE-RELATIONSHIP PATTERN NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Encourage the patient to verbalize feelings of isolation and Promotes a therapeutic relationship where the patient can aloneness by visiting the patient every hour and scheduling a verbalize feelings in a nonthreatening environment. discussion for at least 10 min each shift while awake. • Provide positive feedback and support for social interactional Increases self-confidence. Decreases anxiety in social situations. skills as appropriate. • Encourage the patient to use assistive or corrective devices such Increases self-esteem and self-confidence. as artificial vocal cord; limb, eye or breast prosthesis; or special make-up. Have the patient return-demonstrate self-care management activities at least daily. • Encourage visits from the family and significant others daily. Increases social contacts and interactional skills. • Encourage the patient to participate in diversional activities, Increases social contacts and interactional skills. especially those involving groups, daily. • Encourage the patient to identify and use community support Increases social contacts. Promotes assistance with short-term and systems and groups prior to discharge. long-term goals. Child Health ACTIONS/INTERVENTIONS RATIONALES • Provide opportunities for expression of feelings about desired Ventilation of feelings allows for insight into the patient’s thinking social activity by spending 15–20 min per shift, during waking and assists in reducing anxiety. hours, at [times] with the patient and family. • Determine what obstacles are perceived by the patient and Directed inquiry into obstacles that prevent the patient from family in pursuit of desired social activities by asking both engaging in desired social interaction increases the likelihood of a direct and open-ended questions—e.g., “What do you think more complete database that will allow more individualized prevents you from doing what you want to?” planning. • Identify what realistic patterns for socialization are applicable Realistic goals are more likely to bring about the desired changes for the patient and family in collaboration with the patient and for more effective social interaction. family. • Collaborate with other health care professionals to meet

realistic Appropriate use of resource personnel ensures optimal likelihood goals for patient and family socialization. for goal attainment. • Monitor for contributory related factors to best consider social All factors must be considered to provide a holistic plan of care. activity pattern. • Identify support groups to assist in realization of desired social Support groups provide a sense of sharing and empowerment. activities. • Monitor the patient’s and family’s perceptions of the effect Roles are closely impacted by patterns of social interaction. desired social activities might have on current role-relationship pattern. • Provide appropriate opportunities for assessment of the young The child’s view of self in relationship to social patterns is vital to child’s perceptions of situational needs and how he or she planning the most effective interventions. views self. • Assist the patient to develop schedule for consideration of Appropriate planning serves to increase success with desired desired social activities at least 2 days before dismissal from activities. hospital. • Provide for appropriate follow-up appointment as needed Follow-up plans attach value to long-term care for the patient. before dismissal from hospital. Women’s Health NOTE: When women experience social isolation, it is especially important to assess for the presence of domestic violence. Social isolation may be one of the means abusers use to control his or her partner. The following nursing actions apply to the social isolation experienced by the pa- tient who has sexually transmitted diseases such as herpes genitalis, syphilis, chlamydia, gonorrhea, and AIDS. Copyright © 2002 F.A. Davis Company SOCIAL ISOLATION 587 (continued) ACTIONS/INTERVENTIONS RATIONALES • Assure the patient of confidentiality. Promotes sharing of information by the patient. • Refer for counseling and/or treatment to: Provides long-term support and care for the patient. � Support groups � Professionals, e.g., public health clinic, nurse specialists, or physician • Provide a nonjudgmental atmosphere39 to encourage Provides database needed to provide appropriate care and verbalization of concerns: teaching. � Recurrent nature of disease, especially herpes and chlamydia � Lack of cure for disease (AIDS) � Economics in treating disease � Social stigma associated with disease � Opportunity for entrance into health care system • Encourage honesty in answers to such question as: � Multiple sexual partners (identify contacts) � Describing sexual behavior • Encourage honest communication with sexual partners. Sexual partners will need to seek health care also. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • If delusions and/or hallucinations are present, refer to Disturbed Assists in understanding the client’s worldview, which facilitates Sensory Perception for detailed interventions. the development of client-specific interventions. • If social isolation is related to the client’s feelings of powerlessness, refer to Powerlessness (Chap. 8) for detailed interventions. • Discuss with the client his or her perception of the source of the social isolation, and have him or her list those things he or she has tried to resolve the situation. • Have the client list those persons who are considered family, Facilitates the client’s reality testing of his or her perception of friends, and acquaintances. Then have the client note how being socially isolated. many interactions per week occur with each person. Have the client identify what interferes with feeling connected with these persons. This activity should be implemented by the primary nurse. Note schedule for this interaction here. • When contributing factors have been identified, develop a plan Facilitates the development of alternative coping behaviors that to alter these factors. This could include: enhance role performance. � Assertiveness training � Role-playing difficult situations � Teaching the client relaxation techniques to reduce anxiety in social situations (Note plan and schedule for implementation here.) • Develop a list of those things the client finds rewarding, and Reinforcement encourages positive behavior and enhances provide these rewards as the client successfully completes self-esteem. progressive steps in treatment plan. This schedule should be developed with the client. Note here the schedule for rewards and the kinds of behavior to be rewarded. • Consult with occupational therapist if the client needs to learn Increases the client’s competencies, which enhances role specific skills to facilitate social interactions—e.g., cooking skills so performance and self-esteem. friends can be invited to dinner, craft skills so the client can join others in social interactions around these activities, or dancing. • Provide the client with those prostheses necessary to facilitate social interactions, e.g., hearing aids or eyeglasses. Note here the assistance needed from nursing staff in providing these to the client. Also note where they are to be stored while not in use. • Include the client in group activities on the unit. Assign the client Successful accomplishment of a valued task can provide positive activities that can be easily accomplished and that will provide reinforcement, which encourages behavior. positive social reinforcement from other persons involved in the activities. This could include things like having the client assume responsibility for preparing a part of a group meal or for serving a portion of a meal. (continued) Copyright © 2002 F.A. Davis Company 588 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Role-play with the client those social interactions identified as Repeated practice of a behavior internalizes and personalizes the most difficult. This will be done by primary nurse. Note behavior. schedule for this activity here. • Discuss with the client those times it would be appropriate to Promotes the client’s sense of control, while facilitating the be alone, and develop a plan for coping with these times in a development of alternative coping behaviors. positive manner—e.g., the client will develop a list of books to read, music to listen to, or community activities to attend. • When the client is demonstrating socially inappropriate Lack of positive reinforcement decreases a behavior. behavior, keep interactions to a minimum, and escort to a place way from group activities. • When inappropriate behavior stops, discuss the behavior with Promotes the client’s sense of control, while facilitating the the client, and develop a list of alternative kinds of behavior for development of alternative coping behaviors. the client to use in situations where the inappropriate behavior is elicited. Note here those kinds of behavior that are identified as problematic, with the action to be taken if they are demonstrated—e.g., the client will spend a time-out in seclusion or sleeping area. • Develop a schedule of gradually increasing time for the client in Provides the client with opportunities to practice new behaviors group activities—e.g., the client will spend [number] minutes in a safe, supportive environment. in the group dining hall during mealtimes or will spend [number] minutes in a group game twice a day. Note specific goals for the client here. • Primary nurse will spend 30 min once a day with the client at [time] discussing the client’s reactions to social interactions and assisting the client with reality testing social interactions—e.g., what others might mean by silence or various nonverbal and common verbal expressions. This time can also be used to discuss relationship roles and the client’s specific concerns about relationships. • Assign the client a room near areas with high activity. Facilitates the client’s participation in unit activities. • Assign one staff person to the client each shift, and have this Decreases the client’s opportunities for socially isolating self. person interact with the client every 30 min while awake. • Be open and direct with the client in interactions, and avoid Promotes a trusting relationship. verbal and nonverbal behavior that requires interpretation from the client. • Have the client tell staff his or her interpretation of interactions. Assists the client in reality testing his or her perceptions that might inhibit social interactions. • Have the client identify those activities in the community that Promotes the client’s sense of control. are of interest and would provide opportunities for interactions with others. List the client’s interests here. • Develop, with the client, a plan for making contact with the Promotes the client’s sense of control, and begins the development identified community activities before discharge. of adaptive coping behaviors. • When the client demonstrates tolerance for group interactions, Disconfirms the client’s sense of aloneness, and assists the client to schedule time for the client to participate in a therapy group experience personal importance to others, while enhancing that provides opportunities for feedback about relationship interpersonal relationship skills. Increasing these competencies behavior from peers and for listening to the thoughts and can enhance self-esteem and promote positive orientation. feelings of peers. • Arrange at least 1 h a week for the client to interact with his or Support system understanding facilitates the maintenance of new her support system in the presence of the primary nurse. This behaviors after discharge. will allow the nurse to assess and facilitate these interactions. • Discuss with the support system ways in which they can facilitate client interaction. • Model for the support system and for the client those kinds of behavior that facilitate communication.40 • Limit the amount of time the client can spend alone in room. Provides opportunities for the client to practice new role behaviors This should be a gradual alteration and should be done in steps in a safe, supportive environment. that can easily be accomplished by the client. Note specific schedule for the client here—e.g., the client will spend 5 min per hour in day area. Have staff person remain with the client during these times until the client demonstrates an ability to interact with others. • Refer the client to appropriate community agencies. Copyright © 2002 F.A. Davis Company SOCIAL ISOLATION 589 Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Discuss with the patient what efforts he or she has made to Assists in determining what interventions may result in positive increase social contacts and what results have been obtained. outcomes. • Ask the patient to identify hobbies and activities that have been Provides information on preferred activities, and guides the nurse a part of his or her adult life. in seeking resources that match the patient’s interests. • Ask the patient to identify barriers to continuing with the Barriers may be indicators of need for use of specific resources hobbies and activities he or she enjoyed. such as adaptive equipment or transportation. • Assist the patient in identifying and contacting community In many areas, initial contact with support services can entail support services. numerous telephone calls to reach the appropriate resource. Home Health See Psychiatric Health nursing actions for detailed interventions. ACTIONS/INTERVENTIONS RATIONALES • Involve the client and family in planning and implementing Family involvement in planning enhances the effectiveness of strategies to reduce social isolation: interventions. � Family conference: Discuss perceptions of source of social isolation, and list possible solutions. � Mutual goal setting: Set realistic goals with evaluation criteria. List specific tasks for each family member. � Communication: Provide positive feedback. • Assist the family and patient with lifestyle adjustments that may Permanent changes in behavior and family roles require support. be required: � Promote social interaction. � Provide transportation. � Provide activities to keep busy during lonely times. � Provide communication alternatives for those with sensory deficits. � Assist with disfiguring illness—e.g., refer the patient to enterostomal therapist or prosthesis manufacturer. � Control incontinence, or provide absorbent undergarments when socializing. � Promote self-worth. � Promote self-care. � Develop and utilize support groups. � Use pets. � Establish regular telephone contact. � Inform of volunteer programs in community that person could work for. • Consult with or refer to assistive resources as indicated. Utilization of existing services is efficient use of resources. Self-help groups, occupational therapists, or home-bound programs can enhance the treatment plan. Copyright © 2002 F.A. Davis Company 590 ROLE-RELATIONSHIP PATTERN Social Isolation FLOWCHART EVALUATION: EXPECTED OUTCOME Is the patient participating in a weekly social activity? Yes No Record data, e.g., is assisting in teaching Reassess using initial assessment factors. art at community centers; states, “really enjoying making new friends and we’re going to a concert Friday night.” Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., stated, “attended social functions maybe every other Did evaluation show another month.” Record CONTINUE and problem had arisen? Yes change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A.

Davis Company SORROW, CHRONIC 591 Sorrow, Chronic f. Emptiness g. Fear DEFINITION8 h. Frustration i. Guilt or self-blame Cyclical, recurring, and potentially progressive pattern of pervasive j. Helplessness sadness that is experienced (by a parent, caregiver, individual with k. Hopelessness chronic illness or disability) in response to continual loss, through- l. Loneliness out the trajectory of an illness or disability. m. Low self-esteem n. Recurring loss NANDA TAXONOMY: DOMAIN 9—COPING/STRESS o. Overwhelmed TOLERANCE; CLASS 2—COPING RESPONSES RELATED FACTORS8 NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING ASSISTANCE 1. Death of a loved one NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; 2. Experiences chronic physical or mental illness or disability, such CLASS N—PSYCHOSOCIAL ADAPTATION as mental retardation, multiple sclerosis, prematurity, spina bifida or other birth defects, chronic mental illness, infertility, DEFINING CHARACTERISTICS8 cancer, or Parkinson’s disease 3. Experiences one or more triggering events, for example, crises 1. Feelings that vary in intensity, are periodic, may progress and in- in management of the illness or crises related to developmental tensify over time, and may interfere with the client’s inability to stages and missed opportunities or milestones that bring com- reach his or her highest level of personal and social well-being parisons with developmental, social, or personal norms 2. Expresses periodic, recurrent feelings of sadness 4. Unending caregiving as a constant reminder of loss 3. Expresses one or more of the following feelings: a. Anger RELATED CLINICAL CONCERNS b. Being misunderstood c. Confusion 1. Any chronic physical or mental illness d. Depression 2. Any terminal diagnosis e. Disappointment 3. Less-than-perfect newborn HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Ineffective Individual Coping Chronic Sorrow has relates to a specific potential loss. These could different and more specific related factors. Chronic well be companion diagnoses, and the nursing Sorrow could lead to Ineffective Individual Coping as interventions designed to assist the client with the individual loses physical and mental energy. The either diagnosis would be beneficial in assisting primary differentiation will be in the related factors. with resolution of the other diagnosis. Anticipatory Grieving Chronic Sorrow relates to a continual loss, whereas Anticipatory Grieving EXPECTED OUTCOME TARGET DATES Will verbalize less sadness by [date]. Resolving this diagnosis will require long-term intervention. An ap- propriate target date for initial evaluation of progress would be 10 to 14 days. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Assess the events that precipitate chronic sorrow and make the Provides information for anticipatory guidance. patient feel disparity between self and others. • Assess the patient’s coping methods. Determine what helps Supports the patient, and helps the patient learn effective coping when the patient feels sorrow. Support the coping strategies methods. that work, or teach other strategies that may help. (continued) Copyright © 2002 F.A. Davis Company 592 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Take time to listen, empathize, and support the patient. Listening conveys respect, compassion, and a nonjudgmental position. • Encourage the patient to participate in his or her own care and Helps the patient feel control over own life. maintain involvement in personal interests and activities.41 • Encourage the patient to take one day at a time and concentrate Chronic sorrow is a normal event and should be recognized as on the positive aspects of his or her life.41 such. • Encourage the patient to talk with you or others who have Helps the patient to see that he or she is not alone in the grief experienced the same type of loss. process. • Refer to the Psychiatric Health nursing actions for additional information. Child Health NOTE: Identify developmentally appropriate approach with incorporation of nursing interventions that are appropriate. ACTIONS/INTERVENTIONS RATIONALES • Monitor for all possible contributing factors to chronic sorrow, Provides the most holistic database to offer appropriate including history, family, child, or others as feasible. individualization. • Encourage the child and family members to verbalize feelings Expression of feelings helps reduce anxiety and offers clues to about sorrow. related issues. • Identify preferences of the child to further express feelings per Free and creative expression provides a noninvasive insight to age-appropriate play, art, discussion, or, when appropriate, monitor feelings on an ongoing basis. support groups. • Help the child and family to identify the meaning the chronic Significance of sorrow is often the key to acceptance and reducing sorrow provides. negative effects of sorrow. • Identify ways to cope with factors that contributed or contribute Growth is enhanced when coping strategies familiar to the client to chronic sorrow by determining previously successful coping are valued. patterns. • Introduce additional coping strategies according to the child’s Reinforcement is best timed when the client is successfully dealing and family’s readiness. with demands and is more likely to accept additional modes. • Determine the effect chronic sorrow has on basic daily Sorrow may be interfering with basic daily activities. functioning. • Support the child’s and family’s daily progress in expression of Ongoing assessment and expression foster trust and open feelings and ways to cope with sorrow. communication. • Identify need for other pediatric specialists as needed, e.g., play Experts will best be able to deal with the child’s and family’s therapist, child psychologist, and psychiatrist. long-range needs. • Determine support group for long-term follow-up. Peer support is valued, with likelihood of bonding and reduction of feelings of isolated sorrow. • Provide sensitive inquiry as related to anniversaries or events Valuing of the importance of events for the child and family that may hold significance for the child or family. provides respect and facilitates sharing to foster trust. • Identify, with the child’s and family’s input, ways to effectively Actual resolution of chronic sorrow is possible with individualized cope with chronic sorrow. plan known to be effective and familiar to the client, thereby lessening likelihood of recurrence. Women’s Health For this diagnosis, the Women’s Health nursing actions are similar to Adult, Children, Gerontic, and Psy- chiatric Health, except for the following: ACTIONS/INTERVENTIONS RATIONALES FETAL DEMISE OR STILLBORN • The following are important first steps to help the parents cope Initiates the grieving process in a supportive environment, as with chronic sorrow: well as providing a database that can be used by the family and � Allow the parents to express feelings and participate in therapist when dealing with chronic sorrow. needed decision making. � Prepare the infant for viewing by the parents and significant others. (continued) Copyright © 2002 F.A. Davis Company SORROW, CHRONIC 593 (continued) ACTIONS/INTERVENTIONS RATIONALES � Provide private, quiet place and time for the parents and family to see and hold the infant. � Take pictures, and complete “memory box” for the parents. � Contact faith-based or cultural leader as requested by the parents for desired ceremonies for the infant. � Provide references to supportive groups within community, such as Resolve with Sharing or other parents who have lost infants. • Obtain from the client or other family members information Some deaths of babies are a relief to the parents, such as in the about the cause of sorrow that could help with understanding case of congenital abnormalities or a long, difficult illness of a and, therefore, planning actions to support the client. child. This does not mean they do not love their babies and could � Determine, if possible, the cause of death and the gestational experience feelings of guilt because of the feeling of relief. Many age of fetus and/or infant at time of death. family members and relatives do not know what to say or do, and � Determine nature of attachment of the parents to the infant. therefore ignore the subject, believing this is better for the parents � Discuss past unresolved grief. so they can forget sooner. � Determine social support of parents. (Beware of a “conspiracy of silence.”)42,43 • Discuss with the parents the aspect of anniversaries, birthdays, Such dates often become an anticlimax; they have dreaded the date or holidays. Give suggestions of how to observe the child’s and either find it easy or very difficult. Acknowledgment tells the memory, such as: parents that you share their pain without becoming intrusive. � Have a small ceremony with the family and friends at Holidays are very difficult, particularly when other children are gravesite, in home, or place of worship. celebrating. It often becomes a reminder that they will never be � Plant a tree or flowers in the child’s memory. able to do these things with their child. � Encourage the family and friends to acknowledge awareness of special day to the parent. Psychiatric Health NOTE: Because this is a normal response, clients most likely to have this diagnosis will be seen as out- patients. Inpatient clients may experience this response if a trigger event occurs during hospitalization. ACTIONS/INTERVENTIONS RATIONALES • Provide the client with the information he or she requests Assists with decision making and promotes sense of control.44,45 related to illness and disease process. • Sit with the client [number] minutes [number] times a day to Assists with coping, and promotes sense of control.44 explore and provide specific information he or she may need to cope with the identified situation. • Provide information that indicates to the client that his or her Alleviates feelings of “difference” or isolation, and increases sense reaction is normal. This information should be provided in a of control. Assists client in making room for grief, as a normal manner that does not diminish the individual’s personal process, in his or her life.14,45 experience. • Discuss with the client the situations that might contribute to Promotes client understanding of the experience, and assists with the increase or recurrence of grief feelings. These situations the normalizing of the experience, while providing anticipatory could include comparisons with norms, management crises, guidance.46 Facilitates the development of the belief that grief is anniversaries, unending caregiving, and awareness of role a life process and not something that is “dealt with” or ended.45 changes. Note here the person responsible for this discussion. • Sit with the client [number] minutes [number] times per day to Validates the client’s experience, and legitimizes the emotions.14,47 provide an opportunity for him or her to tell his or her story with the effect of the experience. • Discuss with the client his or her beliefs about grief and how it Understanding the client’s perceptions provides the foundation for affects his or her life. necessary change.45 • Discuss with the client previous strategies utilized to cope with Supports strengths, and assists with the development of loss and the extent to which these were successful. Note here client-specific coping strategies.14,43 the person responsible for this discussion and ongoing follow-up. • Provide the client with necessary supports to utilize identified Facilitates the use of coping strategies.44 coping strategies. Note here those supports, specific for this client, needed from staff. This could include referrals to community support groups, arrangements for respite care, supporting the use of humor and play as a coping strategy, arrangements to interact with spiritual leader, and providing opportunities for physical activity. (continued) Copyright © 2002 F.A. Davis Company 594 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Schedule meeting with the support system to explore their Something that affects one member of the support system affects beliefs and experiences related to loss. Note here the time for other members.45 this meeting and the person responsible. • Meetings with support systems should also include: � Normalization of the support system emotions. Normalizes the experience, and increases sense of control, while (1) Provide stories of the successes of other support systems. providing a context that supports positive coping.45 (2) Sit with them as they express their thoughts and feelings related to the situation. � Support strengths of this system. � Modeling of good communication. (1) Include open, honest communication about those issues Addressing both the perceived positive and negative aspects of a the system finds most difficult to discuss. situation opens communication and decreases guilt.45 (2) Provide information the system needs about the situation Promotes sense of control, and facilitates decision making. and disease process. � Refer support system to community support groups. Normalizes experience, and provides a source for information on coping. � Discuss opportunities for respite from caregiving Decreases guilt related to the need to withdraw from the responsibilities. caregiving role.14 Gerontic Health In addition to the nursing actions provided here, the nurse is referred to the Psychiatric Health section

for this diagnosis. ACTIONS/INTERVENTIONS RATIONALES • Provide the client and/or caregiver with information that is Assists the client and/or caregiver to have a sense of control in understandable, focused on the specific information needed for meeting care needs. the situation, and practical. • Encourage use of community or facility or web site support Gives the client or caregiver access to information and resources services dealing with the specific disability or chronic illness that may help meet the challenges of their condition. involved.48 • Promote use of available respite services as needed. Provides a means of positive coping for the individual. • Advise the older adult to maintain personal interests and Identified in research as a means of coping and maintaining activities as much as possible. control.48,49 • Use empathetic presence (listening, offering support and Helps the client or caregiver feel supported by professionals encouragement and validation of feelings). involved in care needs. • Discuss with the client or caregiver milestones and events that may Presents opportunities for anticipatory guidance. trigger episodes of feeling sorrow, such as anniversaries, birthdays, or celebrations that contrast what could have been with what is.46 Home Health ACTIONS/INTERVENTIONS RATIONALES • Actively listen to the client’s story, helping him or her to put There is an almost universal need to describe the feelings and events in sequence, increasing his or her recall of details, and events of a death or major diagnosis. separating what is real from what is not.50 • Teach the client and significant others the importance of Removes impediments to healthy expression of sadness. expressing and accepting sadness:50 � Avoid platitudes. � Avoid quiet suffering and suppression of grief. � Change settings as necessary to allow expressions of grief. • Assist the client to acknowledge and express feelings of guilt. This is the first step in resolution of feelings of guilt. • If the chronic sorrow is related to death, assist the client in Talking about the relationship is an important element of healing. reviewing his or her relationship with the deceased:50 � Exploring the early days of the relationship, covering negative aspects as well as positive aspects � Exploring what might have been had the death not occurred • Consult with and/or refer the patient to assistive resources as Utilization of existing services is an efficient use of resources. needed. Copyright © 2002 F.A. Davis Company SORROW, CHRONIC 595 Sorrow, Chronic FLOWCHART EVALUATION: EXPECTED OUTCOME Is the client expressing less sadness today compared with the day of admission to services? Yes No Record data, e.g., states feeling less Reassess using initial assessment factors. sadness, is socializing more, and has identified a support group. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., still expressing deep sadness. Refuses to participate Did evaluation show another in former activities. Record problem had arisen? Yes CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 596 ROLE-RELATIONSHIP PATTERN Verbal Communication, Impaired 11. Altered perceptions 12. Lack of information DEFINITION8 13. Stress 14. Alteration of self-esteem or self-concept Decreased, delayed, or absent ability to receive, process, transmit, 15. Physiologic conditions and use a system of symbols. 16. Alteration of central nervous system 17. Weakening of the musculoskeletal system NANDA TAXONOMY: DOMAIN 5—PERCEPTION/ 18. Emotional conditions COGNITION; CLASS 5—COMMUNICATION RELATED CLINICAL CONCERNS NIC: DOMAIN 3—BEHAVIORAL; CLASS Q— COMMUNICATION ENHANCEMENT 1. Laryngeal cancer 2. Cleft lip or cleft palate NOC: DOMAIN II—PHYSIOLOGIC HEALTH; 3. Cerebrovascular accident CLASS J—NEUROCOGNITIVE 4. Facial trauma 5. Respiratory distress DEFINING CHARACTERISTICS8 6. Late-stage Alzheimer’s disease 7. Tourette’s syndrome 1. Willful refusal to speak 8. Psychiatric disorders such as schizophrenic disorders, delu- 2. Disorientation in the three spheres of time, space, and person sional disorders, psychotic disorders, or delirium 3. Inability to speak dominant language 9. Autism 4. Does not or cannot speak 5. Speaks or verbalizes with difficulty 6. Inappropriate verbalization HAVE YOU SELECTED 7. Difficulty forming words or sentences, for example, aphonia, THE CORRECT DIAGNOSIS? dyslalia, and dysarthria 8. Difficulty forming words or sentences, for example, aphasia, Social Isolation Social Isolation can occur dysphasia, apraxia, and dyslexia because of the reduced ability or inability of 9. Dyspnea an individual to use language as a means of 10. Absence of eye contact or difficulty in selective attending communication. The primary diagnosis 11. Difficulty in comprehending and maintaining the usual com- would be Impaired Verbal Communication, munication pattern because resolution of the problem would 12. Partial or total visual deficit assist in alleviating Social Isolation. 13. Inability or difficulty in use of facial or body expressions Disturbed Sensory Perception (Auditory) If 14. Stuttering the individual has difficulty in hearing, then 15. Slurring he or she would also reflect Impaired Verbal Communication. The primary problem would RELATED FACTORS8 be the Auditory difficulty, because correction of this deficit would help improve 1. Decrease in circulation to the brain communication. 2. Cultural difference 3. Psychological barriers, for example, psychosis or lack of stimuli 4. Physical barrier, for example, tracheostomy and intubation 5. Anatomic defect, for example, cleft palate or alteration of the EXPECTED OUTCOME neuromuscular visual system, auditory system, or phonatory Will communicate in a clear manner via [state specific method, e.g., apparatus orally, esophageal speech, or computer] by [date]. 6. Brain tumor 7. Differences related to developmental age TARGET DATES 8. Side effects of medication 9. Environmental barriers The target date for resolution of this diagnosis will be long-range. 10. Absence of significant others However, 7 days would be appropriate for initial evaluation. NURSING ACTIONS/INTERVENTIONS AND RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Maintain a patient, calm approach by: Avoids interfering with the patient’s communication attempts. � Allowing adequate time for communication (continued) Copyright © 2002 F.A. Davis Company VERBAL COMMUNICATION, IMPAIRED 597 (continued) ACTIONS/INTERVENTIONS RATIONALES � Not interrupting the patient or attempting to finish sentences for him or her � Asking questions that require short answers or a nod of the head � Anticipating needs • Provide materials that can be used to assist in communication— Provides alternative methods of communication. Decreases anxiety e.g., magic slate, flash cards, pad and pencil, “Speak and Spell” and feelings of powerlessness and isolation. computer toy, pictures, or letter board. • Inform the family, significant others, and other health care Promotes effective communication. Avoids frustration for the personnel of the effective ways the patient communicates. patient. • Answer call bell promptly rather than using the intercom system. Decreases stress for the patient by not straining communication resources. • Assure the patient that parenteral therapy does not interfere Decreases anxiety. with the patient’s ability to write. • Initiate referral to speech therapist if appropriate. Initial teaching regarding speech may need interventions by specialist. • Initiate referrals to support agencies such as Lost Chord Club or Groups that experienced the same problems can assist in New Voice Club as appropriate. rehabilitationand decrease social isolation. Promotes the patient’s comfort. • Discuss use of electronic voice box and esophageal speech prior Reduces anxiety and increases self-confidence. to discharge. Have the patient practice using device. • Encourage the patient to have recordings made for reaching Promotes safety, increases comfort, and decreases anxiety. police, fire department, doctor, or emergency medical service if impaired verbal communication is a long-term condition. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor the patient’s potential for speech according to subjective Provides database needed to plan more complete and accurate and objective components, to include: interventions. � Reported or documented previous speech capacity or potential � Health history for evidence of cognitive, sensory, perceptual, or neurologic dysfunction � Actual auditory documentation of speech potential � Assessment done by speech specialist � Patterns of speech of parents and significant others � Cultural meaning attached to speech or silence of children � Any related trauma or pathophysiology � Parental perception of the child’s status, especially in instances of congenital anomaly such as cleft lip or palate � Identification of dominant language and secondary languages heard or spoken in the family • Assist the patient and parents to understand needed explanations Provides teaching opportunity. Decreases anxiety, which can for procedures, treatments, and equipment to be used in nursing interfere with communication. care. • Encourage feelings to be expressed by taking time to understand Alternate methods of communication and sensitivity to attempts possible attempts at speech. Use pictures if necessary for young at communication attach value to the patient and serve to children. reinforce future attempts at communication. • Encourage family participation in care of the patient as situation Family input provides an opportunity for communication and allows. fosters parent-child relationship. • Assist the family to identify community support groups. Provides long-term support for coping. • Assist the patient and family in determining the impact Family functioning relies heavily on communication. Impaired Verbal Communication may have for family functioning. • Provide information for long-term medical follow-up as Knowledge helps prepare the family for long-term needs and helps indicated, especially for congenital anomalies. reduce anxiety about unknowns. • Assist in identification of appropriate financial support if the Funding by third party payment may be available, depending on child is able to qualify for help according to state and federal the patient’s medical status. legislation. (continued) Copyright © 2002 F.A. Davis Company 598 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Monitor for potential for related alterations in role-relationship Alterations in communication can affect the role-relationship patterns as a result of Impaired Verbal Communication. pattern. • Monitor potential for related alterations in self-concept or Alterations in communication may impact self-esteem and should coping patterns as a result of Impaired Verbal Communication. be considered as a risk factor. • Provide appropriate patient and family teaching for care of the Basic standards of care for the patient with a tracheostomy. patient if permanent tracheostomy or related prosthetic is to be used, to include: � Appropriate number or size of tracheostomy tube � Appropriate duplication of size of tracheostomy tube in place in event of accidental dislodging or loss � Appropriate administration of oxygen via tracheostomy adapter � Appropriate suctioning technique, sterile and nonsterile � Appropriate list of supplies and how to procure them � Resources for actual care in emergency, with list of numbers including ambulance and nearest hospital � Appropriate indications for notification of physician (Note: These may vary slightly according to physician’s plan or actual patient status.) (1) Bleeding from tracheostomy (2) Coughing out or dislodging of tracheostomy (3) Difficulty in passing catheter to suction tracheostomy (4) Fever higher than 101F � Appropriate daily hygiene of tracheostomy � Caution regarding use of regular gauze or other substances that might be inhaled or ingested through tracheostomy � Need for humidification of tracheostomy Women’s Health This nursing diagnosis will pertain to women the same as to any other adult. The reader is referred to the other sections—Adult Health, Psychiatric Health, and Home Health. Psychiatric Health NOTE: If impaired communication is related to alterations in physiology or surgical alterations, refer to Adult Health nursing actions. ACTIONS/INTERVENTIONS RATIONALES • Establish a calm, reassuring environment. Inappropriate levels of sensory stimuli can increase confusion and disorganization. • If communication difficulties are related to disorientation to person, place, or time, provide appropriate environmental cues to support orientation. These can include: � Calendars � Orientation boards � Seasonal decorations and conversations � Clocks with large numbers � Name signs on doors � Current event groups Note those items that are necessary for this client with the frequency of exposure needed to support the client’s orientation. If disorientation is related to delusions, refer to Disturbed Thought Process (Chap. 7) for additional interventions. • Provide the client with a private environment if experiencing High levels of anxiety decrease the client’s ability to process high levels of anxiety, to assist him or her in focusing on information. relevant stimuli. • Communicate with the client in clear, concise language. Inappropriate levels of sensory stimuli can increase confusion and � Speak slowly to the client. disorganization. When verbal and nonverbal behavior is not in � Do not shout. agreement, a double-bind or incongruent message may be sent. � Face the client when talking to him or her. These incongruent messages place the receiver

in a “darned if you � Role-model agreement between verbal and nonverbal do, darned if you don’t” situation and promote interpersonal behavior. ineffectiveness. (continued) Copyright © 2002 F.A. Davis Company VERBAL COMMUNICATION, IMPAIRED 599 (continued) ACTIONS/INTERVENTIONS RATIONALES • Spend 30 min twice a day at [times] with the client discussing Promotes the development of a trusting relationship, while communication patterns. As the client progresses, this time providing the client a safe environment in which to practice new could also include: behaviors. Behavioral rehearsal helps facilitate the client’s learning � Constructive confrontation about the effects of the new skills through the use of feedback and modeling by the dysfunctional communication pattern on relationships nurse. � Role-playing appropriate communication patterns � Pointing out to the client the lack of agreement between verbal and nonverbal behavior and context � Helping the client understand purpose of dysfunctional communication patterns � Developing alternative ways for the client to have needs met • Develop, with the client’s assistance, a reward program for Reinforcement encourages positive behavior while enhancing appropriate communication patterns and for progress on goals. self-esteem. Note here the kinds of behavior to be rewarded and schedule for reward. • Instruct the client in assertive communication techniques, and Assertiveness improves the individual’s ability to act appropriately practice these in daily interactions with the client. Note here and effectively in a manner that maximizes coping resources.35 those assertive skills the client is to practice and how these are to be practiced—e.g., each medication is to be requested by the client in an assertive manner. • Provide the client with positive verbal rewards for appropriate Reinforcement encourages positive behavior. communication. • Sit with the client while another client is asked for feedback The nurse’s presence provides support while the client can receive about an interaction. feedback on interpersonal skills from a peer. • Keep interactions brief and goal directed when the client is Inappropriate levels of sensory stimuli can increase confusion and communicating in dysfunctional manner. disorganization. • Spend an extra 5 min in interactions in which the client is Time with the nurse can provide positive reinforcement. communicating clearly, and inform the client of this reward of time. • Reward improvement in the client’s listening behavior. This can Improved attending skills improve the client’s ability to understand be evaluated by having the client repeat what has just been communication from others and to clarify unclear portions of heard. Provide clarification for the differences between what communication. was heard and what was said. • Have the support system participate in one interaction per week Behavioral rehearsal provides opportunities for feedback and with the client in the presence of a staff member. The staff modeling from the nurse. Support system understanding facilitates member will facilitate communication between the client and the maintenance of new behaviors after discharge. the support system. Note time for these interactions here, with the name of the staff person responsible for this process. • Arrange for the client to participate in a therapeutic group. Note Provides an opportunity for the client to receive feedback on schedule for these groups here. communication from peers and to observe the interactions of peers so that he or she may increase the requisite variety of responses in social situation. • Request that the client clarify unclear statements or Models appropriate communication skills for the client. communications in private language. • Teach the client to request clarification on confusing Repeated practice of a behavior internalizes and personalizes the communications. This may be practiced with role-play. behavior. • Include the client in unit activities, and assign appropriate tasks Provides opportunities for the client to practice new behaviors in to the client. These should require a level of communication the a supportive environment. client can easily achieve so that a positive learning experience can occur. Note level of activity appropriate for the client here. • If communication problems evolve from a language difference, Decreases the client’s sense of isolation and anxiety. have someone who understands the language orient the client to the unit as soon as possible and answer any questions the client might have. • Use nonverbal communication to interact with the client when Decreases the client’s sense of social isolation, and promotes the there is no one available to translate. development of a trusting relationship. • Obtain information about nonverbal communication in the Decreases the possibilities for misunderstanding to develop. client’s culture and about appropriate psychosocial behavior. Alter interactions and expectations to fit these beliefs as they fit the client. Note here information that is important in providing daily care for this client. (continued) Copyright © 2002 F.A. Davis Company 600 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Determine whether the client understands any English and, if so, Promotes the development of a trusting relationship. how it is best understood—i.e., written or spoken. • If the client does not understand English, determine whether a Communication facilitates social interaction and increases the language other than the one from the culture of origin is spoken. client’s sense of control. Perhaps a common language for staff and the client can be found—e.g., few people other than Navajos speak Navajo, but some older Navajos also speak Spanish. • Do not shout when talking with someone who speaks another Inappropriate levels of sensory stimulation can increase confusion language. Speak slowly and concisely. and disorganization. • Use pictures to enhance nonverbal communication. Pictures facilitate communication when the caregiver and client do not share the same language. • If a staff member does not speak the client’s language, arrange Promotes the client’s sense of control, and decreases social for a translator to visit with the client at least once a day to isolation. answer questions and provide information. Have a schedule for the next day available so this can be reviewed with the client and information can be provided about complex procedures. Have a staff member remain with the client during these interactions to serve as a resource person for the translator. Allow time for the client to ask questions and express feelings. Note schedule for these visits here, with the name of the translator. Gerontic Health The nursing actions for a gerontic patient with this diagnosis are the same as those given in Adult Health and Psychiatric Health. Home Health ACTIONS/INTERVENTIONS RATIONALES • Involve the client and family in planning and implementing Family involvement enhances effectiveness of interventions. strategies to decrease, prevent, or cope with Impaired Verbal Communication: � Family conference: Discuss each member’s perspective of the situation. � Mutual goal setting: Set short-term accomplishable goals with evaluation criteria; specify tasks for each member. � Communication: Identify ways to communicate with the client. • Teach the client and family appropriate information regarding Knowledge bases required to interact with the family member who the care of a person with Impaired Verbal Communication: is verbally impaired. � Use of pencil and paper, alphabet letters, hand signals, sign language, pictures, flash cards, or computer � Use of repetition � Facing the person when communicating � Using simple, one-step commands � Allowing time for the person to respond � Use of drawing, painting, coloring, singing, or exercising � Identifying tasks the person with Impaired Verbal Communication can do well � Decreasing external noise • Assist the patient and family in lifestyle adjustments that may be Lifestyle changes require long-term behavioral changes. Support required: enhances permanent changes in behavior. � Stress management � Changing role functions and relationships � Learning a foreign language � Acknowledging and coping with frustration with communication efforts � Obtaining necessary supportive equipment, e.g., hearing aid, special telephone, or artificial larynx • Consult with or refer to appropriate assistive resources as Self-help groups and rehabilitation services can enhance the required. treatment plans. Copyright © 2002 F.A. Davis Company VERBAL COMMUNICATION, IMPAIRED 601 Verbal Communication, Impaired FLOWCHART EVALUATION: EXPECTED OUTCOME Interview the patient. Can the patient communicate clearly using the stated method? Yes No Record data, e.g., uses esophageal Reassess using initial assessment factors. speech; has had no problems with air retention; has perceived no difficulty in being understood. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., is having problems with esophageal speech, i.e., air retention, Did evaluation show another having to repeat words frequently. problem had arisen? Yes Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 602 ROLE-RELATIONSHIP PATTERN Violence, Self-Directed and Other-Directed, giving away personal items, or taking out a large life insur- Risk for ance policy 19. Persons who engage in autoerotic sexual acts DEFINITIONS8 B. Risk for Other-Directed Violence (Risk Factors) 1. History of violence Risk For Self-Directed Violence Behaviors in which an individ- a. Against others: Hitting someone, kicking someone, spit- ual demonstrates that he or she can be physically, emotionally, ting at someone, scratching someone, throwing objects and/or sexually harmful to self. at someone, biting someone, attempted rape, rape, sex- ual molestation, or urinating or defecating on a person Risk For Other-Directed Violence Behaviors in which an indi- b. Threats: Verbal threats against property, verbal threats vidual demonstrates that he or she can be physically, emotionally, against person, social threats, cursing, threatening notes and/or sexually harmful to others. or letters, threatening gestures, or sexual threats c. Anti-social behavior: Stealing, insistent borrowing, insis- NANDA TAXONOMY: DOMAIN 11—SAFETY/ tent demands for privileges, insistent interruption of PROTECTION; CLASS 3—VIOLENCE meetings, refusal to eat, refusal to take medication, or ig- noring instructions NIC: DOMAIN 4—SAFETY; CLASS V—RISK d. Indirect: Tearing off clothes, ripping objects off walls, MANAGEMENT writing on wall, urinating on floor, defecating on floor, NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; stamping feet, temper tantrums, running in corridors, CLASS O—SELF-CONTROL yelling, throwing objects, breaking a window, slamming doors, or sexual advances 2. Neurologic impairment: Positive electroencephalogram DEFINING CHARACTERISTICS8 (EEG), computed tomography (CT) scan, or magnetic res- onance imaging (MRI); head trauma; positive neurologic A. Risk for Self-Directed Violence (Risk Factors) findings; or seizure disorders 1. Age 15 to 19 or older than 45 3. Cognitive impairment: Learning disabilities, attention deficit 2. Marital status: Single, widowed, or divorced disorder, or decreased intellectual functioning 3. Employment: Unemployed; or recent job loss or failure 4. History of childhood abuse 4. Occupation: Executive, administrator, owner of business, 5. History of witnessing family violence professional, or semiskilled worker 6. Cruelty to animals 5. Interpersonal relationships: Conflictual 7. Firesetting 6. Family background: Chaotic or conflictual, or history of 8. Prenatal and perinatal complications or abnormalities suicide 9. History of drug or alcohol abuse 7. Sexual orientation: Active bisexual or inactive homosexual 10. Pathologic intoxication 8. Physical health: Hypochondriac, or chronic or terminal illness 11. Psychotic symptomatology: Auditory, visual, or command 9. Mental health: Severe depression, psychosis, severe person- hallucinations; paranoid delusions; or loose, rambling, or ality disorder, or alcohol or drug abuse illogical thought processes 10. Emotional status: Hopelessness, despair, increased anxiety, 12. Motor vehicle offenses: Frequent traffic violations, or use of panic, anger or hostility motor vehicle to release anger 11. History of multiple suicide attempts 13. Suicidal behavior 12. Suicidal ideation: Frequent, intense, or prolonged 14. Impulsivity 13. Suicidal plan: Clear and specific lethality; method and avail- 15. Availability and/or possession of weapon(s) ability of destructive means 16. Body language: Rigid posture, clenching of fists and jaw, hy- 14. People who engage in autoerotic sexual acts peractivity, pacing, breathlessness, and threatening stances 15. Personal resources: Poor achievement, poor insight, or affect unavailable and poorly controlled RELATED CLINICAL CONCERNS 16. Social resources: Poor rapport, socially isolated, or unre- sponsive family 1. Physical abuse 17. Verbal clues: Talking about death, “better off without me,” 2. Organic brain syndrome; Alzheimer’s disease or asking questions about lethal dosages of drugs 3. Attempted suicide 18. Behavioral clues: Writing forlorn love notes, directing angry 4. Epilepsy, temporal lobe messages at a significant other who has rejected the person, 5. Panic episode HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Compromised or Disabled Family Coping This Impaired Parenting This diagnosis relates to the diagnosis relates to the inability of the primary relationship between the nurturing figure and the caregiver or caretaker to meet the needs of the child. Child abuse is included

within this patient. No violence is included in this diagnosis. diagnosis, but as an actual fact, not as a risk for. If If such abuse has been assessed, then the diagnosis a risk for abuse exists, then Risk for Violence is the should be changed. most appropriate diagnosis. Copyright © 2002 F.A. Davis Company VIOLENCE, SELF-DIRECTED AND OTHER-DIRECTED, RISK FOR 603 EXPECTED OUTCOME TARGET DATES Will demonstrate at least [number] alternative methods for releas- For the sake of all concerned, the patient should begin to demon- ing anger by [date]. strate progress within 3 to 5 days. However, the patient must be monitored on a daily basis. To totally control violent behavior may take months. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Refer to psychiatric nurse clinician (see Psychiatric Health Violence or risk for violence requires specific interventions by a nursing actions). specialist in the area of mental health. • Monitor for signs of anger or distress such as restlessness, Monitors for deterioration of condition, and promotes early pacing, wringing of hands, or verbally abusive behavior. intervention. • Accept anger of the patient, but do not participate in it when Anger is an acceptable behavior if appropriately handled, but interacting with the patient. escalation of anger is to be avoided. • Remain calm. Set limits on the patient’s behavior, and reduce Decreases sensory stimuli. Decreases anxiety- and environmental stimuli. violence-provoking situations. • Encourage the patient to verbalize angry feelings rather than Promotes an acceptable alternative strategy for dealing with anger. physically demonstrating them or to physically demonstrate them in constructive ways—e.g., working out on a punching bag, banging a trash can, or taking a walk. Schedule 30 min twice a day at [times] to confer with the patient regarding this topic. • Let the patient know that he or she has control of own actions. Reinforces reality, and maintains limits on behavior. He or she is responsible for own actions. Help the patient identify situations that interfere with his or her control during conferences with the patient. • Provide a safe environment by removing clutter, breakables, or Promotes safety, and reduces risk of harm to patients or others. potential weapons. Restrain or seclude the patient as needed. • Observe, at least once an hour, for indications of suicidal Prevents self-inflicted violence. behavior, e.g., withdrawal, depression, or planning and organizing for attempt. • Give medications as ordered (tranquilizer, sedative, etc.), and Determines effectiveness of medication as well as monitoring for monitor effects of medication. unwanted side effects. Child Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient and family to describe usual patterns of Insight into role-relationships is basic in determining the risk for role-relationship activities. violence. • Monitor for precipitating or triggering events that seem to recur Risk indicators can be identified as assessment for repeated violence as the pattern for violence is explored. is considered. • Assist the patient and family to describe their perception of the Insight of the patient or parents reveals basic data about the actual or potential violence pattern. violence pattern, which assists in accurate intervention. • Provide opportunities for expression of emotions related to the Expression of thoughts and feelings in a directive age-appropriate violence appropriate for age and developmental capacity—e.g., manner helps the child understand the impact of the violence and a toddler could use dolls, puppets, or other noninvasive methods. assists in reducing his or her anxiety. • Provide appropriate collaboration for long-term follow-up Valuing long-term follow-up fosters compliance and shows regarding appropriate intervention. sensitivity to the patient’s needs for long-term support. Safety is also at risk. In many instances, legal mandates dictate exact protocols to be enforced. • Provide for role-taking by parents in a supportive manner when Supportive role-modeling provides a safe and nonjudgmental possible. milieu for the parents to practice parenting and appropriate behaviors with the child. It also allows for observation of behaviors to follow reciprocity of parental-infant dyad or triad. (continued) Copyright © 2002 F.A. Davis Company 604 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide consistency in caregivers to best develop a trust for Consistency increases trust in caregivers. nursing staff during hospitalization. • Provide for confidentiality and privacy. Standards that are too often overlooked. • Ensure that discussions regarding the child and family are Objective dialogues are less threatening for all involved. carried out with objectivity. • Address appropriate authorities as needed for protection of the Appropriate child protective measures must be taken. child and family members, to include security or police members according to institutional policy. • Provide support in determining usual coping patterns and how Support in coping and dealing with violence will help reduce these may be enhanced to deal with altered role-relationship likelihood of increasing violence and assist in reducing anxiety. pattern of violence. • Assist in plans for placement, transitional placement, or Appropriate planning for changes in care and the environment dismissal to return home for the family. lessens the emotional trauma of these changes. • Assist in identification of specific resources for long-term Follow-up ensures attention to long-term needs and attaches planning as appropriate. value to follow-up care. • Maintain objectivity in documentation of parent-child interactions. Women’s Health NOTE: These actions relate specifically to the abused, battered woman.51–54 ACTIONS/INTERVENTIONS RATIONALES • All female clients should be screened for the presence of violence upon entry into the health care system: � Have you ever been intentionally hurt by someone? � Are you afraid of your partner or significant other? � Has your partner or significant other ever made you feel afraid, inadequate, or worthless? • Be alert for cues that might indicate battering, such as: Provides database necessary to accurately assess the true causative � Hesitancy in providing detailed information about injury and factor. how it occurred � Explanation for injuries that are inconsistent with the injury, e.g., trunk injury not consistent with a fall � Inappropriate affect for the situation � Delayed reporting of symptoms � Types and sites of injuries, such as bruises to head, throat, chest, breast, or genitals � Inappropriate explanations � Increased anxiety in presence of the batterer � Injuries that are proximal, rather than distal, may indicate a battering injury � Injuries that are in various stages of healing, e.g., old bruises along with new bruises � Vague somatic symptoms with no visible cause • Provide a quiet, secure atmosphere to facilitate verbalization of Provides emotional support to the patient. Fosters security for the fears, anger, rage, guilt, and shame. All discussions about patient so that she will realize that she is not alone or not the only violence should be initiated and conducted with the patient person to have had this experience. isolated away from the partner. • Provide information on options available to the patient, e.g., Provides basic information needed by the patient for future women’s shelters and legal aid societies. planning. • Assist the patient in raising her self-esteem by: � Asking permission to do nursing tasks � Involving the patient in decision making � Providing the patient with choices � Encouraging the patient to ask questions � Assuring the patient of confidentiality � Listening to her concerns and choices without judging • Assist the patient in reviewing and understanding family dynamics. (continued) Copyright © 2002 F.A. Davis Company VIOLENCE, SELF-DIRECTED AND OTHER-DIRECTED, RISK FOR 605 (continued) ACTIONS/INTERVENTIONS RATIONALES • Encourage and assist the patient in planning for economic and Provides the information, long-range support, and essentials for financial needs, such as housing, job, child care, food, clothing, resolving the problem. school for the children, and legal assistance. • Refer the patient to social services for immediate financial assistance for shelter, food, clothing, and child care. • Assist the patient in identifying lifestyle adjustments that each decision could entail. • Encourage development of community and social network systems. • The nurse should monitor his or her own biases about victims Biases negatively impact appropriate nursing interventions. of domestic violence: � Belief that they deserve the abuse because they choose to stay with the abuser � Belief that the patient is powerless to change the situation Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Introduce self to the client, and call the client by name. Conditions that make people feel anonymous facilitate aggressive behavior.55 • If aggressive behavior is resulting from toxic substances, consult Staff and client safety is of primary concern. with physician for medication and detoxification procedure. • Observe the client every 15 min during detoxification, assessing Client safety is of primary concern. vital signs and mental status, until condition is stable. • Place the client in quiet environment for detoxification. Inappropriate levels of sensory stimuli can increase confusion and disorganization. • Eliminate environmental stimuli that affect the client in a Inappropriate levels of sensory stimuli can increase confusion and negative manner. This could include staff, family, and other disorganization, increasing the risk for violent behavior. clients. Establish balance between being in control and being controlling. • Provide a calm, reassuring environment. Respect the client’s requests for quiet, alone time. • Protect the client from harm by: Provides basic client safety. � Removing sharp objects from environment � Removing belts and strings from environment � Providing a one-to-one constant interaction if risk for self-harm is high � Checking on the client’s whereabouts every 15 min � Removing glass objects from environment � Removing locks from room and bathroom doors � Providing a shower curtain that will not support weight � Checking to see whether the client swallows medication • Observe the client’s use of physical space, and do not invade Encroachment of the client’s personal space may be perceived as client’s personal space. a threat.56 • If it is necessary to have physical contact with the client, explain Clarifies role of staff to the client so that the intent of these this need to the client in brief, simple terms before approaching. interactions is framed in a positive manner. • Remove unnecessary clutter and excess stimuli from the Inappropriate levels of sensory stimuli can increase the client’s environment. confusion and disorganization, thus increasing the risk for violent behavior. • Talk with the client in calm, reassuring voice. • Do not make sudden moves. • Remove persons who irritate the client from the environment. The best intervention for violent behavior is prevention. Observe the client carefully for signs of increasing anxiety and tension. • Do not assume physical postures that are perceived as threatening to the client. • If increase in tension is noted, talk with the client about Assists the client in developing coping behaviors. feelings. • Help the client attach feelings to appropriate persons and Assists the client in developing coping behaviors that are situations—e.g., “Your boss really made you angry this time.” appropriate to the situation. Promotes the client’s sense of control.56 (continued) Copyright © 2002 F.A. Davis Company 606 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Suggest to the client alternative behavior for releasing tension— Assists the client in releasing physical tension associated with high e.g., “You really seem tense right now. Let’s go to the gym so levels of anger. you can use the punching bag.” Or, “Let’s go for a walk.” • Provide medication as ordered, and observe the client for signs Provides the least-restrictive way of assisting the client to control of side effects, especially orthostatic hypotension. behavior. • Answer questions in an open, direct manner. Promotes the development of a trusting relationship, and promotes consistency in interventions.56 • Orient the client to reality in interactions. Use methods of Direct confrontations could be perceived as a threat to the client indirect confrontation that do not pose a personal threat to the and precipitate violent behavior.57 client. Do not agree with delusions—e.g., “I do not hear voices other than yours or mine,” or “This is the mental health unit at [name] Hospital.” • Refer to Disturbed Thought Process (Chap. 7) for detailed Promotes the development of a trusting relationship. In crisis, interventions for delusions and hallucinations. clients are more likely to respond positively to someone with whom they have a trusting relationship. Increases consistency in interventions.56 • Assign one staff member to be primary caregiver to the client to facilitate the development of a therapeutic relationship. • Inform the client before any attempts to make physical contact Clients who are prone to violence need increased personal space. are

made in the process of normal provision of care—e.g., Intrusions could provoke violent behavior.56 explain to the client you would like to assist him or her with dressing, would this be all right? • Assist the client in identifying potential problem behavior with Promotes the client’s sense of control, which decreases risk for feedback about his or her behavior. violent behavior.56 • Have the client talk about angry feelings toward self and others. Assists the client to understand the reasons for the anger, which can defuse the situation.56 • Contract with the client to talk with staff member when he or Promotes the client’s sense of control by assuring the client that if she feels an increase in internal tension or anger. he or she can no longer maintain control, the staff has a specific plan to assist him or her.56 • Set limits on inappropriate behavior, and discuss these limits with the client. Note these limits here, as well as the consequences for these kinds of behaviors. This information should be very specific so that the intervention is consistent from shift to shift. Present these limits as choices. • If conflict occurs between the client and someone else, sit with Staff presence can reinforce using appropriate problem-solving them as they resolve the conflict in an appropriate manner. The skills as the client practices these new behaviors. nurse will serve as a facilitator during this interaction. • Discuss tension-reduction techniques with the client, and Promotes the client’s sense of control. Repeated practice of a develop a plan for the client to learn these techniques and apply behavior internalizes and personalizes the behavior. them in difficult situations. Note the plan here. • Develop with the client a reward system for appropriate Positive reinforcement encourages behavior. behavior. Note reward system here. • Talk with the client about the differences between feelings and Promotes the client’s sense of control by establishing limits around behavior. Role-play with the client, attaching different kinds of feelings in the cognitive realm. Repeated practice of a behavior behavior to feelings of anger. internalizes and personalizes the behavior. • Help the client in determining whether the feeling being Placing other names on the feeling may open new behavior experienced is really anger. Explain that at times of high stress possibilities to the client, while promoting a positive orientation— we can misinterpret feelings and must be very careful not to e.g., if this were anger, lashing out would be appropriate, but express the wrong feeling. What we are expressing as anger may because it is anxiety, it is more appropriate to relax. actually be, for example, anxiety or frustration. • When the client is capable, assign him or her to group in which Promotes the client’s sense of control by providing role models for feelings can be expressed and feedback can be obtained from alternative ways of coping with feelings. peers. Note schedule for group activity here. • Review with the client consequences of inappropriate behavior, Assesses the possibility for secondary gain in inappropriate and assess the gains of this behavior over the costs. behavior. • Accept all threats of aggressive behavior as serious. Client and staff safety are of primary importance. • Remind staff to not take aggressive acts personally even if they As the nurse’s level of arousal increases, judgment decreases, appear to be directed at one staff member. making the nurse less effective when working with the client experiencing difficulty.56 • Provide the client with positive verbal feedback about positive Positive feedback encourages behavior. behavior changes. (continued) Copyright © 2002 F.A. Davis Company VIOLENCE, SELF-DIRECTED AND OTHER-DIRECTED, RISK FOR 607 (continued) ACTIONS/INTERVENTIONS RATIONALES • Do not place the client in frustrating experiences without a staff Frustration can increase the risk for aggression.55 member to support the client during the experience. • If the client is suicidal, place him or her in a room with another Decreases the amount of time the client is alone. client. • Provide the client with opportunities to regain self-control Promotes the client’s perception of control while supporting without aggressive interventions by giving the client choices self-esteem. that will facilitate control—e.g., “Would you like to take some medication now or spend some time with a staff member in your room?” Or “We can help you into seclusion, or you can walk there on your own.” • Provide the client with opportunities to maintain dignity. • Assure the client that you will not allow him or her to harm self or someone else. • Reinforce this by having more staff present than necessary to Client and staff safety are of primary concern. physically control the client if necessary. Persons from other areas of the institution may be needed in these situations. If others are used, they should be trained in proper procedures. • If potential for physical aggression is high:56,57 � Place one staff member in charge of the situation. Promotes consistency in intervention, and decreases inappropriate levels of sensory stimulation. � As primary person attempts to “talk the client down,” other Client and staff safety are of primary concern. staff member should remove other clients and visitors from the situation. � Other staff members should remove potential weapons from Assists in reducing levels of emotion. the environment in an unobtrusive manner. This could include pool cues and balls, chairs, flower vases, or books. � Avoid sudden movements. � Never turn back on the client. � Maintain eye contact (this should not be direct, for this can Assists in assessing the client’s intentions without appearing be perceived as threatening to the client), and watch the threatening. client’s eyes for cues about potential targets of attack. � Do not attempt to subdue the client without adequate Client and staff safety are of primary concern. assistance. � Put increased distance between the client and self. Clients who have a potential for violent behavior need more personal space. � Tell the client of the concern in brief, concise terms. Maintains appropriate levels of sensory stimuli. � Suggest alternative behavior. Promotes the client’s sense of control. � Help the client focus aggression away from staff. May prevent the need for more restrictive interventions. � Encourage the client to discuss concerns. Assists in reducing levels of emotion and deescalation of behavior. • If talking does not resolve the situation: � Have additional assistance prepared for action (at least Client and staff safety are of primary concern. 4 persons should be present). � Have those who are going to be involved in the intervention remove any personal items that could harm client or self, e.g., eyeglasses, guns, long earrings, necklaces, or bracelets. � Have seclusion area ready for the client, remove glass objects Prevents sensory overload while providing reassurance to the client. and sharp objects, and open doors for easy entry. � Briefly explain to client what is going to happen and why. � Use method practiced by intervention team to place the client Client and staff safety and coordination are of primary concern. in seclusion or restraints. � Protect self with blankets, arms bent in front of body to Contains the client’s body, and blocks the client’s vision if it is protect head and neck. necessary to disarm the client.57 � Be prepared to leave the situation, and be aware of location Client and staff safety are of primary concern. of exits. • See Impaired Physical Mobility (Chap. 5) for care of the client in seclusion or restraints. • Discuss the violent episode with the client when control has Debriefing diminishes the emotional impact of the intervention been regained. Answer questions the client has about the and provides an opportunity to clarify the circumstances for the situation, and provide the client with opportunities to express intervention, offer mutual feedback, and promote the client’s thoughts and feelings about the episode. self-esteem.58 (continued) Copyright © 2002 F.A. Davis Company 608 ROLE-RELATIONSHIP PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Inform the client of the behavior that is necessary to be released Promotes the client’s sense of control and enhances self-esteem. from seclusion or restraints. • Process situation with the client after incident. • Assess milieu for “organizational provocation.” • If the client has history of violent acts: Provides offenders with the opportunity to rebuild their � Provide the client with individual or group opportunities to: relationship style.59 (1) Take responsibility for the violent act. (2) Develop empathy for the victim. (3) In some way, develop an apology to the victim. (This method may be indirect if it would not be in the best interest of the victim to receive a direct apology.) (4) Explore the interactions of thoughts, feelings, and behaviors in their violent acts. (5) Develop a plan for alternative ways of responding to the identified thoughts and feelings. � Note persons responsible for facilitating this process here, with the meeting schedule. � If partner or family violence is an issue, arrange conjoint, Provides partners with an opportunity to develop alternative ways solution-oriented treatment. This should include a of communicating and problem solving.60,61 no-violence contract between the partners. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • In cases of dementia, discuss with the caregiver if there is a Awareness of violence triggers provides guidelines to adjust usual pattern of violence, e.g., does startling or speaking in environment and staff behaviors. loud tones or having several people speaking at once usually result in a violent outburst by the patient? Home Health ACTIONS/INTERVENTIONS RATIONALES • Teach the client and family appropriate monitoring of signs and Provides database for early recognition and intervention. symptoms of the risk for violence: � Substance abuse � Increased stress � Social isolation � Hostility � Increased motor activity � Disorientation to person, place, and time � Disconnected thoughts � Clenched fists � Throwing objects � Verbalizations of threats to self or others • Assist the client and family in lifestyle adjustments that may be Permanent changes in behavior require support. required: � Recognition of feelings of anger or hostility � Developing coping strategies to express anger and hostility in acceptable manner—exercise, sports, art, music, etc. � Prevention of harm to self and others � Treatment of substance abuse � Management of debilitating disease � Coping with loss � Stress management � Decreasing sensory stimulation � Provision of safe environment � Removal of weapons, toxic drugs, etc. (continued) Copyright © 2002 F.A. Davis Company VIOLENCE, SELF-DIRECTED AND OTHER-DIRECTED, RISK FOR 609 (continued) ACTIONS/INTERVENTIONS RATIONALES � Development and use of support network � Restriction of access to weapons, especially handguns62,63 • Discuss workplace issues related to violence.64 Homicide is a leading cause of occupational death. Prevention is needed. • Develop anticipatory guidance materials for violence Age-appropriate prevention strategies provide support for change. prevention.64,65 • Involve the patient and family in planning and implementing Provides for early intervention. strategies to reduce the risk for violence: � Family conference � Mutual goal setting � Communication • Assist the client and family to set criteria to help them determine when intervention of law enforcement officials or health professionals is required—e.g., if the patient becomes threat to self or others. • Consult with or refer to assistive resources as appropriate. Utilization of existing services is efficient use of resources. Psychiatric nurse clinician and support groups can enhance the treatment plan. Copyright © 2002 F.A. Davis Company 610 ROLE-RELATIONSHIP PATTERN Violence, Self-Directed and Other-Directed, Risk for FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient return-demonstrate X number of alternative methods for releasing anger? Yes No Record data, e.g., has chosen exercise Reassess using initial assessment factors. and relaxation tape as alternative methods; has successfully utilized both according to self and family statements. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., can return- demonstrate progressive relaxation Did evaluation show another accurately; has identified no other problem had arisen? Yes methods. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company CHAPTER 10 Sexuality-Reproductive Pattern 1. RAPE-TRAUMA SYNDROME: 2. SEXUAL DYSFUNCTION 621 COMPOUND REACTION AND SILENT 3. SEXUALITY PATTERNS, REACTION 614 INEFFECTIVE 628 Pattern Description 6. Does the client verbalize any problems related to sexual func- tioning?

This pattern focuses on the sexual-reproductive aspects of individ- a. Yes (Sexual Dysfunction) uals over the entire life span. Sexuality patterns involve sex role be- b. No havior, gender identification, physiologic and biologic functioning, 7. Does the client exhibit any indications of physical or psychoso- as well as the cultural and societal expectations of sexual behavior. cial abuse? An individual’s anatomic structure identifies sexual status, which a. Yes (Sexual Dysfunction) determines the social and cultural responses of others toward the b. No individual and, in turn, the individual’s responsive behavior toward 8. Does the client relate any changes in sexual behavior? others. a. Yes (Ineffective Sexuality Patterns) Reproductive patterns involve the capability to procreate, actual b. No procreation, and the ability to express sexual feelings. The success 9. Does the client report any difficulties or limitations in sexual or failure of psychologically and physically expressing sexual feel- behavior? ings and procreating can affect an individual’s lifestyle, health, and a. Yes (Ineffective Sexuality Patterns) self-concept. b. No The nurse may care for clients who, because of illness, violence, or lifestyles, experience alterations or disturbances in their sexual Conceptual Information health that affect their sexuality and reproductive patterns. Gender development and sexuality are closely entwined with bio- Pattern Assessment logic, psychological, sociologic, spiritual, and cultural aspects of human life. The biologic sex of an individual is decided at the time 1. Following a rape, is the patient experiencing multiple physical of conception, but sexual patterning is influenced from the moment symptoms? of birth by the actions of those surrounding the individual. From a. Yes (Rape-Trauma Syndrome: Compound Reaction) that moment, males and females receive messages about who they b. No are and what it means to be masculine or feminine.1 2. Following a rape, is the patient indicating severe emotional The sexuality of an individual is composed of biologic sex, gen- reactions? der identity, and gender role. The biologic and psychological per- a. Yes (Rape-Trauma Syndrome: Compound Reaction) spectives of culture and society determine how an individual b. No develops sexually, particularly in the sense one has of being male 3. Is the client using alcohol or drugs to cope following a rape? or female (gender identity). Biologic identity begins at the moment a. Yes (Rape-Trauma Syndrome: Compound Reaction) of fertilization, when chromosomal sex is determined, and becomes b. No even more defined at 5 to 6 weeks of fetal life. At this time, the 4. Has the client changed her relationship with males? undifferentiated fetal gonads become ovaries (XX, female chromo- a. Yes (Rape-Trauma Syndrome: Silent Reaction) somal sex) or testes (XY, male chromosomal sex), and hormones b. No finalize the genital appearance between the 7th and 12th weeks. 5. Does the client indicate increased anxiety in follow-up counseling? Fetal androgens (testicular hormones) must be present for male a. Yes (Rape-Trauma Syndrome: Silent Reaction) reproductive structures to develop from the wolffian ducts. If b. No fetal androgens are not present, the fetus will develop female 611 Copyright © 2002 F.A. Davis Company 612 SEXUALITY-REPRODUCTIVE PATTERN reproductive structures. By the 12th week of fetal life, biologic sex Sadly, only 16 percent of the victims tell police about the attack, is well established.1,2 with the victims being concerned about the family finding out, be- Reactions by others begin the moment the biologic sex of the fe- ing blamed by others for the attack, and others knowing about the tus or infant is known. Whether the sex of the infant is known be- attack. These concerns have decreased in victims raped in the past fore birth or not until the time of birth, the parents and those about 5 years; however, in this group, there were increased concerns them prepare for either a boy or a girl by buying clothes and toys about having their name become public, getting AIDS and other for a boy (color blue, pants, shirts, football) or a girl (color pink, sexually transmitted diseases, and becoming pregnant. Confiden- frilly dresses, dolls), as well as speaking to the infant differently ac- tiality of name is a high priority for these victims. cording to sex. Girls are usually spoken to in a high, singsong voice: “Oh, isn’t she cute!” whereas boys are spoken to in a low-pitched, matter-of-fact voice: “Look at that big boy. He will really make a Developmental Considerations good football player one of these days!” These actions contribute to INFANT the infant’s gender identity and perception of self. Behavioral re- sponses from the infant are elicited by the parents, based on their Erickson defines the major task of infancy as the development of views of what roles a boy or girl should fulfill. trust versus mistrust.4 The act of the parents’ nurturing and pro- Gender role is determined by the kinds of sex behavior that are viding care-taking activities allows the infant to begin experiencing performed by individuals to symbolize to themselves and others various pleasures and physical sensations, such as warmth, plea- that they are masculine or feminine.3 Early civilizations assigned sure, security, and trust,1 and it is through these acts of nurturing roles according to who performed what tasks for survival. Women that the infant begins to develop a sense of masculinity or feminin- were relegated to specific roles because of the biologic nature of ity (gender identity). The infant is further molded by the parents’ bearing and rearing children and gathering food. The men were the perceptions of sex-appropriate behavior through reward and pun- hunters and soldiers. Advanced technologies, changing mores, ishment. Female infants tend to be less aggressive and develop birth control, and alternative methods of securing food and rearing more sensitivity because girls are usually rewarded for “being children have led to changes in roles based on gender in Western good,” and male infants develop more aggressively and learn to be society. Gender roles are influenced by cultural, religious, and so- independent because boys are told that “big boys don’t cry” and cial pressures. “Gender role stereotypes are culturally assigned clus- they learn to comfort themselves. By the age of 13 months, sexual ters of behaviors or attributes covering everything from play activ- behavior patterns and differences are in place,1,4 and core gender ities and personal traits to physical appearance, dress and vocational identity is theorized to be formed by 18 months.7 “These early be- activities.”4 haviors are so critical to one’s core gender-identity that children As in gender identity, researchers have noticed gender role-play who experience gender reassignment after the age of 2 years are in children as young as 13 months. Schoolchildren are particularly high-risk candidates for psychotic disorders”4 (p. 321). exposed and pressured into gender role stereotyping by parents, The infant who is sexually abused is usually physically trauma- teachers, and peers, who demand expected, rigid behavior patterns tized and many times dies. Developmental delays can be recognized according to the sex of the child. Molding into gender roles is often in these children by failure to thrive, low weight or no weight gain, accomplished by handling girls and boys differently. Little girls are lethargy, and flat affect. usually handled gently as infants, and adults fuss with their baby’s hair and tell them how pretty they are; little boys are usually rough- TODDLER AND PRESCHOOLER housed and are told “What a big boy you are.” Sex directional train- ing is also accomplished by such verbalizations as “Where’s Daddy’s Neuromuscular control allows toddlers to explore their environ- girl?” and “Big boys don’t cry; be a man.”5 ment, interact with their peers,1,4 and develop autonomy and in- North American society is moving toward a blending of male and dependence.7 Genital organs continue to increase in size but not in female roles; however, stereotyping still exists. According to Schus- function. The toddler’s vocabulary increases; he or she distin- ter and Ashburn,4 stereotyping is not all bad, as it can help “reduce guishes between male and female by recognizing clothing and body anxiety arising from gender differences and may aid in the process parts; and he or she develops pride in his or her own body, espe- of psychic separation from one’s parents.” Therefore, they conclude cially the genital area, as he or she becomes aware of elimination or that stereotypes can provide structure and facilitate development as excretory functions. They need guidance and require parents to set well as restrict development and become too rigid, thus interfering limits as they learn to “hold on” or “let go” in order to achieve a with a child’s potential. sense of autonomy.4 By the age of 3, they have perfected verbal One’s sexuality is a continuing lifetime evolution, changing as terms for the sexes, understand the meaning of gender terms and one matures and progresses through the life cycle. It is impossible the roles associated with those terms (e.g., girl is sister or mother, to separate an individual’s sexuality from his or her development, and boy is brother or father),1 and receive pleasure from kissing and as sexuality combines the interaction of the biophysical and psy- hugging.7 chosocial elements of the individual. The preschooler is busy developing a sense of socialization and According to a national research study6 “Rape in America,” rape purpose. Learning suitable behavior for girls and boys or sex role occurs far more often than previously recognized. This study found behavior is the major task during the preschool years. Preschoolers that 683,000 American women were raped in 1990, which is a far will often identify with the parent of the same sex while forming an higher number than had been estimated. Almost 62 percent of attachment to the parent of the opposite sex. They are inquisitive these women stated they were minors when they were raped, and about sex and are often occupied in exploration of their own bod- about 29 percent stated they were younger than 11 when the rape ies and friends’ bodies. This will often be exhibited in group games occurred. This indicates rape is most definitely a traumatic event such as “doctor-nurse,” urinating “outside,” or masturbating.7 The for our young in America. Of the rapists, 75 percent were known toddlers’ concept of their bodies, not as a whole but as individual by the victim, and included such persons as neighbors, friends, rel- parts, changes when as preschoolers they begin to develop “an atives, boyfriends, ex-boyfriends, husbands, or ex-husbands. Only awareness of themselves as individuals, and become more con- 22 percent of the rapists were strangers to the victim. In 28 percent cerned about body integrity and intactness.”4 of the cases, injuries to the victim, beyond the rape itself, occurred. It is important to note that 6-year-olds are the age group most Copyright © 2002 F.A. Davis Company DEVELOPMENTAL CONSIDERATIONS 613 subjected to sexual abuse.8 How a child handles this experience and ininity, question and then decide on their gender identity, gender his or her future developmental and psychological growth depend orientation, and gender preference. The adolescent deals not only largely on the reactions and actions of the significant adult in the with physical changes but integrates past experiences and role child’s life.7 Rape that occurs during early childhood may simply be models with new experiences and new role models into his or her acknowledged by the child as part of the experience of growing up own gender identity. and may have no long-term effects if not repeated. Usually coun- Violent sexual occurrences during this period of life can devas- seling during this developmental age has great effect. All claims of tate a person for the rest of his or her life. Adolescents are dealing abuse by a child should be investigated and should be handled with with sexual confusion and identification; rape can stop or slow or someone who has the experience and knowledge to deal with the change this process. Fear and loss of self-esteem can dictate actions child and his or her parents in a professional and understanding and influence the sexual identity and gender expression. manner. YOUNG ADULT SCHOOL-AGE CHILD This period of an individual’s life (usually 20s and early 30s) is con- Play is the most important work of children—it allows them to be cerned with selecting a vocation, obtaining an education, military curious and investigate social, sexual, and adult behavior. service, choosing a partner, building a career, and establishing “Through play children learn

how to get their needs met and how an intimate relationship. This is a period of maximal sexual self- to meet the needs of others.”4 Different socialization of boys and consciousness, commitment to a relationship, and social legitimiza- girls tends to become apparent in play during the school years, with tion of sexual experiences.1,4,7 There is a concern with parenting boys engaging in aggressive team play and girls in milder play and and establishment of the marital relationship. forming individual friendships. These activities can lead to stereo- Rape can slow or stop normal sexual relationships during the typing and exaggeration of gender difference. adult years. Fear can become the greater part of life for the victim. Going to school allows children to begin to be more independent These years are ones for forming lasting relationships with the op- and form peer groups of the same sex. Although the peer group posite sex, marrying, and beginning families. Rape can cause with- becomes very important to them, they need adult direction in learn- drawal from any interaction with the opposite sex; relationships can ing socially acceptable forms of sexual behavior and when they break up, not only because of the reaction of the victim of rape, but may engage in them. If they do not receive the information they are also because of the reactions of the family and spouse of the victim. seeking, negative feelings and apprehension about sexuality may develop.1 ADULT Great trauma can occur when rape occurs during these years. It is very damaging to the value systems that are being formed. Sex- Demands placed on adults by their careers and raising children may ual identity can be disturbed, and sexual confusion can occur. interfere with their sexual interest and activity.1 The major task of this period of life is to accent one’s own lifestyle and decisions ADOLESCENT rather than feeling frustrated and disappointed. “Social pressures and expectations, feedback from significant others and finally self- Puberty, “the period of maturation of the reproductive system,”4 perception all influence how one evaluates the success of one’s causes profound changes in the individual’s sexual anatomy and life.”1 physiology and is a major developmental crisis for the adolescent. Although the adult is at the peak of his or her career or profes- Secondary sex characteristics appear—breasts, pubic hair, and sion, physiologic changes begin to influence the adult’s lifestyle. menstruation in girls; testicular enlargement, penile enlargement, The aging process, illnesses, and menopause (male and female) pubic hair, ejaculation, and growth of muscle mass in boys. The cause changes in lifestyles and everyday activities. Sexual activities configuration, contour, and function of the body changes rapidly can undergo changes because of these physical and physiologic and dramatically point out sexual differences and the onset of changes; however, the adult who lives a healthy lifestyle, has good adulthood. These changes bring new feelings that create role con- nutrition, exercises, and has an optimistic outlook usually feels fusion and increase awareness of sexual feelings. “The major task of good and functions well sexually. Often middle-age adults, just as adolescence is the establishment of identity in the fact of role con- they have finished raising their children, are faced with the task of fusion.”1 caring for their elderly parents. Peer groups have an important influence on the young adoles- cent (12 to 15 years), but during late adolescence (16 to 19 years) OLDER ADULT the peer group influence lessens and more intimate relationships with the opposite sex develop.7 These relationships can involve a As in adolescence, dramatic body changes begin in late adulthood wide range of sexual behavior from exploring behavior to inter- and continue into old age. There is no reason that healthy men and course, sometimes with the result of teenage pregnancy. Exploring women cannot continue to enjoy their sexuality into old age. behavior can be either with the opposite sex (foreplay and inter- Women must deal with menopause and postmenopause and men course), the same sex (homosexuality), or self (masturbation). How must often deal with impotence; however, with an interested sex- the teenager views himself or herself sexually will depend on the re- ual partner, good healthy sexuality can continue. assurance and guidance he or she receives from a significant adult Older women are viewed by rapists as easy victims. Slowing of in his or her life. The greatest misunderstandings of teenagers in- physical reactions and disabilities of old age (impaired seeing or volve homosexuality, masturbation, and conception and contra- hearing or slow gait) keep them from being alert to danger and from ception. How these subjects are approached, taught, and supported reacting quickly. More important, the older woman often views can influence their adult sexuality.1,7 herself as inferior, and this contributes to her own victimization.9 It is during adolescence, when new experiences of sexual matu- Because most women outlive men and face changes in lifestyles and rity begin, that questions about maleness or femaleness are asked economic status, they are reluctant, and often cannot afford, to by the individual and concerns arise about “who one is within the leave familiar older parts of cities that often change and deteriorate. peer group.”1 Adolescents must evaluate their masculinity and fem- This may expose them to the accompanying increase in crime rate.9 Copyright © 2002 F.A. Davis Company 614 SEXUALITY-REPRODUCTIVE PATTERN 32. Shock APPLICABLE NURSING DIAGNOSES 33. Fear B. Rape-Trauma Syndrome: Compound Reaction 1. Change in lifestyle, for example, changes in residence, dealing Rape-Trauma Syndrome: Compound with repetitive nightmares and phobias, seeking family sup- Reaction and Silent Reaction port, or seeking social network support in long-term phase 2. Emotional reaction, for example, anger, embarrassment, DEFINITIONS10 fear of physical violence and death, humiliation, revenge, or self-blame in acute phase Rape-Trauma Syndrome Sustained maladaptive response to a 3. Multiple physical symptoms, for example, gastrointestinal forced, violent sexual penetration against the victim’s will and consent. irritability, genitourinary discomfort, muscle tension, or Rape-Trauma Syndrome: Compound Reaction Forced, violent sleep pattern disturbance in acute phase sexual penetration against the victim’s will and consent. The trauma 4. Reactivated symptoms of previous conditions, that is, phys- syndrome that develops from this attack or attempted attack in- ical illness or psychiatric illness in acute phase cludes an acute phase of disorganization of the victim’s lifestyle and 5. Reliance on alcohol and/or drugs (acute phase) a long-term process of reorganization of lifestyle. C. Rape-Trauma Syndrome: Silent Reaction 1. Increased anxiety during interview, that is, blocking of as- Rape-Trauma Syndrome: Silent Reaction Forced, violent sexual sociations, long periods of silence, minor stuttering, or penetration against the victim’s will and consent. The trauma syn- physical distress drome that develops from this attack or attempted attack includes 2. Sudden onset of phobic reactions an acute phase of disorganization of the victim’s lifestyle and a long- 3. No verbalization of the occurrence of rape term process of reorganization of lifestyle. 4. Abrupt changes in relationships with men 5. Increase in nightmares NANDA TAXONOMY: DOMAIN 9—COPING/STRESS 6. Pronounced changes in sexual behavior TOLERANCE; CLASS 1—POST-TRAUMA RESPONSES RELATED FACTORS10 NIC: DOMAIN 4—SAFETY; CLASS U—CRISIS MANAGEMENT A. Rape-Trauma Syndrome 1. Rape NOC: DOMAIN VI—FAMILY HEALTH; CLASS Z— B. Rape-Trauma Syndrome: Compound Reaction FAMILY MEMBER HEALTH STATUS To be developed. C. Rape-Trauma Syndrome: Silent Reaction DEFINING CHARACTERISTICS10 To be developed. A. Rape-Trauma Syndrome RELATED CLINICAL CONCERNS 1. Disorganization 2. Change in relationships Not applicable. 3. Physical trauma, for example, bruising and tissue irritation 4. Suicide attempts 5. Denial 6. Guilt 7. Paranoia HAVE YOU SELECTED 8. Humiliation THE CORRECT DIAGNOSIS? 9. Embarrassment 10. Aggression Sexual Dysfunction Rape can be the cause 11. Muscle tension and/or spasms of Sexual Dysfunction in a patient who 12. Mood swings cannot learn to put into perspective or deal 13. Dependence with the rape experience. Rape-Trauma is 14. Powerlessness always the result of a violent act and must be 15. Nightmares and sleep disturbance dealt with according to the individual 16. Sexual dysfunction situation. Although Sexual Dysfunction can 17. Revenge occur as the result of rape, the nurse must 18. Phobias assist the patient to deal with the trauma of 19. Loss of self-esteem the rape in order to assist with the sexual 20. Inability to make decisions dysfunction. 21. Dissociative disorders 22. Self-blame 23. Hyperalertness EXPECTED OUTCOME 24. Vulnerability 25. Substance abuse Will verbalize [number] positive self-statements related to personal 26. Depression response to the incident by [date]. 27. Helplessness 28. Anger TARGET DATES 29. Anxiety 30. Agitation Because of the varied physical and emotional impact of rape, a tar- 31. Shame get date of 3 days would not be too soon to evaluate for progress. Copyright © 2002 F.A. Davis Company RAPE-TRAUMA SYNDROME: COMPOUND REACTION AND SILENT REACTION 615 NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Explore your own feelings about rape before initiating patient The nurse’s feelings can be sensed by the survivor and can care. Maintain nonjudgmental attitude. Actively listen when the influence the survivor’s coping and sense of self. survivor wants to talk about the event. Encourage verbalization of thoughts, feelings, and perceptions of the event. Explore basis for and reality of thoughts, feelings, and perceptions. • Attend to physical and health priorities such as lacerations or Prompt attention to physical needs provides comfort and facilitates infection with appropriate explanations and preparation. a trusting relationship. • Promote trusting, therapeutic relationship by spending at least Promotes expression of feelings and validates reality. 30 min every 4 h (while awake) at [times] with the survivor. • Use calm, consistent approach when interacting with the survivor. Assists in reducing anxiety. Respect the survivor’s rights. • Be supportive of the survivor’s values and beliefs. The survivor’s sexuality is intimately linked to his or her value-belief system. • Explain need for medicolegal procedures, procedures to assess Enlists the survivor’s cooperation, and prepares her for events in for sexually transmitted diseases, prophylactic medications, and case charges are filed against the alleged rapist. medications to avoid postcoital contraception before performing procedures. Refer to Women’s Health nursing actions for specifics about procedures. • Provide for appropriate privacy and health teaching as care is Avoids perpetuating the survivor’s fear as a result of necessity of administered. Allow the survivor to see own anatomy if this examination and treatment in the same body area involved in the seems appropriate as part of health teaching. rape. Could promote a sensation of rape recurrence. • Assist the survivor in activities of daily living (ADLs) after Promotes a slight sense of return to normalcy. Emotional shock examination. may render the survivor temporarily unable to perform basic ADLs. • Determine to what degree or extent symptoms of physical Basic database needed to plan for long-term effects of rape. reactions exist, such as: � Pain or body soreness � Disturbances in sleep � Altered eating patterns � Anger � Self-blame � Mood swings � Feelings of helplessness • Administer medications as ordered to alleviate pain, anxiety, or Allows time for the survivor to process event in a way that inability to sleep, and teach the survivor how to safely take such maintains self-integrity and self-esteem. medications. • When interacting with the survivor, recognize that she will proceed at her own rate in resolving rape trauma. Do not rush or force the survivor. • Identify available support systems, e.g., rape crisis center, and Support systems that know signs and symptoms of rape-trauma involve the significant other as appropriate. syndrome can provide help for both short-term and long-term interventions. Promotes effective coping for the survivor. • Monitor coping in the survivor and significant other until Monitors for adaptive and maladaptive coping strategies. Provides discharged from hospital. opportunity to assist the survivor and significant other to practice alternative coping strategies. • Assist the survivor to identify own strengths in dealing with Helps build the survivor’s self-esteem and overcome self-blame. the rape. • Provide anticipatory guidance about the long-term effects of Helps prepare for expected and unexpected reactions in self, rape. Promote self-confidence and self-esteem through positive friends, and significant others. feedback regarding strengths, plans, and reality. • Provide for appropriate epidemiologic follow-up in cases of Required by law. venereal disease. • Collaborate with other health care professionals as needed. Promotes holistic approach and more complete plan of care. • Arrange for appropriate long-term follow-up before dismissal Provides for long-term support. from hospital, e.g., counseling. (continued) Copyright © 2002 F.A.

Davis Company 616 SEXUALITY-REPRODUCTIVE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES MALE RAPE VICTIM • Provide same considerations as with a female survivor. (Usually The act of rape is an act of violence regardless of the gender of the these are the result of homosexual relationships. Most reported patient and requires the same type care and concern. cases are children and early adolescents). • Refer the patient to trained male counselor (rape crisis center). Child Health ACTIONS/INTERVENTIONS RATIONALES • Encourage collaboration among health professionals to best Specialist will be required to deal with the unique needs of the address the patient’s needs. young child enduring rape. The likelihood exists for incest or a closely related individual’s being identified as the one who committed the act. • Try to establish trust as dictated by age and circumstances related to rape trauma (with nurse being same sex as the patient). Do not leave the child alone. Be gentle and patient. � Infants and Toddlers: Ensure continuity of caregivers. Explain procedures with dolls and puppets. � Preschoolers: Ensure continuity of caregivers. Allow the patient to perform self-care behavior as ability allows. Use art and methods that deal with general view of what happened, singling out the child as not being the “cause” of this incident. � School-agers: Maintain continuity of caregivers. Assist the patient to express concerns related to incident. Use appropriate techniques in interviewing to determine extent of sexual dysfunction or potential threat to future functioning. � Adolescents: Maintain continuity of caregivers. Encourage the patient to express how this experience affects own self-identity and future sexual activities. Encourage psychiatric assistance in resolving this crisis for any patients of this age group. Look for signs of growth of secondary sex characteristics. • Follow up with appropriate documentation and coordination of Appropriate protocols for documentation and reporting of rape or child protective service needs. Assist the parents or guardians in incest must be followed according to state and federal guidelines. signing proper release forms. Determine whether situation involves incest. • Assist the patient to deal with residual feelings such as guilt for Resolution of unresolved guilt or feelings about the event must be revealing or identifying assailant (in young children this often dealt with as soon as the client’s condition permits. must be dealt with within the family or extended-family situations) by allowing at least 30 min per shift (while awake) at [times]. Use simple language when dealing with the child. • Encourage the family members to assist in care and follow-up Risk behaviors serve as cues to alert the family or caregiver to of the patient’s reorganization plans: monitor the child’s progress in resolving the crisis. � Be alert for signs of distress such as refusing to go to school, dreams, nightmares, or verbalized concerns. � Identify ways to gradually resume normal daily schedule. � Assist the family to identify how best to resolve and express feelings about the incident. • Carry out appropriate health teaching regarding normal sexual Normalcy is afforded as attempts are realistically made to resolve physiology and functioning according to age and developmental any aspects of rape trauma. capacity. INCEST • Monitor for inappropriate sexual behavior among family Provides database needed to accurately assess for incest. members. • Monitor for children who know more about the actual mechanics of sexual intercourse than their developmental age indicates they would. • Monitor for girls who seem to have taken over the mother’s role in the home. • Monitor for mothers who have withdrawn from the home, either emotionally or physically. Copyright © 2002 F.A. Davis Company RAPE-TRAUMA SYNDROME: COMPOUND REACTION AND SILENT REACTION 617 Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Assist the survivor through the procedures for provision of Provides database necessary for intervention. Secures necessary health care treatment. Explain each phase of chain-of-evidence procedure, and assists in reducing anxiety for examination to the survivor. Remain with the survivor at all the client. times. • Obtain history: � List of previous venereal diseases � List of previous pelvic infections � Any injuries that were present before attack � Obstetric and menstrual history • Assist in gathering information to provide proper health and legal care. • Secure the survivor’s description of any objects used in the attack and how these objects were used in the attack. • Maintain sequencing and collection of evidence (chain of evidence): � Label each specimen with: (1) Survivor’s name and hospital number (2) Date and time of collection (3) Area from which specimen was collected (4) Collector’s name � Ensure proper storage and packaging of specimens: (1) Clothing and items that are wet, e.g., with blood or Plastic bags will cause molding of wet items. semen, should be put in paper bags, not plastic. (2) Specimens obtained on microscopic slides or swabs need to be air dried before packaging. � Comb pubic hair for traces of attacker’s pubic hair or other evidence: (1) Submit paper towel placed under the victim to catch combings, as well as the comb used, along with pubic hair. (2) Pluck (do not cut) 2–3 pubic hairs from the patient, and label properly. These are used for comparison. � When custody of evidence is transferred to police, be certain written evidence of transfer is properly recorded: (1) Signatures of individuals involved in transfer (2) Name of person to whom the evidence is being transferred (3) Date and time � Take photographs of injuries or torn clothing. � Have the survivor sign forms for release of information to authorities. � Provide medical treatment and follow-up for: (1) Injuries (2) Sexually transmitted disease: AIDS, gonorrhea, or syphilis (3) Pregnancy • Report to proper authorities any suspicion of family violence. Initiates long-range support for the patient. • Evaluate for increased rate of changing residences, repeated Provides database that allows accurate interpretation of long-range nightmares, and sleep pattern disturbance. impact. Provides information needed to plan long-term care. • Encourage the patient to discuss phobias, frustrations, and fears. • Be available and allow the patient to express difficulties in Provides long-term essential support. establishing normal ADLs and redescribe attack as needed. • Assist the patient in developing a plan of reorganization of ADLs. Promotes realistic planning for problem while avoiding continued denial of problem. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Assign a primary care nurse to the client. This nurse should be Promotes the development of a trusting relationship. of the sex the client demonstrates most comfort with at the current time. (continued) Copyright © 2002 F.A. Davis Company 618 SEXUALITY-REPRODUCTIVE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Primary care nurse will remain with the client during the Promotes the development of a trusting relationship. orientation to the unit. • Limit visitors, as the client feels necessary. Promotes the client’s sense of control, while meeting security needs. • Answer the client’s questions openly and honestly. Promotes the development of a trusting relationship. • Primary care nurse will be present to provide support for the Promotes the development of a trusting relationship, while meeting client during medical or legal examinations if the client has not the client’s security needs. identified another person. • Assist the client in identifying a support person, and arrange for Promotes the client’s sense of control, while meeting security needs. this person to remain with the client as much as necessary. Note the name of this person here. • Provide information to the client’s support system as the client Support system understanding enhances their ability to support indicates is needed. the client in a constructive manner. • Allow the client to talk about the incident as much as is desired. Facilitates the confrontation of the memories of the event and Sit with client during these times, and encourage expression of attachment of meaning to the situation, which will promote a feelings. sense of control.11 • Communicate to the client that his or her response is normal. Normalization of the client’s feelings without diminishing his or This could include expressions of anger, fear, and discomfort her experience enhances self-esteem and helps him or her move with persons of the opposite sex, discomfort with sexuality, or from a position of victim to that of a survivor.12 personal blame. • Inform the client that rape is a physical assault rather than a Promotes the client’s resolution of guilt and feelings of sexual act and that rapists choose victims without regard for age, responsibility. physical appearance, or manner of dress. • Assist the client in developing a plan to return to ADLs. The plan Promotes the client’s sense of control, and inhibits the tendency should begin with steps that are easily accomplished so that the toward social isolation.12 client can regain a sense of personal control and power. Note the steps of the plan here. • Provide positive social rewards for the client’s accomplishment Positive reinforcement encourages behavior while enhancing of established goals. Note here the kinds of behavior that are to self-esteem. be rewarded and the rewards to be used. • Provide the client with opportunities to express anger at the Assists the client in moving from the powerless position of victim assailant in a constructive manner, e.g., talking about fantasies to a position of survivor. of revenge, use of punching bag or pillow, or physical activity. • When the client can interact with small groups, arrange for the Provides the client opportunities to resolve his or her feelings of client’s involvement in a therapeutic group that provides being different, while decreasing social isolation. Promotes interaction with peers. Note time of group meetings here. consensual validation of experience with others from similar situations, which enhances self-esteem and emotional resources available for coping.12 • Involve the client in unit activities. Assign the client activities Prevents social isolation. Accomplished tasks enhance self-esteem that can be easily accomplished. Note the client’s level of with positive reinforcement. Also provides opportunities to reality functioning here along with those tasks that are to be assigned test self-perceptions against those of peers on the unit. to the client. • Primary nurse will spend [number] minutes with the client Promotes reality testing of feelings related to the rape, and inhibits twice a day at [times] to focus on expression of feelings related the development of self-blame and guilt, which often occur in to the rape. Encourage the client not to close these feelings off survivors. too quickly. Assist the client in reducing stress in other life situations while healing emotionally from the rape experience. Begin to facilitate the client’s use of cognitive coping resources by logically assessing various aspects of the situation. • Assist the client in developing a plan to reduce life stressors so Promotes the client’s sense of control, and provides a positive emotional healing can continue. Note this plan here, with the orientation. support needed from the nursing staff in implementing this plan. • Primary nurse will meet with the client and primary support Support system understanding and acceptance facilitate the client’s person once per day to facilitate their discussion of the rape. If coping and the maintenance of these relationships. the client is involved in an ongoing relationship, such as a marriage, this interaction is very important. The support person should be encouraged to express his or her thoughts and feelings in a constructive manner. If it is assessed that the rape has resulted in potential long-term relationship difficulties such as rejection or sexual problems, refer to couple therapy. • Refer the client to appropriate community support groups, and Promotes the client’s reintegration into the community, and assist him or her with contacting these before discharge. inhibits the isolating behavior often exhibited by these clients.12 Copyright © 2002 F.A. Davis Company RAPE-TRAUMA SYNDROME: COMPOUND REACTION AND SILENT REACTION 619 Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • In the event of the rape being secondary to elder abuse, refer Provides a resource for the older adult to explore options and the patient to adult protective services. prevent recurrence of problem. Home Health ACTIONS/INTERVENTIONS RATIONALES • During the acute phase, be sure that appropriate assessment, Early and accurate intervention decreases sequelae and provides law enforcement involvement, and treatment of physical injuries documentation for any legal action. or sexually transmitted diseases are provided. • Assist the client and family in lifestyle changes that may be Provides support and enhances recovery. needed: � Treatment for physical injuries or sexually transmitted disease � Testimony

in court � Protection � Coping with terror, nightmares, or fear � Coping with alterations in sexual response to significant others � Development and use of support networks � Stress management � Changing telephone number or moving � Traveling with companion � Strategies for prevention of rape • Assist the client and family in planning and implementing Crimes of violence upset the family equilibrium and require strategies for resolution of Rape-Trauma Syndrome: support to correct. � Communication, e.g., discussion of feelings among family members � Mutual sharing and trust Involvement of the client and significant others is important to � Problem solving, e.g., providing support for the family ensure successful resolution. members and client; strategies to reduce possibility of future attacks • Consult with or refer the patient to assistive resources as Use of existing resources and expertise provides high-quality care appropriate. and is effective use of already available resources. Copyright © 2002 F.A. Davis Company 620 SEXUALITY-REPRODUCTIVE PATTERN Rape-Trauma Syndrome: Compound Reaction and Silent Reaction FLOWCHART EVALUATION: EXPECTED OUTCOME Interview the patient. Explore feelings, perceptions, and so on. Did the patient make X number of positive statements? Yes No Record data, e.g., states, “feeling much Reassess using initial assessment factors. better; no longer think I asked for it”; made 5 positive statements. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., is still having nightmares; stated, “maybe I Did evaluation show another didn’t bring it on myself” but no problem had arisen? Yes other positive self statements. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company SEXUAL DYSFUNCTION 621 Sexual Dysfunction RELATED FACTORS10 DEFINITION10 1. Misinformation or lack of knowledge 2. Vulnerability Change in sexual function that is viewed as unsatisfying, unreward- 3. Values conflict ing, or inadequate. 4. Psychosocial abuse, for example, harmful relationships 5. Physical abuse NANDA TAXONOMY: DOMAIN 8—SEXUALITY; 6. Lack of privacy CLASS 2—SEXUAL FUNCTION 7. Ineffectual or absent role models 8. Altered body structure or function (pregnancy, recent child- NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING birth, drugs, surgery, anomalies, disease process, trauma, or ASSISTANCE radiation) NOC: DOMAIN I—FUNCTIONAL HEALTH; 9. Lack of significant others CLASS B—GROWTH AND DEVELOPMENT 10. Biopsychosocial alteration of sexuality DEFINING CHARACTERISTICS10 RELATED CLINICAL CONCERNS 1. Change of interest in self and others 1. Endocrine, urologic, neuromuscular, and skeletal disorders 2. Conflicts involving values 2. Genital trauma 3. Inability to achieve desired satisfaction 3. Agoraphobia 4. Verbalization of problem 4. Pelvic surgery 5. Alteration in relationship with significant other 5. Malignancies of the reproductive tract 6. Alteration in achieving sexual satisfaction 6. Female circumcision13 7. Actual or perceived limitation imposed by disease and/or therapy 7. Psychiatric disorders such as mania, major depression, dementia, 8. Seeking confirmation of desirability borderline personality disorder, substance abuse or use, anxiety 9. Alterations in achieving perceived sex role disorder, and schizophrenia HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Ineffective Sexuality Patterns In this diagnosis, the Rape-Trauma Syndrome This diagnosis could result individual is expressing concern about his or her in Sexual Dysfunction because of the patient’s sexuality. This diagnosis could be a result of inability to deal with the violence, trauma, and Sexual Dysfunction, but it is not necessarily a lifestyle changes as a result of rape. It is absolutely problem to the patient. Ineffective Sexuality essential for the nurse to ascertain the cause of the Patterns can be compatible with the patient’s Sexual Dysfunction and to determine whether it is lifestyle for whatever reason and create no the result of the patient’s perception of sexuality in overwhelming problems for the patient. general, pathophysiology, or trauma. EXPECTED OUTCOME TARGET DATES Will report return, as near as possible, to previous levels of sexual Depending on the patient’s perception of the sexual dysfunction, functioning by [date]. target dates may range from 1 week to several months. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Facilitate communication between the patient and partner by Promotes identification of issues involved in sexual dysfunction. providing at least [number] minutes per day for privacy to communicate. • Encourage the patient and partner to talk about concerns and Sexual behavior includes verbal, nonverbal, genital, and nongenital problems during conference. activities. • Talk with the patient and partner about alternative ways to attain sexual satisfaction and express sexuality, e.g., hugging, touching, kissing, masturbation, hand holding, or sexual aids. Provide factual informational material. (continued) Copyright © 2002 F.A. Davis Company 622 SEXUALITY-REPRODUCTIVE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Clarify misconceptions as needed—e.g., sexual activity after a Misinformation and myths contribute to sexual dysfunction. heart attack, older people don’t engage in sexual activity, or hysterectomy decreases sexual drive. • Be nonjudgmental in your attitudes. Sexuality is a highly personal experience. Nonjudgmental attitudes reduce anxiety and open the way for therapeutic communication. • Respect the patient’s values and attitudes about sexuality and Sexual behavior is intimately linked to the value-belief system. sexual functioning. Demeaning these values and beliefs will cause anxiety in the patient. • Provide accurate information on effects of medical diagnosis or Clarifies misconceptions. Provide information on changes or treatment on sexual functioning. modifications in sexual activities that may need to occur as a result of disease process. • Implement measures to improve self-concept, e.g., positive How one feels about self is important in self-perception of self-talk, assertiveness, new hairdo, new clothes, or new social sexuality. surroundings. • Provide privacy for expressing sexuality, e.g., masturbation, Sexuality expression may be inhibited by hospitalization, but need sexual intercourse, particularly when the patient has been exists. hospitalized for a significant length of time or has been separated from significant other for a significant length of time. • Teach the patient importance of adequate rest before and after Sexual activity increases basal metabolic rate and initiates the sexual activity. sympathetic nervous system, creating a high level of stress. • If dyspareunia is a problem, teach the patient and significant Increases comfort and reduces trauma. Eases dryness and avoids other to: irritation. � Use adequate amounts of water-soluble lubricant. � Use vaginal steroid cream. � Take sitz baths. • If impotence is a problem, advise the patient to: Discover underlying causes of impotence. Provides an alternative � Consult with a physician regarding a complete physical method of penile erection to find satisfaction in intercourse. examination. � Consult with sex therapist. � Consider penile prosthesis. Child Health This diagnosis is not appropriate for a child. Women’s Health NOTE: Very little information is found in the literature on Sexual Dysfunction of lesbian women, as they often conceal their sexual orientation when they receive health care and some choose not to receive health care if there is a danger of exposure.14 The following actions refer to those who have a hetero- sexual relationship. ACTIONS/INTERVENTIONS RATIONALES • Obtain detailed sexual history. Provides database needed to plan accurate intervention. • Determine who the patient is: � Female � Male � Couple or partners • Review communication skills between partners • Ascertain the couple’s knowledge of: � Sexual performance � Female and male anatomy and physiology � Female and male orgasm � Anticipatory performance anxiety � Unrealistic romantic ideas � Rigid religious conformity � Negative conditioning in formative years � Erection and ejaculation � Stimulation � Arousal � Sexual anxiety � Fear of failure (continued) Copyright © 2002 F.A. Davis Company SEXUAL DYSFUNCTION 623 (continued) ACTIONS/INTERVENTIONS RATIONALES � Demand for performance � Fear of rejection • Dispel sexual myths and fallacies or misinformation about Provides basic information and support that can assist the patient sexuality by: in long-term care. � Allowing the patient to talk about beliefs and practices in a nonthreatening atmosphere � Providing correct information � Answering questions in an honest manner � Referring to the appropriate agencies or health care providers • Obtain description of current problem: Provides essential database to permit narrowing of focus for � Psychological intervention. � Physical � Social • Determine type of sexual dysfunction: � General � Lack of erotic feeling � Lack of sexual responses � No pleasure in sexual act � Consider it an ordeal � Avoidance � Frustration � Disappointment � Fear � Disgust � Orgasmic difficulties • If the client is sexually responsive but cannot complete sexual response cycle, determine whether this is: � Situational: Client is inhibited, disappointed, or disinterested. � Physiologic: Interruption results from lack of lubrication, impotence, or interference with sexual response cycle. � Psychological: Ambivalence, guilt, or fear is present. • If vaginismus (tight closing of vaginal muscle with any attempt at penetration) is present, determine whether this results from: � Fear of vaginal penetration � Spasm of vaginal muscles � Frustration � Fear of inadequacy � Guilt � Pain � Prior sexual trauma � Strict religious code � Rape � Dyspareunia • Discuss consequences of sexual acts and situations in an honest Initiates intervention in a supportive environment. and nonthreatening manner. • Collaborate with appropriate therapists. Provides the long-term care and support that is needed to resolve the basic problem. Psychiatric Health NOTE: If sexual dysfunction is related to physiologic limitations, loss of body part, or impotence, re- fer to Adult Health care plan. If dysfunction is related to ineffective coping or poor social skills, initi- ate the following actions. ACTIONS/INTERVENTIONS RATIONALES • Set limits on the inappropriate expression of sexual needs. Note Promotes the client’s sense of control, while maintaining the safety the kinds of behavior to be limited and the consequences for of the milieu. inappropriate behavior here—e.g., when the client approaches staff member with sexually provocative remarks, the staff member will use constructive confrontation and discontinue the interaction.15 Inform the client of these limits. (continued) Copyright © 2002 F.A. Davis Company 624 SEXUALITY-REPRODUCTIVE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Assign primary care nurse to the client on each shift. The Promotes the development of a trusting relationship. primary care nurse will spend 15 min with the client twice per shift at [times] to develop a relationship and then begin to explore with the client the effects this behavior has on others and the needs that are being met by the behavior. • Assist the client in identifying environmental stimuli that provoke sexual behavior and in developing alternative responses to these stimuli in inappropriate situations. • Develop with the client a list of alternative kinds of behavior to Promotes the client’s sense of control. meet the need currently being met by the sexual behavior. Note alternative behavior patterns here with plan for implementing them. • Provide the client with information about appropriate sexual Facilitates the development of appropriate coping behaviors. behavior—e.g., what are “normal” sexual expressions, what are appropriate ways to meet sexual needs (intercourse with appropriate person or masturbation at suitable time in an appropriate place). • Role-play with the client those social situations that have been Behavioral rehearsal provides opportunities for feedback and identified as problematic. These could include setting limits on modeling of new behaviors by the nurse. other’s inappropriate behavior toward the client or situations in which the client needs to practice appropriate social responses. • Assist the client in appropriate labeling of feelings and needs— Promotes the client’s sense of control, and facilitates the e.g., anxiety may be inappropriately labeled as “sexual tension.” development of adaptive coping behaviors. • Plan a private time and place for the client. Inform the client that this can be used for appropriate sexual expression. Note this plan here. • If the client begins inappropriate sexual behavior while involved Social isolation inhibits inappropriate behavior by removing social in group activities, remove the client from group to a private rewards. place and explain to the client purpose of this. Inform the client that he or she may return to the group when (the limit set by the care team will be noted here). • If sexual behavior results from anxiety, refer to Anxiety (Chap. 8) for detailed care plan. • Assign the client tasks in unit activities that are appropriate for Promotes the development of adaptive interpersonal skills in an the client’s level of comfort with group interaction—e.g., if the environment that provides supportive feedback from peers. client is uncomfortable with persons of opposite sex, assign

a task that requires involvement with a same-sex group or involvement with an opposite-sex staff member who can begin a relationship. • Recognize and support the client’s feelings—e.g., “You sound Promotes the development of a trusting relationship. Models for confused.” the client appropriate expressions of feelings in a supportive environment. Helps the client learn to talk about feelings rather than act on them. • Engage the client in a socialization group once a day at [time]. Decreases social isolation, and provides the client with an This should provide the client with an opportunity to interact opportunity to practice interpersonal skills in a supportive with peers in an environment that provides feedback to the environment. client in a supportive manner. • Arrange a consultation with occupational therapist to assist the Increases the client’s interpersonal competence, and enhances client in developing needed social skills—e.g., cooking skills or self-esteem. skills at games that require socialization. • Provide an environment that does not stimulate inappropriate Promotes an environment that increases the opportunities for the sexual behavior—e.g., staff member indirectly encourages the client to succeed with new behaviors. This success serves as client’s behavior with dress or verbal comments, or other clients reinforcement that encourages positive behavior and enhances interact with the client in a sexual manner. self-esteem. • Sit with the client [number] minutes once a shift at [time] to Nurses’ interactions can provide social reinforcement for the discuss non-sexual-related information. client’s appropriate interactions. Provides opportunity for the client to practice new behaviors in a supportive environment. Success in this situation provides reinforcement that encourages positive behavior and enhances self-esteem. • Provide positive social rewards for appropriate behavior (the Reinforcement encourages positive behavior and enhances rewards as well as the kinds of behavior to be rewarded should self-esteem. be noted here). (continued) Copyright © 2002 F.A. Davis Company SEXUAL DYSFUNCTION 625 (continued) ACTIONS/INTERVENTIONS RATIONALES • Evaluate the effects of the client’s current medication on sexual Basic monitoring of medication efficiency. behavior, and consult with physician as needed for necessary alterations. • Develop a structured daily activity schedule for the client, and Assists the client in focusing away from issues of sexuality and provide the client with this information. engage in socially appropriate activity. • Schedule time for the client to engage in physical activity. This Physical activity decreases anxiety and increases the production of activity should be developed with the client’s assistance and endorphins, which increase the client’s feelings of well-being.16 could include walking, jogging, basketball, cycling, dancing, Provides opportunities for the client to learn alternative ways of “soft” aerobics, etc. A staff member should participate with the coping with anxiety in a supportive environment. client in these activities to provide positive social reinforcement. Note schedule and type of activity here. • If the client’s concerns are related to his or her relationship with his or her significant other, initiate the following actions: � Assess role current medications and nonprescription drug Medications and nonprescription drugs can have a negative use may have on sexual functioning. Note here the person impact on sexual functioning. These can include antidepressants, responsible for this assessment. If the medications could have antihypertensives, and alcohol.17 a negative impact on sexual functioning, assist the client in discussing a medication change with primary care provider— e.g., an antidepressant with fewer sexual side effects, such as bupropion, could be prescribed. � Explore with the client and his or her significant other their Poor understanding of the normal sexual response cycle can have understanding of normal sexual functioning. Provide a negative impact on sexual functioning.18,19 information as appropriate. This could include referring clients to appropriate references. Note here information and follow-up needed. � Provide the client system with opportunities to discuss Assists clients with developing skills to communicate about their concerns while modeling communication skills. Note here the sexual relationship. person responsible for this interaction. � If providing basic information does not resolve client Sex therapy requires advanced preparation. concerns, arrange a referral to a health care provider with expertise in addressing issues related to sexual functioning. Note here the name of referral source and appointment time. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for use of medications that may induce sexual dysfunction. Identifies correctable source of impotency. Male impotency may be related to antihypertensive medications. • Determine the individual patient’s knowledge of facts and myths Knowledge of expected aging changes may encourage the individual regarding sexual changes in aging. to discuss changes experienced and seek treatment for dysfunction. • Identify resources for assistance with sexual dysfunction, such Provides an information source and support for individuals with a as Impotents Anonymous groups.20 common problem. Impotence, regardless of etiology, shows marked increase beyond age 65. • Provide resources for patients with chronic illnesses, such as chronic obstructive pulmonary disease (COPD) or arthritis, that address and assist in problem solving regarding disease-related sexual difficulties.21 • Provide uninterrupted time for couples, particularly in Assists patients in maintaining sexuality as long as possible. long-term-care settings, where it may be difficult to maintain or attain privacy. Home Health ACTIONS/INTERVENTIONS RATIONALES • Involve the client and significant other in planning and Sexual dysfunction affects and is affected by relationships. implementing strategies for reducing sexual dysfunction and Involvement of significant people in strategies is vital to enhancing sexual relationship: enhance the potential for success. � Communication, e.g., discussion of concerns and ideas for intervention (continued) Copyright © 2002 F.A. Davis Company 626 SEXUALITY-REPRODUCTIVE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Mutual sharing and trust � Problem solving, e.g., identification of specific strategies with roles defined, such as second honeymoon or specific sexual arousal exercises • Assist the patient and significant other with lifestyle adjustments Lifestyle changes require permanent behavior changes. Support that may be required by: and self-evaluation can improve the probability of successful � Providing accurate and appropriate information regarding change. contraception � Teaching stress management � Providing information regarding sexuality and clarifying myths regarding sexuality � Exploring strategies for coping with disabling injury or disease � Using massage � Using touch � Treating substance abuse � Exercising regularly � Coping with changes in role functions and role relationships � Using water-soluble lubricants � Obtaining treatment for physical problems, e.g., vaginal infections or penile discharge � Teaching changes accompanying pregnancy � Teaching side effects of medication • Consult with or refer to assistive resources as indicated. Use of existing resources provides for high-quality care and effective use of services. Copyright © 2002 F.A. Davis Company SEXUAL DYSFUNCTION 627 Sexual Dysfunction FLOWCHART EVALUATION: EXPECTED OUTCOME Interview the patient. Request comparison between sexual functioning 1 yr ago and sexual functioning today. Has functioning returned to extent possible? Yes No Record data, e.g., compares current Reassess using initial assessment factors. sexual functioning favorably with previous sexual functioning; states, “stress management techniques helped both of us.” Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., stated, “Functioning still a long Did evaluation show another way from past functioning”; problem had arisen? Yes sees some improvement— “Not as painful.” Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 628 SEXUALITY-REPRODUCTIVE PATTERN Sexuality Patterns, Ineffective HAVE YOU SELECTED DEFINITION10 THE CORRECT DIAGNOSIS? Expressions of concern regarding own sexuality. Dysfunction Sexual Dysfunction indicates there are problems in sexual functioning. NANDA TAXONOMY: DOMAIN 8—SEXUALITY; Ineffective Sexuality Patterns refers to CLASS 2—SEXUAL FUNCTION concerns about sexuality but does not NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING necessarily mean an overwhelming ASSISTANCE problem. In some instances, this diagnosis may involve a lifestyle different from NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; heterosexual norms. CLASS M—PSYCHOLOGICAL WELL-BEING Rape-Trauma Syndrome Certainly a traumatic event such as a rape could result DEFINING CHARACTERISTICS10 Sexual in an Ineffective Sexuality Patterns. The nurse would focus, however, in assisting the 1. Reported difficulties, limitations, or changes in sexual behaviors patient to deal with the rape trauma first. or activities Resolving this problem would assist in resolving the Ineffective Sexuality Patterns. RELATED FACTORS10 Many of the other nursing diagnoses can 1. Lack of significant others impact sexual feelings and functioning in 2. Conflicts with sexual orientation or variant preferences both men and women. Examples are 3. Fear of pregnancy or of acquiring a sexually transmitted disease Disturbed Body Image, Pain, Chronic Pain, 4. Impaired relationship with a significant other Fear, Anxiety, Dysfunctional Grieving, and 5. Ineffective or absent role models Ineffective Role Performance. 6. Knowledge or skills deficit about alternative responses to health- related transitions, altered body function or structure, illness or medical treatment 7. Lack of privacy EXPECTED OUTCOME Will identify at least [number] factors contributing to ineffective RELATED CLINICAL CONCERNS sexual pattern by [date]. 1. Mastectomy 2. Hysterectomy TARGET DATES 3. Cancer of the reproductive tract Because of the extremely personal nature of sexuality, the patient 4. Any condition resulting in paralysis may be reluctant to express needs or problems in this area. For this 5. Sexually transmitted disease, for example, syphilis, gonorrhea, reason, a target date of 5 to 7 days would be acceptable. or AIDS NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Establish therapeutic and trusting relationship with the patient Promotes therapeutic and open communication. and significant other. • Address other primary nursing needs, especially physiologically Meeting these needs promotes solving of the ineffective sexuality related and self-image related. pattern. • Actively listen to the patient’s and significant other’s efforts Promotes open and therapeutic communications. to talk about fears or changes in body image affecting sexuality or altered sexual preferences. Assist the patient and family to identify how the desired sexual function may be attained. • Help the patient and significant other to understand that Misinformation and myths may create unrealistic expectations sexuality does not necessarily mean intercourse. about sexuality and the sexual experience. • Discuss alternative methods for expressing sexuality, including Sexuality includes verbal, nonverbal, genital, and nongenital sexual masturbation. activities. (continued) Copyright © 2002 F.A. Davis Company SEXUALITY PATTERNS, INEFFECTIVE 629 (continued) ACTIONS/INTERVENTIONS RATIONALES • Do not be judgmental with the patient or significant other. Sexuality is a highly personal behavior. The nurse’s attitude can create guilt feelings and stress in the patient. • Provide privacy and time for the patient and significant other to Allows for sexual expressions. be alone if so desired. • Administer medications as ordered, with monitoring of potential side effects. • Monitor for contributory causative components, and provide Permits a more fully developed and accurate plan of care. Provides appropriate education and follow-up. for long-term support. Child Health ACTIONS/INTERVENTIONS RATIONALES • Encourage the child and family to verbalize perception of altered Provides the database necessary to accurately plan intervention. sexual functioning, e.g., undescended testicle. • Assist the patient and family to identify how the desired sexual Specific plans for goals of sexual function desired will assist in how function may be attained. the client will be treated, e.g., surgeries for future procreation. • Include appropriate collaboration with other health care team Specialist may best meet the unique needs represented with members as needed. ineffective sexual functioning. • Provide attention to developmentally appropriate role modeling Opportunities appropriate for age with role models serve as for age and situation. valuable learning modes. • Encourage peer support during hospitalization as appropriate. Peer support fosters sense of self, which is also a composite of sexuality. • Plan for potential long-term nursing follow-up. The chronic nature of many physiologic components will necessitate serial rechecks and treatment over time as the child grows and matures. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient to describe her sexuality and understanding of Provides database needed to plan for successful interventions. sexual functioning as it relates to her lifestyle and lifestyle decisions. • Allow the patient time to discuss sexuality and sex-related problems in a nonthreatening atmosphere. Obtain a complete sexual history, including current emotional state. • Assist the patient in listing lifestyle adjustments that need to be made—e.g., different methods of achieving sexual satisfaction in the presence of mutilating surgery. • Identify significant others in the patient’s life and involve them, if so desired by the patient, in discussion and problem-solving activities regarding sexual adjustments. • Provide atmosphere that allows the patient to discuss

freely: Assists the patient in planning coping strategies to various life � Partner choice situations, and provides information the patient needs to achieve � Sexual orientation the planning. � Sexual roles • Assist the patient in identifying lifestyle adjustments to each different cycle of reproductive life: � Puberty � Pregnancy � Menopause � Postmenopause • Discuss pregnancy and the changes that will occur during Provides essential information needed by the patient to offset pregnancy and the postpartum period: concerns regarding maintaining sexuality during and after � Sexuality pregnancy. � Mood swings • Discuss aspects of sexuality and intercourse during pregnancy. Answer questions promptly and factually: (continued) Copyright © 2002 F.A. Davis Company 630 SEXUALITY-REPRODUCTIVE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Positions � Frequency � Effects on fetus � Effects on pregnancy � Fears about sexual changes • Discuss postpartum healing process and timing of resumption of intercourse. • Assist the patient facing surgery or body structure changes in identifying lifestyle adjustments that may be needed—e.g., ileostomy, colostomy, mastectomy, or hysterectomy. • Allow the patient to grieve loss of body image. • Reassure the patient that she can still participate in sexual Provides support to the patient who is questioning continuance of activities. sexuality. • Ensure confidentiality for the patient with sexually transmitted Promotes sharing of information necessary to plan care. diseases. • Encourage verbalization of concerns with sexually transmitted Provides the database needed to most accurately plan care. diseases: � Recurrent nature of disease, especially herpes and Chlamydia � Lack of cure for disease (AIDS) � Economics in treating disease � Social stigma associated with disease • Encourage honesty in answers to such questions as: � Multiple sex partners � Describing sexual behavior • Encourage honest communication with sexual partners(s). Sexual partner will require health care. � Discuss impact of male partner’s prostate surgery and possible impotence. � Discuss impact on either partner of medication that may affect libido. � Discuss means of satisfying sexual desires other than intercourse: (1) Cuddling (2) Massaging, stroking, or touching partner (3) Masturbation Psychiatric Health NOTE: If alteration is related to altered body function or structure or illness, refer to Adult Health nursing actions. ACTIONS/INTERVENTIONS RATIONALES • Assign primary care nurse who is comfortable discussing Promotes the development of a trusting relationship. related material with the client. • Primary nurse will spend [number] minutes [number] times a day with the client discussing issues related to diagnosis. These discussions will include: � Client’s use of prescription and nonprescription medications. Prescription and nonprescription medications can have a negative If current medications could have a negative impact on sexual impact on sexual functioning. functioning, assist the client in discussing possible medication changes with primary health care provider. � Client’s current physiologic health Disease states can have a negative impact on sexual functioning. This can include cardiovascular disease and diabetes. � Client’s thoughts and feelings about alteration Expression of feelings and perceptions in a supportive environment � Other stressors and concerns in the client’s life that could facilitates the development of alternative coping behaviors. affect sexual patterns � Client’s perceptions of partner’s responses � Client’s perceptions of self as a sexual person without a partner � Client’s perceptions of social or cultural expectations � Client’s thoughts and feelings about sexuality (continued) Copyright © 2002 F.A. Davis Company SEXUALITY PATTERNS, INEFFECTIVE 631 (continued) ACTIONS/INTERVENTIONS RATIONALES • If alteration is related to lack of information, develop a Provides guide to ensure that the client gets accurate and consistent teaching plan and note teaching plan here. information. • When the client identifies specific difficulties that contribute to Promotes the client’s sense of control, and enhances self-esteem. the concern, develop specific action plan to cope with these and note the plan here. • If alteration is related to problems with the significant other, Provides opportunity for nurse to facilitate communication arrange a meeting with the client and significant other to between the partners and for the partners to communicate their discuss the perceptions each has about the problem. If these relationship needs as well as personal needs in a nonthreatening difficulties are related to a lack of information, develop a environment. teaching plan and note it here. If alteration is related to long-term relationship or if alteration is only one of several problems, refer to marriage and family therapist or clinical nurse specialist. • Arrange private time for the client and partner to discuss Provides recognition and support for this relationship. relationship issues, including sexuality. Note time and place arranged for this discussion here. • During interactions with the client and significant other, have Promotes the development of a positive expectational set. Positive them express feelings about their relationship. These should be feelings enhance self-esteem and enhance personal psychological both positive and negative feelings. resources for coping with the difficult aspects of the relationship. Gerontic Health The nursing actions for the older adult with this diagnosis are the same as for the Adult Health patient. Home Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for factors contributing to Ineffective Sexuality Patterns Provides database for early identification and intervention. by [date]. • Involve appropriate family members—e.g., significant others or Sexual behavior can affect the entire family. Involvement of the parents of child—in planning, implementing, and promoting family in problem identification and intervention enhances the reduction or elimination of Ineffective Sexuality Patterns: probability of successful intervention. � Communication—e.g., discussion of values and sexual mores � Mutual sharing and trust � Problem solving—e.g., identification of strategies acceptable to all involved with the role of each person identified � Sex education—e.g., clarify any misconceptions regarding sexual behavior and sexuality • Assist the client and family with lifestyle adjustments that may Provides knowledge and support necessary for permanent be required: behavioral change. � Providing accurate and appropriate information regarding sexuality and contraception � Providing time and privacy for development and improvement of sexual relationship � Teaching stress management � Coping with loss of sexual partner � Providing accurate and appropriate information regarding sexually transmitted diseases � Providing accurate and appropriate information regarding sexual orientation, e.g., homosexuality, heterosexuality, or transsexuality � Coping with physical disability � Explaining side effects of medical treatment • Consult with assistive resources as indicated. Specialized counseling may be indicated. Use of existing resources provides effective use of resources. Copyright © 2002 F.A. Davis Company 632 SEXUALITY-REPRODUCTIVE PATTERN Sexuality Patterns, Ineffective FLOWCHART EVALUATION: EXPECTED OUTCOME Has patient identified at least X factors contributing to ineffective sexual pattern? Yes No Record data, e.g., has identified fatigue Reassess using initial assessment factors. and stress as major factors; has attended stress management conference; states, “Attention to time management has helped.” Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., states, “It upsets me to think about it so I don’t, Did evaluation show another but then it’s frustrating to have problem had arisen? Yes my problem. It’s just a mess.” Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company CHAPTER 11 Coping–Stress Tolerance Pattern 1. ADJUSTMENT, IMPAIRED 637 5. INDIVIDUAL COPING, 2. COMMUNITY COPING, INEFFECTIVE 661 INEFFECTIVE AND READINESS A. Coping, Defensive FOR ENHANCED 645 B. Denial, Ineffective 3. FAMILY COPING, COMPROMISED 6. POST-TRAUMA SYNDROME, RISK FOR AND DISABLED 650 AND ACTUAL 670 4. FAMILY COPING, READINESS FOR 7. SUICIDE, RISK FOR 676 ENHANCED 657 Pattern Description 3. Does the client deny problems or weaknesses in spite of evidence to the contrary? Stress has been defined as the response of the body or the system a. Yes (Defensive Coping) to any demand made on it.1 This response can be both physiologic b. No and psychosocial. Because demands are synonymous with living, 4. Is the client projecting blame for the current situation on other stress has been defined as “life itself.”1 The system’s (individual, persons or events? family, or community) ability to respond to these demands has an a. Yes (Defensive Coping) effect on the well-being of the system. Stress tolerance pattern refers b. No to the system’s usual manner of responding to stress or to the 5. Did the patient delay seeking health care assistance to the detri - amount of stress previously experienced. This includes the stress ment of his or her health? response history of the individual, family, or community.2 Coping a. Yes (Ineffective Denial) has been defined as “efforts to master condition of harm, threat, or b. No challenge when a routine or automatic response is not readily 6. Does the patient downplay condition? available.”3 Thus, the coping pattern is the system’s pattern of re- a. Yes (Ineffective Denial) sponding to nonroutine threats. The client’s ability to respond to b. No stress is affected by a complex interaction of physical, social, 7. Does the patient verbalize nonacceptance of health status and emotional reactions. Assessment of this pattern focuses on change? gaining an understanding of the interaction of these factors within a. Yes (Impaired Adjustment) the system. Interventions are related to maximizing the system’s b. No well-being.1,3 8. Is the patient moving toward independence? a. Yes Pattern Assessment b. No (Impaired Adjustment) 9. Is the client’s primary caregiver denying the severity of the 1. Does the client verbalize inability to cope? client’s problem? a. Yes (Ineffective Individual Coping) a. Yes (Disabled Family Coping) b. No b. No 2. Does the client demonstrate inability to problem solve? 10. Does the client demonstrate indications of neglect? a. Yes (Ineffective Individual Coping) a. Yes (Disabled Family Coping) b. No b. No 633 Copyright © 2002 F.A. Davis Company 634 COPING-STRESS TOLERANCE PATTERN 11. Does the client state concerns about care being received from systems experience as a part of living. This stress calls on the primary caregiver? self-regulating processes of the system for adaptation. Intrasystem a. Yes (Compromised Family Coping) coping mechanisms are used, and the system does not require as- b. No sistance from outside sources to adapt. Level 2 responds to less- 12. Can the primary caregiver verbalize understanding of care re- routine or new experiences encountered by the system. The system quirements? experiences a mild alarm reaction that is not prolonged. The indi- a. Yes vidual system might experience a mild increase in heart rate, sen- b. No (Compromised Family Coping) sations of bladder fullness and increased frequency of urination, 13. Does the family indicate physical and emotional support for temporary insomnia, tachypnea, anxiety, fear, guilt, shame, or frus- the client? tration. Some outside assistance may be necessary to facilitate adap- a. Yes (Readiness for Enhanced Family Coping) tation. This assistance could be in the form of identifying stressors b. No and strengths or encouraging the individual to solve problems. 14. Does the family or primary caregiver indicate interest in a sup- Level 3 consists of the moderate amount of stress that occurs when port group? a persistent stress is encountered or when a new situation is per- a. Yes (Readiness for Enhanced Family Coping) ceived as threatening. Emergency adaptation processes are acti- b. No vated. The individual would experience tachycardia, palpitations, 15. Does the patient exhibit re-experience of traumatic events tremors, weakness, cool pale skin, headache, oliguria, vomiting, (flashbacks or nightmares)? constipation, and increased susceptibility to infections. This level a. Yes (Post-Trauma Syndrome) of stress usually requires assistance from a professional helper. This b. No assistance can include identifying problems and coping strengths, 16. Does the patient exhibit vagueness about traumatic event? teaching, performing tasks for the client, or altering the environ- a. Yes (Post-Trauma Syndrome) ment to facilitate coping. When the system cannot adapt to a stress- b. No ful situation with assistance, a severe degree of stress is experienced. 17. Is there evidence of positive communication and community This is labeled level 4. This occurs when all coping strategies are ex- participation in planning for predicted community stressors? hausted. Intervention at this level requires the assistance of profes- a. Yes (Readiness for Enhanced Community Coping) sionals who have the skills to assist with the development of unique b. No coping strategies. 18. Is there evidence of community conflict and deficits in com- Because stress is life itself, adaptation to reduce the effects of munity participation? stress on the system is

imperative. To begin this process, it is im- a. Yes (Ineffective Community Coping) portant to understand those factors that can influence the system’s b. No ability to respond to stress. Stress can arise from biophysical, chem- 19. Has the patient threatened to kill himself or herself? ical, psychosocial, and cultural sources. The basic health of the af- a. Yes (Risk for Suicide) fected system improves the ability to respond to these stressors. Re- b. No sponse to the biophysical-chemical stressors can be improved by 20. Has the patient demonstrated marked changes in behavior, at- improving the condition of the biologic system. This would include titude, or school performance? proper nutrition, appropriate amounts of rest, appropriate levels of a. Yes (Risk for Suicide) exercise, and reduced exposure of the system to toxic chemicals.1 b. No The literature1 indicates that a great deal of psychosocial-cultural stress evolves from a philosophy of life that is impossible to fulfill. Conceptual Information This would indicate that a great deal of stress arises from the per- ception of events, not in the events themselves. This is com- To understand coping, one must first understand the concept of pounded by the social and cultural influences on the system. The stress, because coping is the system’s attempt to adapt to stress. An sociocultural influences could include the cultural attitudes about understanding of these concepts and their relationship is crucial for age, body appearance, and family roles and the social approaches the promotion of well-being. Research has clearly demonstrated to assistance for working mothers, advancement in employment that undue stress can be related to major health problems if inap- status, and so on. The system’s beliefs about these social-cultural propriate coping is present.1 stressors can affect the degree to which the stressors affect the Stress has been defined as the body’s nonspecific response to any system. If the stressor is perceived as unnatural or impossible to demand placed on it.1 These demands can be any situation that would adapt to, the system’s stress level will be increased. Response to the require the system to adapt. For the individual, this could include any- psychosocial-cultural stressors can be improved with attitude as- thing from getting out of bed in the morning to experiencing the loss sessment and interventions that reduce the physiologic response to resulting from a major environmental disaster. Stress is life. psychosocial stressors. The body’s physiologic response to stress involves activation of Coping has been defined as behavior (conscious and unconscious) the autonomic nervous system. The symptoms of this activation can that a system uses to change a situation for the better or to manage include sweating, tachycardia, tachypnea, nausea, and tremors. This the stress-resultant emotions.5 These kinds of behavior can occur on process has been labeled the general-adaptation syndrome (GAS)4 and the biologic, psychological, and social levels. Effective coping uses occurs in three stages: alarm reaction, resistance, and exhaustion. biologic, psychological, and social resources in attempts to manage The alarm stage mobilizes the system’s defense forces by initiating the situation. the autonomic nervous system response. The system is prepared for A coping model has been presented3 that addresses the biologic, “fight or flight.” In the resistance stage, the system fights back and psychological, and sociocultural aspects of this process. The model adapts, and normal functioning returns. If the stress continues and indicates that systems have generalized resistance resources (GRRs) to all attempts of the system to adapt fail, exhaustion occurs, and the facilitate coping. GRRs are those characteristics of the system that system is at risk for experiencing major disorganization. can facilitate effective tension management. Genetic characteristics Four levels of psychophysiologic stress responses have been de- that provide increased resistance to the effects of stressors are con- scribed.4 The first level comprises the day-to-day stressors that all sidered physical and biochemical GRRs. These GRRs can include Copyright © 2002 F.A. Davis Company DEVELOPMENTAL CONSIDERATIONS 635 levels of immunity, nutritional status, and the adaptability of the and acceptance for personal interests, ideas, needs, and talents; sta- neurologic system. Valuative and attitudinal GRRs describe consis- ble role models; challenges that foster development of competence tent features of the system’s coping behavior. This could include and responsibility; opportunities to explore all of their feelings; a personality characteristics and the system’s perception of the stres- variety of experiences; opportunities for age-appropriate problem sor. The more flexible, rational, and long term these are, the more solving and the knowledge that they must live with the conse- effective they are as GRRs. Interpersonal-relational GRRs include quences of their decisions; opportunities to develop commitments social support systems and can provide an important resource in to others; and encouragement in the development of their own managing stress. Finally, those cultural supports that facilitate cop- standards, values, and goals.9 ing are referred to a macrosociocultural GRRs. Macrosociocultural According to developmental stages, there are some specific eti- GRRs could include religions, rites of passage, and governmental ologies and symptom clusters. structures. In 1979, Kobasa introduced the concept of hardiness to the lit- INFANT erature on coping.6,7 She described the hardy individual as having three characteristics that provide him or her with the ability to cope Interactions with significant others are the primary source of the in- effectively with stress. The first characteristic is commitment or a fant’s response to trauma or stress. If the significant other is sup- purpose and involvement in life. Challenge is the second charac- portive and consistent, the effects of the event on the infant are min- teristic of the hardy individual. Challenge is the belief that the imized. Events that separate infants from their significant others changes in life can be meaningful opportunities for personal also pose a threat to this age group. Primary symptoms are disrup- growth. The third characteristic is control. Control has three com- tions in physiologic responses. ponents: cognitive control, decisional control, and repertoire of The chronic diseases place this age group at special risk. Because coping skills. Kobasa and other authors proposed that the hardy in- the development of coping behavior is limited at this age, the pri- dividual would remain healthier and experience less disabling psy- mary caregivers (usually the parents) provide the child with the chological stress. support to cope. If the caregivers cannot provide the proper sup- An understanding of the concept of hardiness can facilitate the ports, then the child is affected. Chronic illness in the child places nurse’s assessment of the client’s potential ability to cope with life’s an extreme stress on the family and can result in divorce. Support stresses. Based on this assessment, the nurse can then develop in- for the parents is crucial in supporting the child’s coping. terventions that support or develop commitment, challenge, and control for the client. These interventions might include providing TODDLER AND PRESCHOOLER the client with as much control as possible in the situation, facili- tating his or her positive orientation with reframes, and assisting in Responses of significant others are still the primary supports for the the development of a variety of coping strategies.6 child in this age group. Thus, as for the infant, the response of sig- Wagnild and Young8 have questioned the validity of hardiness as nificant others or separation from these persons can have an effect a concept. The concern of these authors evolves from their obser- on the toddler and preschooler. In addition, threats to body in- vation that the tools utilized to measure the various components of tegrity pose a special threat to this age group. Traumatic events that hardiness do not provide clear distinctions between the identified inflict physical damage on these children place the child at greatest concepts and other influencing variables. Wagnild and Young con- risk. Regression is the primary symptom and coping behavior. This clude that it is important to continue the research related to a har- can be frustrating to caregivers who expect the child to assist in a diness concept, and, until a more precise understanding of what time of crisis with age-appropriate developmental behavior when constitutes this concept is developed, it will be difficult to apply it the child may regress to a very dependent stage. Other methods to therapeutic interventions.8 From a clinical perspective, hardiness used by young children in coping include denial, repression, and is a useful concept to consider when interacting with the client sys- projection. Coping may be more difficult because adults may not tem, for it provides a model for understanding client response and recognize that young children can experience crisis and will, there- presents fertile content for clinical nursing research related to psy- fore, not provide assistance with the coping process.10 chosocial aspects of coping. Effective coping can occur when the system has a strong physi- SCHOOL-AGE CHILD ologic base combined with adequate psychosociocultural support. This implies that any intervention that addresses coping behavior Symptoms include problems with school performance, withdrawal should address each of these areas. Interventions that have been ap- from family and peers, behavioral regression, physical problems re- plied to this process include therapeutic touch, kinesiology, medi- lated to anxiety, and aggressive behavior to self or others. Coping be- tation, relaxation training, hypnosis, family therapy, nutritional havior includes that used by the younger child, only in a more effec- counseling, massage, and physical exercise. tive manner. This age group may find a great deal of support from siblings during crisis. Situations that can precipitate crisis in this age Developmental Considerations group include school entry, threats to body image, peer problems, and family stress such as divorce or death of a loved one.10 The number of resources available to the system greatly affects its Chronic disease or disability also affects the adjustment of this ability to cope with stressors. Thus, there is a need to maximize age group. Again, the primary support for adaptation comes from physical, cognitive, and psychosocial development. Cross-cultural the primary caregivers, usually the parents. research has identified those characteristics that are common to in- dividuals who are perceived as mature and capable of coping effec- ADOLESCENT tively. These characteristics include an ability to anticipate conse- quences; calm, clear thinking; potential fulfillment; problem solving The adolescent demonstrates more adultlike coping behavior. Symp- that is orderly and organized; predictability; purposefulness; real- toms of stress include anxiety, increased physical activity, increased isticness; reflectiveness; strong convictions; and implacability.9 The daydreaming, increased apathy, change in mood cycles, alteration development of these characteristics is maximized in environments in sleeping patterns, aggressive behavior directed at self or others, that provide children with a loving, warm environment; respect and physical symptoms associated with anxiety. Crisis-producing Copyright © 2002 F.A. Davis Company 636 COPING-STRESS TOLERANCE PATTERN situations can include role changes, peer difficulties, threats to body with life experience can facilitate creative problem solving with the integrity, rapidly changing body functioning, conflict with parents, support of health care personnel.11 personal failures, sexual awareness, and school demands.10 Response to traumatic events is similar to that of adults. Etiolo- FAMILY LIFE CYCLE gies of crisis-producing events, for this age group, are also similar to those for adults. Specific events that place this age group at The following is a presentation of the developmental framework of greater risk are those that affect the peer group and could have ef- the family life cycle as described by Carter and McGoldrick.12 fects on body image or sexual functioning. Coping behavior is adultlike. This age group may find support from peers especially Between Families The unattached young adult: The process of useful in facilitating coping. Coping may also be affected by limited this level is accepting parent-child separation. The individ- life experience and impulsive behavior. ual must separate from his or her family of origin and de- Illnesses that threaten body image could result in difficulties in velop intimate peer relationships and a career. adjustment. Peers again provide a primary support system and can Joining of Families Through Marriage The newly married have a great impact on the adolescent’s acceptance. Educating sig- couple: The process of this level involves commitment to a nificant peers about the client’s situation could facilitate their ac- new system. The individuals form a marital system and re- ceptance of the client and in turn facilitate the client’s adjustment align relationships with extended families and friends to in- to the change in health status. Adjustment could also be facilitated

clude spouse. by involving the client in a support group composed of peers with Family with Young Children The task faced is to accept a new similar alterations. generation of members into the system. The marital system adjusts to make space for the child(ren) and assumes parent roles. Another realignment takes place to include parenting YOUNG ADULT and grandparenting roles. Symptoms of problems with coping include changes in perfor- Family with Adolescents The family task is to increase flexi- mance of roles at home and at work, aggressive behavior directed bility of family boundaries to include children’s indepen- at self or others, and physical symptoms associated with anxiety dence. The parent-child relationships shift to allow the ado- and denial. Changes in role performance might include loss of in- lescents to move in and out of the system. The parents terest in sexual relationships or withdrawal from the community. refocus on midlife marital and career issues, and there is a Situations that might tax the coping abilities of the young adult in- beginning shift toward concerns for the older generation. clude balancing increasing role responsibilities, dealing with Family in Later Life Accepting the shifting of generational threats to the self or to body integrity, leaving home, and making roles is the task of this stage. The system maintains individ- career choices.10 ual and couple functioning and interests in conjunction with Alterations in health status that affect the ability of role perfor- physiologic decline. There is an exploration of new role op- mance place this age group at risk for impaired adjustment. This tions with more support for a more central role for the mid- could include loss of ability to function in job responsibilities. Be- dle generation. The system also makes room for the wisdom havior can include regression, but this does not necessarily indicate and experience of the elderly and to support the older gen- that the client is experiencing impaired adjustment. eration without overprotecting them. This stage will also in- clude coping with the deaths of significant others and prepa- ration for death. ADULT Specific problems can arise in family coping when the family de- Coping resources have broadened for this age group as a result of velopmental cycle or expectations do not correspond with the de- past successful coping experiences and the possible addition of adult velopmental tasks of individual family members. There are three children as supports during crisis. Symptoms of difficulties with stages that are nodal points in family development. coping are similar to those of the young adult. Age-related stressors The joining of families through marriage requires a commitment include loss, such as significant others and physical functioning; role to a new system. If the separation from the parents is not success- changes, such as job loss and the leaving of adult children; aging par- ful, then the new family does not have an opportunity to form its ents; career pressures; and cultural role expectations.10 own identity, combining the experiences both bring into this new relationship. Symptoms of unsuccessful resolution of this stage OLDER ADULT could result in the marital partners returning home to their parents when conflict arises or an ongoing struggle over loyalties to fami- Symptoms of extreme stress in this age group may be overlooked lies of origin. and attributed to senility. These symptoms include withdrawal, de- The second major shift occurs when children enter the system. creased functioning, increased physical complaints, and aggressive The new role of parent is assumed, and the couple boundaries must behavior. Decreased function of hearing, vision, and mobility as be opened to accept the child. Unsuccessful resolution of this stage well as loss of support systems and other resources affects coping could result in physical or emotional abuse of the child. If there is behavior. These problems can be balanced by life experience that a developmental delay in the parents and they are not ready to as- has provided the individual with many situations of successful cop- sume the responsibilities that accompany parenthood, family dys- ing to fall back on during stressful times. Situations that place this function can occur. age group at risk are multiple losses, decreased physical function- A family with adolescents is faced with the task of increasing flex- ing, increased dependence, retirement, relocation, and loss of re- ibility to include children’s independence. This may require a ma- spect because of cultural attitudes. jor shift in family rules. This is also influenced by the parents’ per- The effects of multiple losses related to alteration in health status ception of the adolescent and the environment. If the adolescent is and the loss of support systems place the older adult at risk for im- seen as being competent, and the environment that the adolescent paired adjustment. In the absence of illness affecting cognitive func- interacts in is seen as safe, then it will be much easier for the fam- tioning, the older adult can assume responsibility for making deci- ily to provide the necessary shifts in relationships. When this stage sions related to alterations in health status. This ability combined is not resolved successfully, the adolescent may enhance behavior Copyright © 2002 F.A. Davis Company ADJUSTMENT, IMPAIRED 637 that highlights his or her differences with the family to force sepa- NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; ration, or the frequency and intensity of family conflict may in- CLASS N—PSYCHOSOCIAL ADAPTATION crease. Unsuccessful resolution of this stage may indicate that the family has overly rigid boundaries to the external world and indi- DEFINING CHARACTERISTICS15 vidual boundaries that are overly permeable. Application of the concept of coping at the aggregate or com- 1. Denial of health status change munity level is in the process of development. Additional research 2. Failure to achieve optimal sense of control is needed to identify and validate community-based diagnoses. 3. Failure to take actions that would prevent further health problems Successful communities are healthy communities.13,14 4. Demonstration of nonacceptance of health status change NOTE: For the individual diagnoses in this chapter, the psy- RELATED FACTORS15 chiatric health nursing actions serve as the generic nursing ac- tions, because the nature of the diagnoses in this chapter call for 1. Low state of optimism the skills, knowledge, and expertise of a psychiatric–mental 2. Intense emotional state health nursing specialist. 3. Negative attitudes toward health behavior 4. Absence of intent to change behavior 5. Multiple stressors APPLICABLE NURSING DIAGNOSES 6. Absence of social support for changed beliefs and practices 7. Disability or health status change requiring change in lifestyle 8. Lack of motivation to change behaviors Adjustment, Impaired DEFINITION RELATED CLINICAL CONCERNS Inability to modify lifestyle or behavior in a manner consistent with 1. Alzheimer’s disease a change in health status.15 2. Head injury sequelae 3. Any new diagnosis for the patient NANDA TAXONOMY: DOMAIN 9—COPING/STRESS 4. Couvade syndrome TOLERANCE; CLASS 2—COPING RESPONSES 5. Postpartum depression or puerperal psychosis 6. Personality disorders NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING 7. Substance use or abuse disorders ASSISTANCE 8. Psychotic disorders HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Ineffective Individual Coping This diagnosis ability to adapt, then the appropriate primary results from the client’s inability to cope diagnosis would be Disturbed Sensory Perception. appropriately with stress. Impaired Adjustment is Disturbed Thought Process This diagnosis can the client’s inability to adjust to a specific disease inhibit the client’s ability to adapt effectively to an process. If the client’s behavior were related to the alteration in health status. If the inability to adapt adjustment to a specific disease process, the to the alteration is related to an alteration in diagnosis would be Impaired Adjustment; thought processes, then the appropriate primary however, if the behavior were related to coping diagnosis would be Disturbed Thought Process. with general life stressors, the diagnosis would be Dysfunctional Grieving Grieving can have a Ineffective Individual Coping. strong effect on the client’s ability to adjust to an Powerlessness This diagnosis would be alteration in health status. The differentiation is appropriate as a primary or codiagnosis if the complicated by the fact that a normal response to client demonstrates the belief that personal action an alteration in health status can be grief. If, cannot affect or alter the situation. Impaired however, the client is not reporting a sense of loss, Adjustment may result from Powerlessness. If this then the appropriate diagnosis would be Impaired is the situation, then the appropriate primary Adjustment. If the client reports a sense of loss diagnosis would be Powerlessness. with the appropriate defining characteristics, then Disturbed Sensory Perception This diagnosis can the appropriate diagnosis would be Grieving. If the affect the individual’s ability to adjust to an grieving is prolonged or exceptionally severe, then alteration in health status. If it is determined that an appropriate codiagnosis with Impaired perceptual alterations are affecting the client’s Adjustment would be Dysfunctional Grieving. EXPECTED OUTCOME TARGET DATES Will return-demonstrate measures necessary to increase indepen- Adjustment to a change in health status will require time; therefore, dence by [date]. an acceptable initial target date would be no sooner than 7 to 10 days following the date of diagnosis. Copyright © 2002 F.A. Davis Company 638 COPING-STRESS TOLERANCE PATTERN NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Establish a therapeutic relationship with the patient and A therapeutic relationship promotes cooperation in the plan of care significant others by showing empathy and concern for the and gives the patient a person to talk with. patient, calling the patient by name, answering questions honestly, involving the patient in decision making, etc. • Explain the disease process and prognosis to the patient. Knowledge of disease process and limitations is necessary for adjustment. • Encourage the patient to ask questions about health status by Increasing knowledge and understanding leads to improved allowing opportunity and asking the patient to share his or her coping and adjustment. understanding of the situation. • Encourage the patient to express feelings about disease process Verbalization of feelings leads to understanding and adjustment. and prognosis by sitting with the patient for 30 min once a shift at [times]. Use techniques such as active listening, reflection, and asking open-ended questions. • Identify previous coping mechanisms, and assist the patient to Determines what coping strategies have been successful, and find new ones. provides an opportunity to try new strategies. • Help the patient find alternatives or modification in previous Helps the patient continue to have satisfaction in activities, and lifestyle behavior by using assistive devices, changing level of provides a sense of control in lifestyle. participation in activities, learning new behaviors, etc. • Encourage independence in self-care activities by focusing on Provides a sense of control, and increases self-esteem and the patient’s strengths, rewarding small successes, etc. adjustment. • Refer to psychiatric nurse practitioner (see Psychiatric Health Collaboration promotes holistic approach to care, and problems nursing actions). may need intervention by specialist. Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for all possible etiologic factors via active listening by Provides the database needed to most accurately plan care. asking questions that are appropriate for the child (who, what, where, and when) regarding first feeling of not being able to adjust. • Help the child realize it is normal to need some time and Realistic planning increases the likelihood of compliance and assistance in adjusting to changes, e.g., the child needing increases sense of success. assistance with ambulating following surgery. • Explore the child’s and family’s previous coping strategies. Previous coping strategies serve as critical information in developing interventions for the current status. • Identify ways the child can feel better about coping with the Effective coping can empower the child and family and thereby needed adjustment, including reinforcement of desired afford a positive adjustment. behavior. • Assist the child and family in creating realistic goals for Realistic goals enhance success. coping. • Collaborate with related health team members as needed. Collaborations with specialists serve to meet the unique needs of the patient and family. • Provide clear and simple explanations for procedures. Simple and clear instructions promote the child’s functioning while in a stressful situation. • Address educational needs related to health care. Knowledge serves to empower and provide guidelines for compliance with expected behavior. • Deal with other primary care needs promptly. Basic primary needs require prompt attention to offer the best likelihood of minimizing adjustment difficulty. • Provide for posthospitalization follow-up

with home care as Follow-up affords long-term resolution of adjustment. needed. • Assist the patient and family in identification of community Identification of resources before discharge will encourage the resources that can offer support. patient and family to use the resources as needed and will help them cope with the changes in their lifestyle. Copyright © 2002 F.A. Davis Company ADJUSTMENT, IMPAIRED 639 Women’s Health ACTIONS/INTERVENTIONS RATIONALES COUVADE SYNDROME • When counseling with expectant fathers, be alert for Provides database that allows early intervention. characteristics for couvade syndrome.16 � Syndrome affects males only. � Wives are pregnant and usually in the third or ninth month of gestation. � Symptoms are confined to the gastrointestinal (GI) or genitourinary (GU) system; notable exceptions are toothache and skin growths. � Anxiety and affective disturbances are common—e.g. constant worrying about labor events, “I can’t do this” or “I just know I will faint”—and/or overmanaging arrangements for he new baby—e.g., painting nursery three times. � Physical findings are minimal. � Laboratory and x-ray testing yields normal results. � Patient makes no connection between his symptoms and his wife’s pregnancy. • Provide a nonjudgmental atmosphere to allow the patient (in Encourages the patient to talk about feelings, and allows planning this instance, a man with the medical diagnosis of couvade of how to channel feelings into activities that will assist in syndrome) to express concerns of: preparing for fatherhood. � Self-image as a father � Relationship with his father � Self-responsibility � Feelings about wife’s or partner’s pregnancy � Concerns about wife’s or partner’s safety • Accurately record physical symptoms described by the Allows more effective interventions and planning. expectant father: � Fatigue � Weight gain � Nausea or vomiting � Headaches � Backaches � Food cravings • Support and guide the expectant father through the changes being experienced. • Assure the expectant couple that: Emphasizes that this is not necessarily unusual behavior. Assists � Expectant fathers can suffer physical symptoms during with positive actions that support both partners, and allows the partner’s pregnancy. man to view pregnancy realistically. � Pregnancy affects both partners. � Fathers also have emotional needs during pregnancy. POSTPARTUM AFFECTIVE DISORDERS Postpartum Blues This affects approximately 50 to 85 percent of all delivering women, is viewed as part of the adaptation process to childbirth, and usually resolves with normal support of family; therefore, it is not considered to be an impairment and will not be discussed here. Postpartum Depression Described as postpartum major affective disorder in psychiatric literature (usually occurs 2 wk to 3 mo post partum). • Encourage the client to express fears about the less-than-perfect infant. This can include: � Low-birth-weight infant � Different sex than desired by parents � Fussy infant � Premature infant (continued) Copyright © 2002 F.A. Davis Company 640 COPING-STRESS TOLERANCE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Unwanted infant (could be infant as result of unwanted pregnancy and/or a result of rape) • Continually assess the new mother’s mood, observing for Nursing observations can be critical in getting these patients the signs of: professional help they need. Too often women feel this is just part � Continuous crying of being a new mother and that they have no one who will listen. � Insomnia not related to care of the infant Often these signs and symptoms go unreported and unrecognized � Mood swings by family members.17 � Loss of appetite � Withdrawal � Irritability � Guilt feelings � Feeling of inability to care for self or the infant or function in roles of wife and mother � Impaired memory � Lowered self-image • Provide nonjudgmental atmosphere for the patient to discuss Encourages the patient to discuss feelings and verbalize problematic situations. Issues may include: disappointments or problems so that plans for coping with reality � Partner’s lack of sexual interest of birth experience can be initiated. � Any illness or problems with older children � Marital status � Disappointment in experience (unwanted cesarean section, medications administered during labor, or any unexpected occurrences) � Isolation during postpartum period (unable to return to work immediately, no adults available to talk to during day, unable to complete daily activities owing to fatigue, demands of infant, uncooperative partner, lack of support system, and so on) Postpartum Psychosis The incidence of postpartum psychosis is approximately 1 in 1000 deliveries. Onset is acute and abrupt.17 • Obtain a complete patient history and family history, particularly regarding previous depressive or psychotic episodes. (Usually has familial and/or genetic basis.) • Collaborate with family members to never leave the patient alone, particularly with the infant. • Arrange for the family to take and care for the infant. • If needed, arrange for community resources for care of the infant. • Obtain immediate assistance from psychiatric health colleagues This diagnosis needs professional assistance immediately and is for the mother. beyond the scope of practice for perinatal nursing. The main duty of the perinatal nurse is to see that no harm comes to the mother or infant until mental health colleagues can assume care of the mother. • Explain to family the likelihood of repetition of psychosis with subsequent pregnancies. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Discuss with the client his or her perception of the current Communicates respect for the client and his or her experience of alteration in health status. This should include information the stressor, which promotes the development of a trusting about the coping strategies that have been attempted and his or relationship. Provides information about the client’s strengths that her assessment of what has made them ineffective in promoting can be utilized to promote coping, and provides the nurse with an adaptation. opportunity to support these strengths in a manner that promotes a positive orientation. • Provide the client with clocks and calendars to promote Maintains the client’s cognitive strengths in a manner that will orientation and involvement in the environment. facilitate the development of coping strategies.6 • Give the client information about the care that is to be provided, Promotes the client’s sense of control. including times for treatments, medicines, group, and other therapy. (continued) Copyright © 2002 F.A. Davis Company ADJUSTMENT, IMPAIRED 641 (continued) ACTIONS/INTERVENTIONS RATIONALES • Assign the client appropriate tasks during unit activities. These Accomplishment of tasks provides the positive reinforcement that should be at a level that can easily be accomplished. Provide the enhances self-esteem and motivates behavior. Also assists the client client with positive verbal support for completing the task. to develop a positive expectational set. Gradually increase the difficulty of the tasks as the client’s abilities increase. • Sit with the client [number] minutes [number] times per day at Communicates concern for the client, and facilitates the [times] to discuss current concerns and feelings. development of a trusting relationship. Promotes the client’s sense of control by communicating that his or her ideas and concerns are important. • Provide the client with familiar needed objects. These should be Promotes the client’s sense of control, while meeting safety and noted here. These should assist the client in identifying a security needs. personal space over which he or she feels some control. This space is to be respected by the staff, and the client’s permission should be obtained before altering this environment. • Provide the client with an environment that will optimize Appropriate levels of sensory input decrease confusion and sensory input. This could include hearing aids, eyeglasses, disorganization, maximizing the client’s coping abilities. pencil and paper, decreased noise in conversation areas, and appropriate lighting. (These actions should indicate an awareness of sensory deficit as well as sensory overload, and the specific interventions for this client should be noted here—e.g., place hearing aid in when client awakens and remove before bedtime [9:00 p.m.].) • Communicate to the client an understanding that all coping behavior to this point has been his or her best effort and asking for assistance at this time is not failure—a complex problem often requires some outside assistance to resolve. • Call the client by the name he or she has identified as the Promotes a positive orientation, while enhancing self-esteem. preferred name with each interaction. Note this name on the chart. • Have the client dress in “street clothing.” This should be items Promotes positive orientation and the client’s sense of control by of clothing that have been brought from home and in which the supporting normal daily routine and activities. client feels comfortable. • Provide the client with opportunities to make appropriate Promotes the client’s sense of control, and enhances self-esteem decisions related to care at his or her level of ability. This may when appropriate decisions are made. begin as a choice between two options and then evolve into more complex decision making. It is important that this be at the client’s level of functioning so that confidence can be built with successful decision-making experiences. Note here those decisions that the client has made. • Provide the client with primary care nurse on each shift. Nurse Promotes the development of a trusting relationship, while will spend 30 min once per shift at [time] developing a promoting the client’s sense of control with knowledge about the relationship with the client. This time could be spent answering environment. the client’s questions about the hospital, about daily routines, etc., or providing the client with a backrub. • Identify with the client methods of anxiety reduction. The High levels of anxiety interfere with decision making. Increased specific method selected by the client should be noted here. For control over anxiety promotes the client’s sense of control. The the first 3 days, the staff should remain with the client during a presence of the nurse can provide positive reinforcement, which 30-min practice of the selected method. The method should be encourages behavior. Behavioral rehearsal internalizes and practiced 30 min 3 times a day at [times]. (See Anxiety, Chap. 8, personalizes the behavior. for specific instructions about anxiety reduction methods.) • Provide positive social reinforcement and other behavioral Reinforcement encourages positive behavior and enhances rewards for demonstration of adaptation. Those things that the self-esteem. client finds rewarding should be listed here with a schedule for use. The kinds of behavior that the team is to be rewarding should also be listed with the appropriate reward. • Assist the client in identifying support systems and in Support systems can facilitate the client’s coping strategies. developing a plan for their use. The support systems identified should be noted along with the plan for their use. • Schedule a meeting with the identified support system to assist Promotes the development of a trusting relationship, and provides them in understanding alterations in the client’s health. Provide the support system with the information they can utilize to provide time to answer any questions they may have. Note the time for more effective support. this meeting here and the person responsible for this meeting. (continued) Copyright © 2002 F.A. Davis Company 642 COPING-STRESS TOLERANCE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide the client with group interaction with [number] persons, Disconfirms the client’s sense of aloneness, and assists the client to [number] minutes, [number] times per day at [times]. This experience personal importance to others while enhancing activity should be graded with the client’s ability—e.g., on interpersonal relationship skills. Increasing these competencies admission, the client may tolerate one person for 5 min. If the can enhance self-esteem and promote positive orientation. interactions are brief, the frequency should be high—e.g., 5-min interactions should occur at 30-min intervals. If the client is meeting with a large client group, this may occur only once a day. The larger groups should include persons who are more advanced in adapting to their alterations and persons who may be less advanced. • Make available items necessary for the client to groom self. Have Appropriate grooming enhances self-esteem. Reinforcement these items adapted as necessary to facilitate client use. List encourages positive behavior while enhancing self-esteem. those items that are necessary here, along with any assistance that is necessary from the nursing staff. Assign one person per day to be responsible for this assistance. Provide positive social reinforcement for the client’s accomplishments in this area. • Set an appointment to discuss with the client and significant Promotes communication in the system that can serve as the basis others effects of the loss or change

on their relationship (time for developing coping strategies. and date of appointment and all follow-up appointments should be listed here). Note person responsible for these meetings. • Monitor nurse’s nonverbal reactions to loss or change, and Promotes the development of a trusting relationship and the provide the client with verbal information when necessary to development of a positive orientation. establish nurse’s acceptance of the change. • If nursing staff is having difficulty coping with the client’s Staff thoughts and feelings can be indirectly communicated to the alterations, schedule a staff meeting where these issues can be client, which could have a negative effect on the client’s developing discussed. An outside clinical nurse specialist may be useful in a positive orientation. facilitating these meetings. Schedule ongoing support meetings as necessary. • Utilize constructive confrontation if necessary to include “I” Models appropriate communication skills, while providing the statements, relationship statements that reflect nurse’s reaction client with information that facilitates consensual validation. to the interaction, and responses that will assist the client in understanding, such as paraphrasing and validation of perceptions. • When a relationship has been developed, the primary care nurse Promotes the development of adaptive coping strategies. will spend 30 min twice a day at [time] with the client discussing thoughts and feelings related to the alteration in health status. These discussions could include memories that have been activated by this alteration, the client’s fears and concerns for the future, the client’s plans for the future before the alteration in health status, the client’s perceptions of how this alteration will affect daily life, and the client’s perceptions of how this alteration will affect the lives of significant others. • Provide the client with information about care and treatment. Promotes the client’s sense of control. Inappropriate levels of Give information in concise terms appropriate to the client’s sensory input can increase the client’s confusion and level of understanding. Note here those areas for which the disorganization. client needs the most information, and include a plan for providing this information. • Do not argue with the client while he or she is experiencing an Arguing with these perceptions decreases the client’s self-esteem alteration in thought process (refer to Disturbed Thought and increases his or her needs to enlist dysfunctional coping Process, Chap. 7, for related nursing actions). behavior. • Develop with the client a very specific behavioral plan for Achievement of a specific plan provides positive reinforcement adapting to the alteration in health status. Note that plan here. and enhances self-esteem, which motivates positive behavior. This plan should include achievable goals so the client will not become frustrated. • Refer the client to occupational therapy to develop the necessary Successful adaptation to the occupational role enhances self-esteem. adaptations to the occupational role. Note time for these meetings here. • Schedule time for the client and his or her support system to be Provides opportunities for the support system to maintain normal together without interruptions. The times for these interactions relationships while the client is hospitalized. should be noted here. (continued) Copyright © 2002 F.A. Davis Company ADJUSTMENT, IMPAIRED 643 (continued) ACTIONS/INTERVENTIONS RATIONALES • If the client is disoriented, orient to reality as needed and before Enhances the client’s cognitive functioning, improving his or her attempting any teaching activity. Provide the client with clocks ability to problem solve and to cope. and calendars, and refer to day, date, and time in each interaction with this client. • Refer the client to appropriate assistive resources as indicated. Establishes the client’s support system in the community. Note here those referrals made and the name of the contact person. Gerontic Health The nursing actions for the gerontic patient with this diagnosis are the same as those for the adult health and mental health patient. Home Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for factors contributing to impaired adjustment—e.g., Provides database for intervention. psychological, social, economic, spiritual, or environmental factors. • Involve the client and family in planning, implementing, and Family involvement enhances effectiveness of interventions. promoting reduction or elimination of impaired adjustment: � Family conference: Discuss feelings and altered roles, and identify coping strategies that have worked in the past. � Mutual goal sharing: Establish realistic goals and specify role of each family member—e.g., provide safe environment and support self-care. � Communication: Clear and honest communication should be promoted among family members. If sensory impairments exist, corrective interventions are needed, e.g., eyeglasses or a hearing aid. • Assist the client and family in lifestyle adjustments that may be Family relationships can be altered by impaired adjustment. required: Permanent changes in behavior and family roles require evaluation � Stress management and support. � Development and use of support networks � Treatment for disability � Appropriate balance of dependence and independence � Grief counseling � Change in role functions � Treatment for cognitive impairment � Provision of comfortable and safe environment � Activities to increase self-esteem • Consult with or refer to appropriate assistive resources as Utilization of existing services is efficient use of resources. indicated. Resources such as an occupational therapist, a psychiatric nurse clinician, and support groups can enhance the treatment plan. Copyright © 2002 F.A. Davis Company 644 COPING-STRESS TOLERANCE PATTERN Adjustment, Impaired FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient return-demonstrate independence-oriented measures? Yes No Record data, e.g., selected Reassess using initial assessment factors. appropriate diet from given list that will help avoid production of gas and diarrhea; irrigated ostomy and changed bag accurately and safely. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., continues to have problems with diet selection Did evaluation show another and with changing bag; does problem had arisen? Yes irrigate ostomy correctly and safely. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company COMMUNITY COPING, INEFFECTIVE AND READINESS FOR ENHANCED 645 Community Coping, Ineffective and 6. Active planning by community for predicted stressors 7. Active problem solving by community when faced with issues Readiness for Enhanced 8. Positive communication among community members DEFINITIONS15 RELATED FACTORS15 Ineffective Community Coping Pattern of community activities for adaptation and problem solving that is unsatisfactory for meet- A. Ineffective Community Coping ing the demands or needs of the community. 1. Natural or man-made disasters 2. Ineffective or nonexistent community systems, for example, Readiness for Enhanced Community Coping Pattern of com- lack of emergency medical system, transportation system, or munity activities for adaptation and problem solving that is satis- disaster planning systems factory for meeting the demands or needs of the community but can 3. Deficits in community social support services and resources be improved for management of current and future problems or 4. Inadequate resources for problem solving stressors. B. Readiness for Enhanced Community Coping 1. Community has a sense of power to manage stressors NANDA TAXONOMY: DOMAIN 9—COPING/STRESS 2. Social supports available TOLERANCE; CLASS 2—COPING RESPONSES 3. Resources available for problem solving NIC: DOMAIN 7—COMMUNITY; CLASS C— COMMUNITY HEALTH PROMOTION AND RELATED CLINICAL CONCERNS CLASS D—COMMUNITY RISK MANAGEMENT 1. High incidence of violence NOC: DOMAIN VII—COMMUNITY HEALTH; 2. High illness rates CLASS B—COMMUNITY WELL-BEING AND CLASS C—COMMUNITY HEALTH PROMOTION HAVE YOU SELECTED DEFINING CHARACTERISTICS15 THE CORRECT DIAGNOSIS? A. Ineffective Community Coping 1. Expressed community powerlessness Effective Management of Therapeutic 2. Deficits of community participation Regimen, Community This is an actual 3. Excessive community conflicts diagnosis that indicates a community has 4. Expressed vulnerability resolved its problems. Ineffective 5. High illness rate Community Coping and Readiness for 6. Stressors perceived as excessive Enhanced Community Coping indicate the 7. Community does not meet its own expectations community is either still in the throes of its 8. Increased social problems, for example, homicides, vandal- problem or has just started problem solving. ism, arson, terrorism, robbery, infanticide, abuse, divorce, or unemployment B. Readiness for Enhanced Community Coping EXPECTED OUTCOME 1. Deficits in one or more characteristic that indicates effective coping Community will demonstrate fewer defining characteristics of inef- 2. Positive communication between community or aggregates fective coping by [date]. and larger community 3. Programs available for recreation and relaxation TARGET DATES 4. Resources sufficient for managing stressors 5. Agreement that community is responsible for stress manage- These diagnoses are very long term. Appropriate target dates would ment be expressed in terms of months or years. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health Nursing actions specific for this diagnoses will require implementation in the home and community environment; therefore, the reader is referred to the Home Health nursing actions for this diagnosis. Child Health Same as for Adult Health, with acknowledgement of parents and caregivers assuming role of advocacy. Use developmentally appropriate approach. May be dependent on funding or interest of local potential supporters. Copyright © 2002 F.A. Davis Company 646 COPING-STRESS TOLERANCE PATTERN Women’s Health ACTIONS/INTERVENTIONS RATIONALES INEFFECTIVE COMMUNITY COPING NOTE: With early discharge of the new mother and baby, it has been noted that many communities are ineffective in having in place follow-up programs to assist these new mothers and their infants in the first critical postpartum days. Even with states’ mandating “48-hour stays,” there still exists a great need to support new mothers and their newborns after discharge from the hospital. • Investigate what programs are available to the new mother and Provides a coordinated flow of care for the patient. Allows for her infant in the community. Different communities have more equal distribution of scarce resources, which can eliminate different programs, such as: duplication of services to some while others have none. � Well-baby clinics � Public health department programs � Nursing centers (usually at schools of nursing in university settings) � State and federal programs such as First Steps, First Start, and maternity support programs • Network with nursing colleagues in the community to assess how you can assist one another in providing continuity of care for these mothers and their newborns. READINESS FOR ENHANCED COMMUNITY COPING NOTE: Many private nursing agencies and acute care hospitals have or are putting into place follow-up programs to deal with the issue of early discharge of the new mother and her infant. These programs include telephone follow-up, postpartum after-care centers, and home visits.18–21 Telephone Follow-up • Call the discharged mother within 36–48 h after discharge. Provides follow-up contact with the new mother and her family. Allow the mother time to answer questions and expand on her This contact can provide important information and monitoring, answers if necessary. (Sometimes this takes some leading and reinforcement of previous education, emotional and professional directed questioning by the nurse.) support to new parents, and referral to appropriate professional services if needed. • Provide a nonjudgmental atmosphere that allows the new mother and/or father to verbalize concerns and needs. • Ask for descriptions of the infant’s color, cord, circumcision (if appropriate), feeding patterns, stool patterns, and number of wet diapers. • Ask the mother to describe feeding sessions. If breastfeeding: � How often and how long does the infant nurse? � Does the infant nurse on both sides? � How do her breasts look (cracks, bleeding, or sore)? � Does the infant latch on correctly? � What does the infant’s stool look like, and how many wet diapers are there in a 24-h period? If formula feeding: � How often does the infant feed? � How many ounces does the infant take? � Is the infant tolerating formula (not spitting excessively or having projectile vomiting)? � What is the color of the stool and pattern? How many wet diapers? • Discuss potential for injury to the infant, covering the following topics: � Use of approved car seat � Smoking in presence of the infant or in home where infant is � Use of proper bedding and proper positioning of the infant in bed (on back or side) � Environmental safety (“childproofing” the house) (continued) Copyright © 2002 F.A. Davis Company COMMUNITY COPING, INEFFECTIVE AND READINESS FOR ENHANCED 647 (continued) ACTIONS/INTERVENTIONS RATIONALES • Ask the mother how she is feeling (tired, overwhelmed, out of sorts, etc.). Inquire about her physical well-being: � Episiotomy � Incision (if cesarean section) � Any alterations in involution (lochia—rubra, serosa, or alba) � Breasts �

Stools (diarrhea or constipation) � Any signs and symptoms of infection (increased temperature, increased tenderness of uterus [abdomen], foul-smelling lochia) • Instruct the mother and/or father to call primary health care provider if any signs or symptoms of infection are noted. • If concerns are noted, make arrangements for the mother, father, Provides a creative solution to the early discharge of new mothers and infant to return to postpartum follow-up center or clinic, and their infants from the acute care system after birth. Allows for and/or schedule a home visit by a nurse. If concerns are urgent, continuation of quality nursing care and monitoring of the recommend that the mother, father, and infant go to emergency postpartum progress of the mother and her infant. room and/or their primary health care provider immediately. Follow-up Clinic and/or Home Visit • Assess interaction between the parents and the parents with the newborn. If siblings are present, assess interaction with the parents and the new baby. • Assess the mother for physical and psychological well-being. (See previous interventions for physical well-being. See Impaired Adjustment for psychological well-being.) • Assess home for social economic needs and referrals, such as: � Enough to eat � Cleanliness � Does the new mother have help in home � Transportation • Assess the infant for physical well-being. (See previous interventions.) • Document findings, and place them in the mother’s and infant’s charts when returning to hospital. Send copy of documentation to primary health care provider for both the mother and infant. Psychiatric Health Refer to Home Health actions and interventions for these care plans. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES INEFFECTIVE COMMUNITY COPING • Discuss examples of ineffective coping in order to begin Increases awareness of problems in the community, and stimulates problem solving. interest. • Clarify questions related to coping that arise from Helps identify strategies that may increase coping skills. problem-solving sessions. • Identify fiscal resources available to the community for problem Local, regional, state, or federal programs may have funds solving. dedicated to addressing problems related to aging. • Identify local leaders (formal as well as informal) who have power within the community, and gain their perspective. • Encourage use of community services to network for problem Conserves money. Also increases likelihood of reaching the target solving, such as radio or television stations that offer to air public audience in the community. service announcements, newspapers to publish letters to the editor, or libraries to make available access to community internets. READINESS FOR ENHANCED COMMUNITY COPING • Encourage participation in community activities. Older adults are more likely to be involved in organized activities, such as senior citizens’ groups. They are also more likely to vote and actively support or campaign for governmental candidates. (continued) Copyright © 2002 F.A. Davis Company 648 COPING-STRESS TOLERANCE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Enlist older adults in community setting in problem-solving Can provide historical perspective on the community and its meetings. growth pattern and needs. • Consult with organized community resources such as RSVP or Provides a wealth of life experiences for problem solving within American Association of Retired Persons (AARP) groups for the community. problem solving and future planning. • Consider use of telephone trees, computer connections, or letter Time is an important factor in community growth and planning, writing for older adults with decreased mobility who can still and older adults may have more time to assist the community. add to community life and growth. Activities such as those mentioned may be possible even for those with limited mobility. Home Health ACTIONS/INTERVENTIONS RATIONALES • Involve community groups in problem identification and Involvement at the local level enhances community development program development: and communication. � Identify local needs for addressing problems or stressors. � Encourage participation in the community process. • Identify community strengths and weaknesses. Community recognition of strengths, weaknesses, and resources � Develop strategies to enhance strengths and correct enhances the potential. weaknesses. � Identify resources needed and resources available. • Develop collaborative relationships within the community to Supportive relationships enhance the success of the plan. promote development of the community. • Utilize strategies identified for enhanced community coping to identify factors leading to Ineffective Community Coping: � Develop strategies to correct the deficits. � Develop plan with community involvement to correct deficits. Copyright © 2002 F.A. Davis Company COMMUNITY COPING, INEFFECTIVE AND READINESS FOR ENHANCED 649 Community Coping, Ineffective and Readiness for Enhanced FLOWCHART EVALUATION: EXPECTED OUTCOME Review defining characteristics. Does community exhibit fewer of the characteristics? Yes No Record data, e.g., exhibits only 2 of Reassess using initial assessment factors. the defining characteristics. List here. Record RESOLVED. (May want to use CONTINUE until no characteristics present.) Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., still exhibit 6 of 8 characteristics. List here. Did evaluation show another Record CONTINUE and change problem had arisen? Yes target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 650 COPING-STRESS TOLERANCE PATTERN Family Coping, Compromised and Disabled 7. Neglectful care of the client in regard to basic human needs and/or illness treatment DEFINITIONS15 8. Impaired restructuring of a meaningful life for self 9. Impaired individualization or prolonged overconcern for Compromised Family Coping Usually supportive primary per- client son (family member or close friend) provides insufficient, ineffec- 10. Distortion of reality regarding the client’s health problem, tive, or compromised support, comfort, assistance, or encourage- including extreme denial about its existence or severity ment that may be needed by the client to manage or master adaptive 11. Desertion tasks related to his or her health challenge. 12. Decisions and actions by the family that are detrimental to Disabled Family Coping Behavior of significant person (family or economic or social well-being other primary person) that disables his or her own capacities and 13. Carrying on usual routines, disregarding client’s needs the client’s capacities to effectively address tasks essential to either 14. Abandonment person’s adaptation to the health challenge. 15. Client’s development of helpless, inactive dependence 16. Disregarding needs NANDA TAXONOMY: DOMAIN 9—COPING/STRESS TOLERANCE; CLASS 2—COPING RESPONSES RELATED FACTORS15 NIC: DOMAIN 5—FAMILY; CLASS X—LIFE SPAN A. Compromised Family Coping CARE 1. Temporary preoccupation by a significant person who is trying to manage emotional conflicts and personal suffering and is un- NOC: DOMAIN VI—FAMILY HEALTH; CLASS X— able to perceive or act effectively in regard to the client’s needs FAMILY WELL-BEING 2. Temporary family disorganization and role changes 3. Prolonged disease or disability progression that exhausts DEFINING CHARACTERISTICS15 supportive capacity of significant people 4. Other situational or developmental crises or situations the A. Compromised Family Coping significant person may be facing 1. Subjective 5. Inadequate or incorrect information or understanding by a a. Client expresses or confirms a concern or complaint about primary person significant other’s response to his or her health problems. 6. Little support provided by the client, in turn, for primary b. Significant person describes or confirms an inadequate person understanding or knowledge base that interferes with ef- B. Disabled Family Coping fective assistive or supportive behaviors. 1. Significant person with chronically unexpressed feelings of c. Significant person describes preoccupation with personal guilt, anxiety, hostility, despair, etc. reaction (e.g., fear, anticipatory grief, guilt, or anxiety) to 2. Arbitrary handling of the family’s resistance to treatment, client’s illness, disability, or to other situational or devel- which tends to solidify defensiveness, as it fails to deal ade- opmental crises. quately with underlying anxiety 2. Objective 3. Dissonant discrepancy of coping styles for dealing with a. Significant person attempts assistive or supportive behav- adaptive tasks by the significant person and the client or iors with less than satisfactory results. among significant people b. Significant person displays protective behavior dispro- 4. Highly ambivalent family relationships portionate (too little or too much) to the client’s abilities or need for autonomy. RELATED CLINICAL CONCERNS c. Significant person withdraws or enters into limited or temporary personal communication with the client at the 1. Alzheimer’s disease time of need. 2. AIDS B. Disabled Family Coping 3. Any disorder resulting in permanent paralysis 1. Intolerance 4. Cancer 2. Agitation, depression, aggression, or hostility 5. Any disorder of a chronic nature, for example, rheumatoid 3. Taking on illness signs of client arthritis 4. Rejection 6. Substance abuse or use 5. Psychosomaticism 7. Somatoform disorders 6. Neglectful relationships with other family members Copyright © 2002 F.A. Davis Company FAMILY COPING, COMPROMISED AND DISABLED 651 HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Compromised versus Disabled Coping diagnosis can be made as Ineffective Family Compromised dysfunction reflects the family that Coping with no attached label. cannot provide appropriate support to the Family Coping, Readiness for Enhanced This identified patient. This problem removes a possible diagnosis is appropriate for families that are coping support system from the client. If the family well with current stressors and are in a position to dysfunction results in further dysfunction for the enhance their coping abilities. Ineffective Family identified patient, then the diagnosis is Disabled. Coping describes a family that has a deficit in Because this diagnosis is used to describe family coping abilities that threatens the family’s existence. processes, it may be difficult at times to Impaired Parenting This diagnosis refers to an differentiate between compromised and disabled inability to fulfill the parenting role. This because there is not an identified patient or the dysfunction is circumscribed to the parent-child effects of the family patterns on the client cannot relationship and is time-limited when contrasted be determined. When this is the situation, the with Ineffective Family Coping. EXPECTED OUTCOME TARGET DATES Will identify the effects current coping strategies have on the fam- The target dates should reflect the complexity and power of the sys- ily by [date]. tem. Four-week intervals would be appropriate to assess for progress. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Encourage and assist the family and significant others to Allows for identification of specific stressors, and promotes verbalize their needs, fears, feelings, and concerns by sitting creative problem solving. with the patient for 30 min per shift at [times] or planning a family conference. Actively listen and facilitate discussion. • Provide accurate information about the situation. Clarifies misconceptions and misunderstanding. • Include the family and significant others in decision making Promotes active participation, motivation, and compliance. and plan of care when planning care and intervening. • Assist the family and significant others to identify and explore Promotes creative problem solving. alternatives to dealing with the situation, e.g., respite care, Mom’s day out, or daycare centers. • Assist the family and significant others to identify before Community resources can help strengthen family coping process discharge sources of community support that could assist and prevent isolation of the family. them to cope with their feelings and to supply relief when needed. • Encourage the family to provide time for themselves on a Reduces stresses and strengthens coping skills. regular basis. • Initiate referral to psychiatric clinical nurse specialist as needed. Problems may need intervention by specialist. Child Health ACTIONS/INTERVENTIONS RATIONALES • Encourage the child and family to express feelings and fears by Expression of concerns provides insight into views about problem allotting 30 min per shift, while awake, for this purpose. and the values of the patient and family. • Review family dynamics previous to crisis. Family dynamics in usual times is paramount in understanding coping dynamics during times of stress. • Encourage family members to participate in the child’s care, Family and patient input ensures individualized plan of care. including bathing, feeding, comfort, and diversional activity. Provides teaching opportunity, and increases the child’s security. • Provide education to all family members regarding the child’s Reduces anxiety, increases likelihood of compliance, and illness, prognosis, and special needs as appropriate. empowers the family. (continued) Copyright © 2002 F.A. Davis Company 652 COPING-STRESS TOLERANCE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Involve health team members in collaboration for care. Increases the likelihood of a holistic plan of care for both short-term and long-term goals. • Provide referral to appropriate community resources for support Provides for long-term follow-up and support. purposes. • Provide for home discharge planning at least 5 days before Allows time

for teaching, practice, and return-demonstration. discharge. • Make referral for home health care as needed. Provides for long-term follow-up and support. Women’s Health NOTE: This diagnosis would be most likely to relate to the single mother in the area of Women’s Health. ACTIONS/INTERVENTIONS RATIONALES • Review the physical, mental, social, and economic status of the Provides a database that can be used to plan appropriate single mother, taking into account if she is widowed, divorced, interventions and locate support systems for the patient. single and a parent by choice, or single and a parent not by choice. (See Impaired Adjustment.) • Identify support system available to the single mother e.g., family, friends, coworkers, or formal support groups such as church or community organizations. • Review the patient’s perception of employment status, e.g., Assists the patient to realistically plan for fiscal needs of herself educational level and skills, job opportunities, and opportunity and her infant. Allows identification of resources that could assist for improvement of employment status. in improving income status. • Identify child care requirements considering the age of children, who has legal custody of children, and child support (financial and emotional). • Suggest strategies for exposing the children to male role Provides for male role modeling in the absence of a father figure. models22: � Assign to classes with male teachers. � Ask for assistance from brothers or grandparents. � Involve the children in sports (coaches are usually male). Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Role-model effective communication by: Models for the family effective communication that can enhance � Seeking clarification their problem-solving abilities. � Demonstrating respect for individual family members and the family system � Listening to expression of thoughts and feelings � Setting clear limits � Being consistent � Communicating with the individual being addressed in a clear manner � Encouraging sharing of information among appropriate system subgroups • Each meeting with the family, provide positive verbal Promotes hope, and helps the family develop a positive view of reinforcement related to the observed strengths. themselves and their abilities, promoting an environment for change. Supports the development of a positive therapeutic relationship.23 • Demonstrate an understanding of the complexity of system Promotes the development of a trusting relationship, while problems by: developing a positive orientation. � Not taking sides in family disagreements � Providing alternative explanations of behavior patterns that recognize the contributions of all persons involved in the problem, including health care providers if appropriate � Requesting the perspective of multiple family members on a problem or stressor (continued) Copyright © 2002 F.A. Davis Company FAMILY COPING, COMPROMISED AND DISABLED 653 (continued) ACTIONS/INTERVENTIONS RATIONALES • Determine risk for physical harm, and refer to appropriate Client safety is of primary concern. authorities if risk is high (child protective services, battered women’s centers, or police). • Assist the family in developing behavioral short-term goals by: Accomplishments of goals provide reinforcement, which motivates � Asking what changes they would expect to see when the continued positive behavior and enhances self-esteem. problem is improved � Having them break the problem into several parts that combine to form the identified stressor or crisis � Setting a time limit of 1 wk to accomplish a task—e.g., “What could you do this week to improve the current situation?” • Develop with the family a priority list. Promotes the family’s sense of control, and promotes the development of a trusting relationship by communicating respect for the client system. • Begin work with the presenting problem, and enlist the system’s Promotes the development of a trusting relationship, while assistance in resolving concerns. enhancing the client system’s sense of control. • Include assessment data in determining how to work on the presenting problem—e.g., if behavioral controls for a child are requested, the nurse can develop a plan for teaching and implementing them in the home that includes both parents. • Encourage communication between family members by: Assists the family in developing problem-solving skills that will � Having the family members discuss alternatives to the serve them in future situations. problem in the presence of the nurse � Having each family member indicate how he or she might help resolve the problem � Having each family member indicate how he or she contributes to the maintenance of the problem or how he or she does not help the identified patient change behavior � Spending time having the family members give each other positive feedback • Discuss with the family the need for taking breaks from the Provides the family with balance between illness demands and the focus on the health challenge. Options to accomplish this might need for self-care activities.23 Assists the family in discovering include: positive aspects of their relationships. � Arranging for respite care � Planning a family vacation � Planning a family play day Note here family plan and support needed from staff. • Support the development of appropriate subgroups by: Promotes healthy family functioning. � Presenting problems to the appropriate subsystems for discussion—e.g., if the problem involves a discussion of how the sexual functioning of the marital couple will change as a result of illness, this issue should be discussed with the husband and wife � Providing an opportunity for the children to discuss their concerns with their parents � Supporting appropriate generational boundaries—e.g., parent’s attempts to exclude children from parental roles • Develop direct interventions that instruct a family to do Provides information on the family’s ability to change at this point something different or not to do something. If direct in time, while promoting a positive orientation. interventions are not successful and reassessment indicates they were presented appropriately, this may indicate the family system is having unusual problems with the change process and should be referred to an advanced practitioner for further care. • Provide experiences for the family to learn how they can think Promotes a positive orientation, while assisting the family in differently about the problem—e.g., a job loss can be seen as an developing problem-solving skills. opportunity to reevaluate family goals, focus on interpersonal closeness, and enhance family problem-solving skills. • Provide opportunities for the expression of a range of affect; this Validates the family members’ emotions, and helps identify the can mean laughing and crying together. This may require that appropriateness of their affective responses. the nurse “push” the family to express feelings with the skills of confrontation or providing feedback.23,24 • Develop a teaching plan to provide the family with information that will enhance their problem solving. (continued) Copyright © 2002 F.A. Davis Company 654 COPING-STRESS TOLERANCE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Assist the family with interactions with other systems by: Facilitates the development of support networks in the community � Providing information about the system that can be called on in future situations. � Maintaining open communication between nurse and other agencies or systems � Having the family identify what their relationship is with the system and how they could best achieve the goals they have for their interactions with this system • Provide constructive confrontation to the family about Facilitates the development of functional coping behaviors in a problematic coping behavior.24 Those kinds of behavior warm, supportive environment. identified by the treatment team as problematic should be listed here. • Teach the family methods to reduce anxiety, and practice and High levels of anxiety can interfere with adaptive coping behaviors. discuss the use of these methods with the family [number] times Repeated practice of a behavior internalizes and personalizes the per week. This should be done at least once a week until family behavior. members are using this as a coping method. This could include deep muscle relaxation, physical exercise, family games that require physical activity, or cycling. Those methods selected by the family should be listed here, with the time schedule for implementation. The family should be given “homework” related to the practice of these techniques at home on a daily basis. • Provide the family with the information about proper nutrition Proper nutrition promotes physical well-being, which facilitates that was indicated as missing on the assessment. This should adaptive coping. Successful accomplishment of goals provides include time spent on discussing how proper nutrition can fit positive reinforcement and motivates behavior, while enhancing the family lifestyle. This teaching plan should be listed here. A self-esteem. “homework” assignment related to the necessary pattern change should be given. This should involve all the family members. Make an assignment that has high potential for successful completion by the family. • If a homework assignment is not completed, do not chastise the Promotes positive orientation. family. Indicate that the nurse misjudged the complexity of the task, and assess what made it difficult for the family to complete the task. Develop a new, less complex task based on this information. If a family continues not to complete tasks, they may need to be referred to an advanced practitioner for continued care. • Monitor the family’s desire for spiritual counseling, and refer to appropriate resources. The name of the resource person should be listed here. • Assist the family in identifying support systems and in developing a plan for their use. This plan should be recorded here. • Refer the family to community resources as necessary for Provides resources that can provide support in the community. continued support. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Refer to adult protective services if risk of physical harm is high. Provides means for monitoring the patient and family. Effective use of resources to reduce risk of harm for the patient. Home Health See Psychiatric Health nursing actions for detailed family-oriented interventions. ACTIONS/INTERVENTIONS RATIONALES • Involve the client and family in planning and implementing Family involvement and clarification of roles are necessary to strategies to improve family coping: enhance interventions. � Crisis management: Identify actions to identify crisis and intervene—e.g., removing individuals from situation. (continued) Copyright © 2002 F.A. Davis Company FAMILY COPING, COMPROMISED AND DISABLED 655 (continued) ACTIONS/INTERVENTIONS RATIONALES � Mutual goal setting: Identify realistic goals and specify activities for each family member. � Communication: Provide realistic feedback in positive manner. � Family conference: Each member identifies how he or she is involved, and possible interventions are considered. � Support for the caregiver. • Assist the family and client in lifestyle adjustments that may Changes in family roles and behaviors require long-term behavioral be required: changes. Support is required to facilitate these lifestyle changes. � Stress management � Altering past ineffective coping strategies � Treatment for substance abuse � Treatment for physical illness � Appropriate use of denial � Avoiding scapegoating � Activities of daily family living � Financial concerns � Change in geographic or sociocultural location � Potential for violence � Identify family strengths � Obtain temporary assistance, e.g., housekeeper, sitter, or temporary placement outside home • Consult with and refer to assistive resources as appropriate. Utilization of existing services is efficient use of resources. Such resources as a family therapist, protective services, a psychiatric nurse clinician, and community support groups can enhance the treatment plan. Copyright © 2002 F.A. Davis Company 656 COPING-STRESS TOLERANCE PATTERN Family Coping, Compromised and Disabled FLOWCHART EVALUATION: EXPECTED OUTCOME Has the family identified current coping strategies? Yes No Has family identified effect these No Reassess using initial assessment factors. strategies have on family? Yes No Is diagnosis validated? Record data, e.g., family identified that avoiding issue allows problem to Record new assessment data. increase and that physical Record REVISE. Add new punishment leads to lying. diagnosis, expected outcome, Record RESOLVED. (may target date, and nursing actions. Yes wish to use CONTINUE Delete invalidated diagnosis. until family implements plan to offset negative effects.) Delete nursing diagnosis, expected outcome, target Start new evaluation process. date, and nursing actions. Record data, e.g., have identified current strategies of avoidance Did evaluation show another and physical punishment; have problem had arisen? Yes not identified effects. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company FAMILY COPING, READINESS FOR ENHANCED 657 Family Coping, Readiness for Enhanced RELATED CLINICAL CONCERNS DEFINITION15 1. Alzheimer’s disease 2. AIDS Effective managing of adaptive tasks by family member involved 3. Any disorder resulting in permanent paralysis with the client’s health challenge, who now is exhibiting desire and 4. Cancer readiness for enhanced health and growth in regard to

self and in 5. Any disorder of a chronic nature, for example, rheumatoid arthritis relation to the client. NANDA TAXONOMY: DOMAIN 9—COPING/STRESS HAVE YOU SELECTED TOLERANCE; CLASS 2—COPING RESPONSES THE CORRECT DIAGNOSIS? NIC: DOMAIN 5—FAMILY; CLASS X—LIFE SPAN CARE Ineffective Family Coping and Interrupted Family Processes Readiness for Enhanced NOC: DOMAIN VI—FAMILY HEALTH; CLASS X— Family Coping addresses the family that is FAMILY WELL-BEING currently handling stresses well and that is in a position to enhance their coping abilities. DEFINING CHARACTERISTICS15 The other nursing diagnoses related to family functioning address various aspects of family 1. Individual expressing interest in making contact on a one-to-one dysfunction. If any dysfunction is present, basis or on a mutual-aid group basis with another person who Readiness for Enhanced Family Coping has experienced a similar situation would not be the diagnosis of choice. 2. Family member moving in direction of health-promoting and enriching lifestyle, which supports and monitors maturational processes, audits and negotiates treatment programs, and gen- EXPECTED OUTCOME erally chooses experiences that optimize wellness 3. Family member attempting to describe growth impact of crisis Will verbalize satisfaction with current progress toward family on his or her own values, priorities, goal, or relationships goals by [date]. RELATED FACTORS15 TARGET DATES Needs sufficiently gratified and adaptive tasks effectively addressed Depending on the family size and the commitment of each mem- to enable goals of self-actualization to surface. ber toward growth, the target date could range from weeks to months. A reasonable initial target date would be 2 weeks. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Provide opportunities for the family and significant others to Promotes understanding, open communication, creative problem discuss the patient’s condition and treatment modalities by solving, and growth. scheduling at least one family session every other day. • Include the family and significant others in planning and Promotes active participation, motivation, and compliance. providing care as care is planned and implemented. Provides a teaching opportunity and an opportunity for the family to practice in a supportive environment. • Provide instruction as needed in supportive and assistive Understanding and knowledge base are needed to adapt to behavior for the patient. situations. Reduces anxiety. • Answer questions clearly and honestly. Promotes a trusting relationship. • Refer the family and significant others to support groups and Coordination and collaboration organize resources and decrease resources as indicated. duplication of services. Provides a broader range of networked resources. Child Health ACTIONS/INTERVENTIONS RATIONALES • Identify how the child views the current crisis by using play, The impact of the crisis on the child is basic data needed for puppetry, etc. planning care. (continued) Copyright © 2002 F.A. Davis Company 658 COPING-STRESS TOLERANCE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Identify the family’s and the child’s previous and current coping Family coping behaviors serve as reference data to understand the patterns. child’s response and behavior. Will also provide needs assessment data for planning of teaching. • Assist the child in identifying ways the current crisis or situation Viewing current situation for beneficial outcomes can assist in a can enhance his or her coping for future needs. positive outcome. • Identify appropriate health members who can assist in providing Specialists may best assist the patient in positive resolution of crisis. support for growth potential. • Offer educational instruction to meet the patient’s and family’s Knowledge serves to empower the patient and family and assists in needs related to health care. reduces anxiety. • Allow for sufficient time while in hospital to reinforce necessary Learning in a supportive environment provides reinforcement of skills for care, e.g., range of motion (ROM) exercises. desired content. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Encourage participation of significant others in preparation for Enhances support system for the patient, and promotes positive birth, e.g., spouse, boyfriend, partner, children, in-laws, anticipation of birth. grandparents, and others who are important to the individual. • Discuss childbirth and the changes that will occur in the family unit. • Encourage the patient to list family lifestyle adjustments that Provides directions for anticipation of birth, and allows more need to be made. Involve significant others in discussion and long-range planning that can prevent crises. problem-solving activities regarding family adjustments to the newborn, e.g., child care, working, household responsibilities, social network, or support groups. • Encourage the woman and partner (significant other) to attend Provides basic information that assists in easing labor experience. childbirth education classes or parenting classes in preparation Promotes a more positive birth experience, and reduces anxiety. for the birthing experience. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Talk with the family to identify their goals and concerns. Promotes development of a trusting relationship by communicating respect and concern for the family. • Assist the family in identifying strengths. Promotes a positive orientation. • Commend family strengths at each meeting with the family. Promotes hope, and helps the family develop a positive view of themselves and their abilities, promoting an environment for change. Supports the development of a positive therapeutic relationship.23 • Refer the family to appropriate community support groups. Provides support networks in the community. • Teach the family those skills necessary to provide care to an ill Provides the family with an increased repertoire of behavior that member. they can use to effectively cope with the situation. • Talk with the family about the role flexibility necessary to cope Assists the family in anticipatory planning for the necessary with an ill member and how this may be affecting their family. adjustments that could evolve from the present situation. Anticipatory planning increases their opportunities for successful coping, which enhances self-esteem. • Provide the family with information about normal developmental Promotes sense of control, and increases opportunities for stages and anticipatory guidance related to these stages. successful coping. • Discuss with the family normal adaptive responses to an ill Promotes the family’s strengths. family member, and relate this to their current functioning. • Support appropriate family boundaries by providing information Promotes healthy family functioning. to the appropriate family subgroup. • Model effective communication skills for the family by using Effective communication improves problem-solving abilities. active listening skills, “I” messages, problem-solving skills, and open communication without secrets. • Spend 1 h with the family on a weekly basis providing them Behavioral rehearsal provides opportunities for feedback and with the opportunity to practice communication skills and to modeling of new behaviors by the nurse. share feelings (if this is an identified goal). (continued) Copyright © 2002 F.A. Davis Company FAMILY COPING, READINESS FOR ENHANCED 659 (continued) ACTIONS/INTERVENTIONS RATIONALES • Arrange 1-h appointments with the client weekly for 1 mo to Provides opportunities for the nurse to give positive reinforcement, assess progress on the established goals. The need for continued and promotes positive orientation. follow-up can be decided at the end of the last scheduled visit. • Accept the family’s decisions about goals for care. Promotes the family’s sense of control. • Discuss with the family the role nutrition has in health Nutrition impacts coping abilities. maintenance, and develop a family nutritional plan. Consult with nutritionist as necessary. • Discuss with the family the role exercise has in improving ability Exercise improves physical stamina and increases the production to cope with stress, and assist in the development of a family of endorphins. exercise plan. Consult with physical therapist as necessary. Gerontic Health The nursing actions for the gerontic patient with this diagnosis are the same as those for the adult health and mental health patient. Home Health See Psychiatric Health nursing actions for specific family-oriented activities. ACTIONS/INTERVENTIONS RATIONALES • Involve the client and family in planning and implementing Family involvement in planning enhances growth and strategies to enhance health and growth: implementation of the plan. � Family conference: Identify family strengths. � Mutual goal setting: Establish family goals, and identify specific activities for each family member. � Communication: Enhance family discussions and support. • Assist the family and client in lifestyle adjustments that may be Support enhances permanent behavioral changes. required: � Provide information related to health promotion. � Provide information related to expected growth and development milestones, both individual and family. � Assist in development and use of support networks. • Consult with and refer to assistive resources as appropriate. Community services provide a wealth of resources to enhance growth—e.g., service organizations such as Lion’s Club, Altrusa, etc., colleges and universities, or recreational facilities. Copyright © 2002 F.A. Davis Company 660 COPING-STRESS TOLERANCE PATTERN Family Coping, Readiness for Enhanced FLOWCHART EVALUATION: EXPECTED OUTCOME Interview the family as a whole and then individually. Do they verbalize satisfaction with current progress? Yes No Record data, e.g., interviews elicited positive Reassess using initial assessment factors. statements regarding progress; family as a whole “communicating more” and “doing more together.” Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., interviews demonstrate family feeling more Did evaluation show another comfortable with each other but problem had arisen? Yes still having some communication problems. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company INDIVIDUAL COPING, INEFFECTIVE 661 Individual Coping, Ineffective 7. Superior attitude toward others 8. Hostile laughter or ridicule of others DEFINITIONS15 9. Difficulty in perception of reality or reality testing 10. Difficulty establishing or maintaining relationships Ineffective Individual Coping Inability to form a valid appraisal C. Ineffective Denial of the stressors, inadequate choices of practiced responses, and/or 1. Delays seeking or refuses health care attention to the detri- inability to use available resources. ment of health Defensive Coping Repeated projection of falsely positive self- 2. Does not perceive personal relevance of symptoms or danger evaluation based on a self-protective pattern that defends against 3. Displaces source of symptoms to other organs underlying perceived threats to positive self-regard. 4. Displays inappropriate affect 5. Does not admit fear of death or invalidism Ineffective Denial Conscious or unconscious attempt to disavow 6. Makes dismissive gestures or comments when speaking of the knowledge or meaning of an event to reduce anxiety or fear to distressing events the detriment of health. 7. Minimizes symptoms 8. Unable to admit impact of disease on life pattern NANDA TAXONOMY: DOMAIN 9—COPING/STRESS 9. Uses home remedies (self-treatment) to relieve symptoms TOLERANCE; CLASS 2—COPING RESPONSES 10. Displaces fear of impact of the condition NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING ASSISTANCE RELATED FACTORS15 NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; A. Ineffective Individual Coping CLASS N—PSYCHOSOCIAL ADAPTATION 1. Gender differences in coping strategies 2. Inadequate level of confidence in ability to cope 3. Uncertainty DEFINING CHARACTERISTICS15 4. Inadequate social support created by characteristics of re- A. Ineffective Individual Coping lationship 1. Lack of goal-directed behavior or resolution of problem, in- 5. Inadequate level of perception of control cluding inability to attend to and difficulty with organizing 6. Inadequate resources available information 7. High degree of threat 2. Sleep disturbance 8. Situational or maturational crises 3. Abuse of chemical agents 9. Disturbance in pattern of tension release 4. Decreased use of social supports 10. Inadequate opportunity to prepare for stressor 5. Use of forms of coping that impede adaptive behavior 11. Inability to conserve adaptive energies 6. Poor concentration 12. Disturbance in pattern of appraisal of threat 7. Inadequate problem solving B. Defensive Coping 8. Verbalization of inability to cope or inability to ask for help To be developed. 9. Inability to meet basic needs C. Ineffective Denial 10. Destructive behavior toward self or others To be developed. 11. Inability to meet role expectations 12. High illness rate RELATED CLINICAL CONCERNS 13. Change in usual communication pattern 14. Fatigue 1. Eating disorders 15. Risk taking 2. Substance abuse or use disorders B. Defensive Coping 3. Psychotic disorder 1. Grandiosity 4. Somatoform disorders 2. Rationalization of failures 5. Dissociative disorders 3. Hypersensitive to slight or criticism 6. Adjustment disorders 4. Denial of obvious problems or weaknesses 7. A diagnosis with a terminal prognosis 5. Projection of blame or responsibility 8. Chronic illnesses or disabilities 6. Lack of follow-through or participation in treatment or 9. Any condition that can cause alterations in body image or therapy function Copyright © 2002 F.A. Davis Company 662 COPING-STRESS TOLERANCE PATTERN HAVE YOU SELECTED THE CORRECT DIAGNOSIS?

Anxiety Ineffective Individual Coping would be Disturbed Thought Process This diagnosis can used if the client demonstrates both an inability to affect the individual’s ability to cope. If these cope appropriately and anxiety. If the client is alterations are present with Ineffective Individual demonstrating anxiety with appropriate coping, Coping, then the primary diagnosis should be then the diagnosis would be Anxiety. Ineffective Disturbed Thought Process. Effective problem Individual Coping would be used only if the client solving is inhibited as long as this disruption in could not adapt to the anxiety. thinking is present. Risk for Violence If the aggressive behavior of the Dysfunctional Grieving If the client’s behavior can client poses the threat of physical or psychological be related to resolving a loss or change, then the harm, the most appropriate diagnosis would be appropriate diagnosis is Dysfunctional Grieving. Risk for Violence. If the client’s risk for violence is The loss can be actual or perceived. If the client assessed to be very low, then this would be the demonstrates an inability to manage this process, secondary diagnosis, with Ineffective Individual then the appropriate diagnosis would be Ineffective Coping being the primary diagnosis. In this Individual Coping. situation, the diagnosis of Risk for Violence would Powerlessness This diagnosis can produce a serve as a reminder to care providers to remain personal perception that would result in Ineffective alert to the potential for this behavior. Individual Coping. If one perceives that one’s own Disturbed Sensory Perception If coping abilities actions cannot influence the situation, then are affected by alterations in sensory input, then Powerlessness would be the primary diagnosis. Disturbed Sensory Perception would be the most appropriate primary diagnosis. EXPECTED OUTCOME TARGET DATES Will return-demonstrate at least [number] new coping strategies by A realistic target date, considering assessment and teaching time, [date]. would be 7 days from the date of the diagnosis. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient to identify and explore specific situations that Identification of problem area is the first step in problem solving are creating stress and possible alternatives for dealing with the and promotes creative problem solving. situation by allowing at least 1 h per shift for interviewing and teaching. • Help the patient evaluate which methods he or she has used Allows for strengthening of effective coping methods and that have not been successful or have been only partially elimination of ineffective ones. successful. • Monitor for and reinforce behavior suggesting effective coping Strengthens and enhances coping skills. Increases confidence to continuously. risk new coping strategies. • Maintain consistency in approach and teaching whenever Reduces stress. Promotes trusting relationship. interacting with the patient. • Encourage participation in care by assisting the patient to Promotes self-care, enhances coping, builds self-esteem, and maintain activities of daily living to degree possible. increases motivation and compliance. • Encourage support from the family and significant others by Broadens support network. Builds self-esteem in support systems. allowing participation in care, encouraging questions, and allowing expression of feelings. • Teach relaxation techniques such as meditation, exercise, yoga, Reduces stress, and provides alternative coping strategies. deep breathing, or imagery. Have the patient practice for 10 min twice a shift at [times]. • Assist the patient to identify and use available support systems Broadens support network to reach short-term and long-term before discharge from hospital. goals. • Initiate referral to psychiatric clinical nurse specialist as needed. Specialized skills may be needed to intervene in significant problem areas. Copyright © 2002 F.A. Davis Company INDIVIDUAL COPING, INEFFECTIVE 663 Child Health ACTIONS/INTERVENTIONS RATIONALES • Establish a trusting relationship with the child and respective Promotes communication, and allows gathering of data that family by allowing time (30 min) per shift, while awake, for enhance care planning. verbalization of concerns and their perception of the situation. • Identify need for collaboration with related health team members. Specialist, e.g., mental health, may best be able to deal with the problem. • Reinforce appropriate behavior of choosing or coping by verbal Positive reinforcement will enhance learning of coping praise. mechanisms. • Assist the patient and family in setting realistic goals. Realistic goals enhance success, which increases coping ability. • Provide appropriate attention to primary nursing needs. Meeting of primary care needs allows the patient to focus energy on coping. • Offer education to provide clarification of information as needed, Provides basic knowledge needed to avoid future crises. Increases regarding any health-related needs. options for coping choices. • Determine appropriate developmental baseline behavior versus Baseline data will provide valuable information for comparative actual coping behavior. follow-up. • Administer medications as ordered, including sedatives. Relaxation assists in decreasing anxiety. Conserves energy to deal with crisis. • Set aside time each shift [specify] to deal with how the child and Acting out or expression of feelings provides valuable data that parents feel about the defensive behavior. This may require art, increase the likelihood of a successful plan of care. puppetry, or related expressive dynamics. • Provide feedback with support for progress. When progress is Feedback serves to clarify and allows for reviewing the specific not occurring, provide reflective referral back to the child and coping activity with reteaching as needed. parent as applicable. • Provide ongoing information regarding the child’s health status, Factors related to coping may well be influenced by residual effects which could affect defensive behavior by the child or parents. from illness. Misinformation or lack of information can also be detrimental to positive coping. • Throughout defensive coping period, monitor and ensure the Basic standard of care. child’s safety. • Determine disciplinary plans for all to abide by with safety in Structured limit setting will provide security and safety. mind. • Provide appropriate reality confrontation according to readiness Reality confrontation helps keep perspective on here and now and of the child and parents. is a useful approach to initiate coping with current situation. • Provide for discharge planning with reinforcement of value of Attaching value to follow-up increases the likelihood of follow-up appointments as needed. satisfactory attendance for appointments and other follow-up activities. • Identify, along with the patient and family, resources to assist in Support groups provide empowerment and a sense of shared coping, including support groups. concern. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Identify groups at risk for ineffective individual coping, Provides database that allows for early recognition, planning, and e.g., single parent, minority women, women with “superwoman” action. syndrome, and lesbians. • Identify situations that place patients at risk for ineffective individual coping—e.g., unwanted or unplanned pregnancy, unhappy home situation (marriage), demands at work, or demands of children or spouse. (See Impaired Adjustment for Postpartum Depression.) • Assist the patient in identifying typical stressful times—e.g., at home, at work, in social situations, or during an average day. • Assist the patient in identifying lifestyle adjustments that may Supports the patient in identification and planning of strategies to be made to lower stress levels—e.g., planning for divorce or reduce stress. planning for job change (either part-time or unemployment for a period of time). (continued) Copyright © 2002 F.A. Davis Company 664 COPING-STRESS TOLERANCE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Assist the patient in identifying factors that contribute to Identification of factors that contribute to the situation is the ineffective coping—e.g., depression, guilt (blaming self ), first step in learning positive rather than negative skills. assuming helplessness, passive acceptance of traditional feminine role, anger toward self and others (aggressive behavior, suicide threats, or substance abuse), failure to make time for self (relaxation, pleasure, or self-care). • Assist the patient in developing problem-solving skills to modify Assists the patient in planning positive actions and in stressors—e.g., using 12-step plans (as developed by Alcoholics communicating her needs to others. Anonymous) or planning time for self-rewarding activities such as exercise or long quiet baths. • Assist the patient in identifying negative and positive responses to stressors—e.g., pressures at work such as being constantly interrupted or become defensive when challenged. • Assist the patient in developing an individual plan of stress management—e.g., relaxation techniques or assertiveness training. • Involve significant others in discussion and problem-solving activities. • Provide a nonjudgmental atmosphere that allows the patient to discuss her feelings about the pregnancy, including such areas as lifestyle, children, or support systems. • Explore the patient’s use of what she perceives are Provides basis for planning lifestyle options. contraceptives,25 e.g., pills, intrauterine devices, diaphragm, withdrawal, feminine hygiene products, douching, foams (spermicides), or rhythm. • Explore the patient’s lack of contraceptive use due to26: ignorance Provides health care personnel information to plan care that (“It won’t happen to me” syndrome), guilt (“If I use the pill, then enhances likelihood of successful compliance. I am not good”), spontaneity, excitement due to risk, loneliness, crisis or pressure, or uncertainty in sex role relationships or self-image. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Determine the client’s functional abilities and developmental Cognitive abilities can impact the client’s ability to develop level for the adaptation of all future interventions. The results appropriate coping behaviors. of this assessment should be noted here. • Discuss with the client his or her perception of the current Promotes the development of a trusting relationship by crisis and stressors. This should include information about the communicating respect for the client. coping strategies that the client has attempted and his or her assessment of what has made them ineffective in resolving this stressor or crisis. • Assist the client in developing an appropriate time frame for the “De-catastrophizes” the client’s perceptions of the situation.27 resolution of the situation. (Often when experiencing a crisis, the individual has the perception that resolution must take place immediately.) This could include, as appropriate to the client’s situation: � Informing the client that any difficulty that has taxed his or her resources as much as this one has will take an extended time to resolve because it must be complex � Informing the client that a situation that is as important as this one is to the individual’s future deserves a well-thought- out answer and that a decision should not be made hastily � Assisting the client in determining the source of the time pressure and the appropriateness of this time frame � Assisting the client in developing an appropriate perspective on the time frame (One question that could be useful is “What would be the worst that could happen if this problem is not resolved by [put client’s stated time frame here]?”) (continued) Copyright © 2002 F.A. Davis Company INDIVIDUAL COPING, INEFFECTIVE 665 (continued) ACTIONS/INTERVENTIONS RATIONALES � Assist the client in understanding that goals should be modest. Provides opportunity for client success in achieving change while Complex change should be taken slowly. enhancing self-esteem. • Provide a quiet, nonstimulating environment or an environment Inappropriate levels of sensory stimuli can increase confusion and that does not add additional stress to an already overwhelmed disorganization. coping ability. (Potential environmental stressors for this client should be listed here with the plan for reducing them in this environment.) • Sit with the client [number] minutes [number] times per day at Communication of concerns in a supportive environment can [specify times here] to discuss current concerns and feelings. facilitate the development of adaptive coping behaviors. Continues the development of a trusting relationship. • Assist the client with setting appropriate limits on aggressive Inappropriate levels of environmental stimuli can increase behavior. (See Risk for Violence, Chap. 9, for more detailed disorganization and confusion, increasing the risk for acting-out nursing actions if this diagnosis develops.) behavior. • Decrease environmental stimulation as appropriate (this might include a secluded environment). • Provide the client with appropriate alternative outlets for Physical activity decreases the tension that is related to anxiety. physical tension. (This should be stated specifically and could Appropriate control of behavior promotes the client’s sense of include walking, running, talking with a staff member, using a control and enhances self-esteem. punching bag, listening to music, or doing a deep muscle relaxation sequence.) Strategies should be used [number] times per day at [times] or when increased tension is observed. These outlets should be selected with the client’s input. • Orient the client to date, time, and place. Provide clocks, Orientation enhances the client’s coping abilities. calendars, and bulletin boards. Make references to this information in daily interactions with the client. The frequency needed for this

client should be noted here, e.g., every 2 h, every day, or 3 times a day. • Provide the client with familiar or needed objects. These should Promotes the client’s sense of control, while meeting security be noted here. needs. • Provide the client with an environment that will optimize Inappropriate levels of sensory stimuli can increase confusion and sensory input. This could include hearing aids, eyeglasses, disorganization. pencil and paper, decreased noise in conversation areas, or appropriate lighting. (These interventions should indicate an awareness of sensory deficit as well as sensory overload.) The specific interventions for this client should be noted here—e.g., place hearing aid in when client awakens and remove before bedtime (9:00 p.m.). • Provide the client with achievable tasks, activities, and goals Accomplishment of these goals provides reinforcement and (these should be listed here). These activities should be provided encourages positive behavior, while enhancing self-esteem. with increasing complexity to give the client an increasing sense of accomplishment and mastery. • Communicate to the client an understanding that all coping Assists the client to maintain self-esteem, diminishes feelings of behavior to this point has been his or her best effort and that failure, and promotes a positive orientation. asking for assistance at this time is not failure. A complex problem often requires some outside assistance to resolve. • Provide the client with opportunities to make appropriate decisions related to care at his or her level of ability. This may begin as a choice between two options and then evolve into more complex decision making. • It is important that decision making be at the client’s level of Promotes the client’s sense of control. functioning so that confidence can be built with successful decision-making experience. • Provide the client with a primary care nurse on each shift. Promotes the development of a trusting relationship. • When relationship has been developed with primary care nurse, Promotes development of a trusting relationship. Discussion of this person will sit with the client [number] minutes per shift concerns in a supportive environment promotes the development to discuss concerns about sexual issues, fears, and anxieties of alternative coping behaviors. (begin with 30 min and increase as the client’s ability to concentrate improves). • Provide constructive confrontation for the client about Assists the client in reality testing of coping behaviors. problematic coping behavior.24 Those kinds of behavior identified by the treatment team should be listed here. (continued) Copyright © 2002 F.A. Davis Company 666 COPING-STRESS TOLERANCE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide the client with information about care and treatment. Promotes the client’s sense of control. Inappropriate levels of Give information in concise terms appropriate to the client’s sensory stimuli increase confusion and disorganization. level of understanding. • Identify with the client methods for anxiety reduction. Those High levels of anxiety decrease the client’s coping abilities and specific methods selected should be listed here. interfere with the learning of new behaviors. • Assist the client with practice of anxiety reduction techniques, Repeated practice of a behavior internalizes and personalizes the and remind him or her to implement these techniques when behavior. level of anxiety is increasing. • Provide the client with opportunities to test problem solutions Behavioral rehearsal helps facilitate the client’s learning new either by role-playing or by applying them to graded real-life skills through the use of feedback and modeling by the nurse. experiences. • Assist the client to revise problem solutions if they are not Promotes positive orientation, and enhances the client’s self-esteem effective. (This will assist the patient to learn that no solution is by turning disadvantages into advantages.27 perfect or final and that problem solving is a process of applying various alternatives and revising them as necessary.) • Allow the client to discover and develop solutions that best fit Promotes the client’s sense of control, and development of new his or her concerns. The nurse’s role is to provide assistance and behaviors enhances the client’s problem-solving behaviors and feedback and to encourage creative approaches to problem improves self-esteem. behavior. • Teach the client those skills that facilitate problem solving, such Increases repertoire of coping behaviors, decreasing all-or-none as assertive behavior, goal setting, relaxation, evaluation, thinking.27 information gathering, requesting assistance, and early identification of problem behavior. Those skills that are identified by the treatment team as being necessary should be listed here with the teaching plan. This should include a schedule of the information to be provided and identification of the person responsible for providing the information. • Spend [number] minutes 2 times per day at [times] with the Repeated practice of a behavior internalizes and personalizes the client role-playing and practicing problem solving and behavior. implementation of developed solutions. This will be the responsibility of the primary care nurse. • Assist the client in identifying those problems he or she cannot Increases the client’s opportunities for success in early control or resolve and in developing coping strategies for these problem-solving attempts. This success provides reinforcement, situations. This may involve alteration of the client’s perception which motivates positive behavior and enhances self-esteem. of the problem. • Monitor the client’s desire for spiritual counseling, and refer to Increases the resources available to the client. appropriate resources. • Provide positive social reinforcement and other behavioral Reinforcement encourages positive behavior and enhances rewards for demonstration of adaptive problem solving. (Those self-esteem. things that the client finds rewarding should be listed here with a schedule for use. The kinds of behavior that are to be rewarded should also be listed). • Assist the client in identifying support systems and in Decreases the client’s sense of social isolation. developing a plan for their use. • The following interventions relate to the client who is experiencing problems related to organic brain dysfunction: � Maintain a consistent environment; do not move furniture or Inappropriate levels of sensory stimuli increase confusion and personal belongings. disorganization. � Remove hazardous objects from the environment, such as Client safety is of primary concern. loose rugs or small items on the floor. � Provide environmental cues to assist the client in locating important places such as the bathroom, own room, or the dining room. � Do not argue with the client about details of recent past. The client cannot remember this information, and arguing increases the client’s levels of frustration, which can precipitate aggressive behavior. � Avoid situations that result in aggressive behavior by Prevention provides the safest approach to aggression. redirecting the client’s attention. � Provide a constant daily routine and a homelike atmosphere, Appropriate levels of sensory stimuli can increase orientation and to include personal belongings, music, social mealtimes with organization. assistance with meal preparation. This can often provide appetite cues to the client and stimulate memories. (continued) Copyright © 2002 F.A. Davis Company INDIVIDUAL COPING, INEFFECTIVE 667 (continued) ACTIONS/INTERVENTIONS RATIONALES � Provide group experiences that explore current events, Promotes the client’s orientation, and maximizes cognitive seasonal changes, reminiscence, and organizing life abilities. experiences. • The following interventions related to the client who is experiencing Defensive Coping: � Approach the client in a positive, nonjudgmental manner. Promotes the development of a trusting relationship. � Focus any feedback on the client’s behavior. Communicates acceptance of the client, while providing information on coping behaviors that create problems. � Provide an opportunity for the client to share his or her Promotes the development of a trusting relationship by perspectives and feelings. communicating acceptance of the individual. This relationship will decrease the need for defensive coping. � Use “I” statements—e.g., “I feel angry when I see you Provides modeling of more effective coping behaviors. breaking the window.” � Develop a trusting relationship with the client before using Trusting relationship decreases need for defensive coping and confrontation or requesting major changes in behavior.28,29 increases the client’s ability to respond to this information constructively. � Provide positive reinforcement for the client when issues are Reinforcement encourages positive behavior while enhancing addressed (those things that are reinforcing for this client self-esteem. should be noted here). � When the client’s defenses increase, reduce anxiety in situation. Anxiety increases the client’s use of familiar coping behaviors and (See Anxiety, Chap. 8, for precise information on anxiety makes it difficult to practice new behaviors. control.) � Determine the kinds of behavior by staff members that Provides an environment that is supportive of the client’s learning increase the client’s defensive coping, and note them here new coping behaviors. with a plan to decrease them. � Be clear and direct with the client. Inappropriate levels of sensory stimuli can increase confusion and disorganization. � If defensive coping is related to alteration in self-concept, refer to the appropriate nursing diagnosis for interventions. � Reduce or eliminate environmental stressors or threats. � Arrange time for the client to be involved in activity that he Promotes positive orientation. or she enjoys and that provides him or her with positive emotional experiences. Note activity and time for this activity here. • The following interventions are for the client experiencing High levels of anxiety increase the client’s use of familiar coping Denial: behaviors and make it difficult to practice new behaviors. � Determine whether current use of denial is appropriate in the current situations. � If denial is determined to be inappropriate, initiate the Communicates acceptance of the client, promoting the following interventions: development of a trusting relationship. (1) Provide a safe, secure environment. (2) Allow the client time to express feelings. (3) Provide a positive, nonjudgmental environment. Promotes positive orientation. (4) Develop a trusting relationship with the client before A trusting relationship decreases the client’s need to enlist presenting threatening information. dysfunctional coping behaviors. (5) Present information in a clear, concise manner. Inappropriate levels of sensory stimuli can increase the client’s confusion and disorganization. � Determine which kinds of staff behavior reinforce denial, and Models appropriate coping behavior, while decreasing direct note them here with alternative behavior. threats to the client’s self-system. � Utilize “I” messages, and reflect on the client’s behavior.23 � Present the client with information that demonstrates Places in question the client’s current coping behaviors, and inconsistencies between thoughts and feelings, between facilitates the examining of options and alternatives.27 thoughts and behavior, and between thoughts about others and their perceptions of the situation. � Arrange for the client to participate in a group that will Assists the client to experience personal importance to others, provide feedback from peers regarding the stressful situation. while enhancing interpersonal relationship skills. Increasing the client’s competencies can enhance self-esteem and promote positive orientation. � Present the client with differences between his or her Assists the client in questioning the evidence that he or she has perceptions and the nurse’s perceptions with “I” messages. been using to support ineffective coping behaviors without directly challenging them. This decreases the need for the client to use ineffective coping behaviors.27 (continued) Copyright © 2002 F.A. Davis Company 668 COPING-STRESS TOLERANCE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Do not agree with the client’s perceptions that are related to Would support and reinforce ineffective coping behaviors. denial. � Schedule time for the client and support system to discuss Support system understanding promotes the continuation of new issues related to the current problem. (Note this time here coping behaviors after discharge. with the name of the staff person responsible for this session.) � Assist the support system in learning constructive ways of coping with the client’s denial. � Schedule time for the client to be involved in positive esteem-building activity. (This activity should be selected with client input.) � Provide positive feedback for the client, addressing concerns Feedback encourages positive behavior and enhances self-esteem. in a direct manner. (Note here those things that are rewarding for the client.) � Determine needs that are being met with denial. Establish and present the client with alternative kinds of behavior for meeting these needs. Note alternatives here. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Discuss with the patient any recent life changes that may have Recent or multiple losses may significantly impact usual coping affected his or her coping, such as loss of a loved one, relocation, skills. loss of best friend, or loss of a pet.30 Home Health See Psychiatric Health nursing actions for detailed interventions. ACTIONS/INTERVENTIONS RATIONALES • Involve the client and family in planning and implementing Family involvement enhances effectiveness of interventions. strategies to improve individual

coping: � Family conference: Identification of problem and role each family member plays. � Mutual goal setting: Set realistic goals. Specify activities for each family member. Establish evaluation criteria. � Communication: Use accurate and honest feedback in a positive manner. • Assist the family and client in lifestyle adjustments that may be required: � Stress management � Development and use of support networks � Alteration of past ineffective coping strategies � Treatment for substance abuse � Treatment for physical illness � Activities to increase self-esteem: Exercise or stress management � Temporary assistance: Babysitter, housekeeper, or secretarial support • Identify signs and symptoms of illness. Permanent changes in behavior and family roles require support and accurate information. • Point out hazards and benefits of home remedies, self-diagnosis, and self-prescribing. • Consult with and refer the patient to assistive resources as Utilization of existing services is efficient use of resources. appropriate. Resources such as a psychiatric nurse clinician, a family therapist, and support groups can enhance the treatment plan. Copyright © 2002 F.A. Davis Company INDIVIDUAL COPING, INEFFECTIVE 669 Individual Coping, Ineffective FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient accurately return-demonstrate X number of new coping strategies? Yes No Record data, e.g., return-demonstrates Reassess using initial assessment factors. progressive relaxation and assertiveness with accuracy; is using frequently and states, “Feel much better about myself.” Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., can accurately return-demonstrate progressive Did evaluation show another relaxation; is having problems problem had arisen? Yes with assertiveness, stating “Think I need some more help with it.” Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 670 COPING-STRESS TOLERANCE PATTERN Post-Trauma Syndrome, Risk for and Actual 16. Altered mood states 17. Shame DEFINITIONS15 18. Panic attacks 19. Alienation Risk for Post-Trauma Syndrome At risk for sustained maladap- 20. Denial tive response to a traumatic, overwhelming event. 21. Horror Post-Trauma Syndrome Sustained maladaptive response to a 22. Substance abuse traumatic, overwhelming event. 23. Depression 24. Anxiety 25. Guilt NANDA TAXONOMY: DOMAIN 9—COPING/STRESS 26. Fear TOLERANCE; CLASS 1—POST-TRAUMA RESPONSE 27. Gastric irritability NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING 28. Detachment ASSISTANCE 29. Psychogenic attachment 30. Irritability NOC: DOMAIN VI—FAMILY HEALTH; CLASS Z— 31. Numbing FAMILY MEMBER HEALTH STATUS 32. Compulsive behavior 33. Flashbacks DEFINING CHARACTERISTICS15 34. Headaches A. Risk for Post-Trauma Syndrome (Risk Factors) RELATED FACTORS15 1. Occupation, for example, police, fire, rescue, corrections, emergency room staff, and mental health A. Risk for Post-Trauma Syndrome 2. Exaggerated sense of responsibility The risk factors also serve as the related factors. 3. Perception of event B. Post-Trauma Syndrome 4. Survivor’s role in event 1. Events outside the range of usual human experience 5. Displacement from home 2. Physical and psychosocial abuse 6. Inadequate social support 3. Tragic occurrence involving multiple deaths 7. Nonsupportive environment 4. Sudden destruction involving one’s home or community 8. Diminished ego strength 5. Epidemic 9. Duration of the event 6. Being held prisoner of war or criminal victimization (torture) B. Post-Trauma Syndrome 7. Wars 1. Avoidance 8. Rape 2. Repression 9. Natural disasters and/or man-made disasters 3. Difficulty in concentrating 10. Serious accidents 4. Grief 11. Witnessing mutilation, violent death, or other horrors 5. Intrusive thoughts 12. Serious threat or injury to self or loved ones 6. Neurosensory irritability 13. Industrial and motor vehicle accidents 7. Palpitations 14. Military combat 8. Enuresis (in children) 9. Anger and/or rage RELATED CLINICAL CONCERNS 10. Intrusive dreams 11. Nightmares 1. Rape victim 12. Aggression 2. Multiple injuries (motor vehicle accident) 13. Hypervigilant 3. Victims of assault and torture31 14. Exaggerated startle response 4. Post-traumatic stress disorder 15. Hopelessness 5. Multiple personality disorder Copyright © 2002 F.A. Davis Company POST-TRAUMA SYNDROME, RISK FOR AND ACTUAL 671 HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Anxiety This may be the initial diagnosis given to Dysfunctional Grieving This is the appropriate the individual. As the relationship with the client diagnosis if the client’s behavior is related to progresses, it may become evident that the source resolving a loss or change and this loss or change of the anxiety is a traumatic event. If this is the case, is not the result of an overwhelming traumatic then the diagnosis of Post-Trauma Syndrome would event. If it is the result of a traumatic event, then be added. As long as the symptoms of Anxiety are Post-Trauma Syndrome is the most appropriate predominant, this would be the primary diagnosis. diagnosis for the behavior the client is Disturbed Thought Process Some of the symptoms demonstrating. of Post-Trauma Syndrome are similar to those of Rape-Trauma Syndrome This diagnosis is the Disturbed Thought Process. If these alterations are correct diagnosis if the individual’s symptoms are present in the client who has experienced a related to a rape. If the symptoms are related to traumatic event, then the primary diagnosis would another overwhelming traumatic event or if the be Post-Trauma Syndrome. If the disruption in rape occurred in conjunction with another thinking persists after intervention has begun for overwhelming traumatic event, then the Post-Trauma Syndrome, then Disturbed Thought appropriate diagnosis would be Post-Trauma Process should be reconsidered as a diagnosis. Syndrome. EXPECTED OUTCOME TARGET DATES Will demonstrate return to pretrauma behavior by [date]. Because of the highly individualized and personalized response to trauma, target dates will have to be highly individualized and based on initial assessment. A reasonable initial target date would be 7 days. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Establish a therapeutic relationship by actively listening, calling Promotes trust and open expression of feelings. the person by name, showing empathy and concern, not belittling feelings, etc. • Avoid prolonged waiting periods for the patient for routine This tactic may have been one used by the torturer, and standard procedures. care procedures, e.g., drawing blood or electrocardiography, may be perceived as torture because of the memories they evoke.31 • Encourage the patient to express feelings about the event by Provides database for planning interventions. actively listening, asking open-ended questions, reflection, etc. • Help the patient see the event realistically by clarifying Provides objective view. Promotes problem solving. misconceptions and looking at both sides of the situation. • Before discharge, help the patient identify support groups who Enhances coping methods. Promotes use of community resource have previously experienced the same or similar traumatic events. networks to help meet short- and long-term goals and advocate for the patient. • Initiate a psychiatric nursing consultation as needed. Situation may require specialized skills to intervene. • Help the patient identify diversional activities to activate when Provides alternative coping strategy. he or she feels he or she is going to re-experience the event. • Orient the patient to reality as needed. Helps the patient focus on here and now rather than on past events. • Engage the patient in social interactions with nurses or with Decreases isolation. Encourages communication. Provides other support groups as appropriate. diversional activity. • Teach the patient relaxation and stress management techniques Reduces stress. Promotes alternative coping methods. before discharge. Copyright © 2002 F.A. Davis Company 672 COPING-STRESS TOLERANCE PATTERN Child Health ACTIONS/INTERVENTIONS RATIONALES • Monitor for details surrounding the incident causing Circumstances surrounding the event may provide clues as to Post-Trauma Syndrome. how the child may be internalizing people, places, and objects as symbols or reminders. • Allow for developmental needs in encouraging the child to Appropriate methods should help resolve the emotions express feelings about trauma: surrounding the incident and avoid further traumatization. � Play for infants � Puppets or dolls for toddlers � Stories or play for preschoolers • Deal appropriately with other primary nursing needs, e.g., Allows focusing of energy on dealing with the crisis. nutrition or rest. • Provide for one-to-one care and continuity of staff. Enhances trust. • Encourage the patient and family to note positive outcomes of Potential for growth exists in crisis management. experience, e.g., being able to deal with crisis. • Review previous coping skills. Coping may be enhanced by consideration of previous skills within framework of current situation. • Address educational needs according to situation, e.g., rights of Knowledge provides empowerment and enhances decision the individual or related follow-up. making. • Allow for visitation by the family and significant others. Family visitation offers opportunity for reassurance and promotes resuming daily routines and relationships. • Refer the patient appropriately for continuity and follow-up after Continuity and follow-up will foster likelihood of resolution of discharge from hospital. major conflicts. • Provide for diversional activity of the child’s choice. Promotes relaxation. • Allow for potential sleep disturbances. Provide favorite toy or Recurrent nightmares may occur as a result of the trauma. security object. Offer adequate comforting such as by holding the infant on waking. • Provide for follow-up for delayed Post-Trauma Syndrome up to Delayed response can be noted long after the initial event and 2 yr after the trauma. must be included in the planning of care.32 • Reassure the child that he or she is not being punished and is Depending on the cognitive level and coping ability, the child not responsible for trauma. may associate the event as being caused by something “wrong” he or she did or said. Women’s Health This nursing diagnosis will pertain to the woman the same as to any other adult. The reader is referred to Rape-Trauma Syndrome (Chap. 10) and to the other nursing actions in this section. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Assign a primary care nurse to the client, and assign the same Promotes the development of a trusting relationship. staff member to the client each day on each shift. • Begin appropriate anxiety-reducing interventions if this is a Provides the client with increased repertoire of coping behaviors significant problem for the client. (See Anxiety, Chap. 8, for to cope with intense emotional experiences. detailed intervention strategies and assessment criteria.) • Discuss with the client his or her perception of the current Promotes the client’s sense of control, while communicating situation and stressors. This should include information about respect for the client’s experience. the coping strategies that the client has attempted and his or her assessment of what has made them ineffective in resolving this situation. • If the client describes or demonstrates high levels of guilt, assess Clients with guilt related to the experience may view suicide as a for suicide risk and implement appropriate precautions. Note way to end this guilt.33 here the actions to be taken. (See Chap. 9, Risk for Violence, Self-Directed, for detailed interventions.) • Provide a quiet, nonstimulating environment or an environment Inappropriate levels of sensory stimuli can increase confusion and that does not add additional stress to an already overwhelmed disorganization. coping ability. (Potential environmental stressors for this client should be listed here, with the plan for reducing them in this environment.) (continued) Copyright © 2002 F.A. Davis Company POST-TRAUMA SYNDROME, RISK FOR AND ACTUAL 673 (continued) ACTIONS/INTERVENTIONS RATIONALES • Sit with the client [number] minutes [number] times a day at Promotes the development of a trusting relationship, while [times] to discuss the traumatic event. Person responsible for providing the client with an opportunity to review and attach this activity should be listed here. This should be the nurse who meaning to the client’s experience.28 has established a relationship with the client. • Assist the client with setting appropriate limits on aggressive behavior by (see Risk for Violence, Chap. 9, for nursing actions if this is an appropriate diagnosis): � Decreasing environmental stimulation as appropriate (this Inappropriate levels of sensory stimuli can increase confusion and might include a secluded environment or a time-out). disorganization, which increases the risk for aggressive behavior. � Providing the client with appropriate alternative outlets for Physical activity decreases physical tension and increases the physical tension (this should be stated specifically and could production of endorphins, which can increase the feeling of include walking, running, talking with staff member, using a well-being. This also provides the client with opportunities to punching bag, listening to music, or doing a deep muscle practice new coping behaviors in a supportive environment. relaxation sequence) [number] times per day at [times] or

when increased tension is observed. These outlets should be selected with the client’s input. Those outlets that the client selects should be listed here. � Talking with the client about past situations that resulted in Increases the client’s coping options, and assists with cognitive loss of control, and discussing alternative ways of coping with appraisal of past coping behaviors.27 these situations. (Persons responsible for this discussion should be noted here. This will not be accomplished in one discussion; the time and date for the initial discussion should be noted, with the times and dates for follow-up discussions.) • Once the symptoms have been identified and linked to the Promotes the client’s positive orientation. traumatic event, the primary nurse will sit with the client [number] minutes (begin with 30 and increase as the client’s ability to concentrate improves) per shift to discuss the traumatic event. These discussions should include: � The uniqueness of the situation, noting that one could not plan for the behavior that might be needed to endure the situation � Ways of evaluating behavior, noting that the usual moral and Assists the client to evaluate and gain perspective on behavior, ethical standards may be inappropriate for the unique while moving away from all-or-none thinking.27 situation of a traumatic event � Details of the event as the individual remembers them and Assists the client in attaching meaning to the experience. the thoughts and feelings that occur with these memories � Meaning of life since the event and the implications this has Promotes positive orientation, while assisting the client to review for the future cognitive distortions.27 � Client’s perceptions of the current actions of those around Assists the client with reality testing his or her perceptions of them and information about the care provider’s perceptions current situations and motivations of others.33 • If feelings become extreme, such as with rage or despondency, Inhibits automatic behavioral responses.27 then the client should focus on thoughts rather than feelings about the event. • Provide constructive confrontation for the client about Assists the client to gain a perspective on the experience and to problematic coping behavior.23 Those kinds of behavior label cognitive distortions that inhibit effective coping.27 identified by the treatment team as problematic should be listed here with the selected method of confrontation. • Provide the client with information about care and treatment. Promotes the client’s sense of control. • Provide the client with opportunities to make appropriate Success in this activity provides positive reinforcement and decisions related to care at his or her level of ability. This may promotes the client’s utilizing alternative coping behaviors, while begin as a choice between two options and then evolve into more enhancing self-esteem. complex decision making. It is important that this decision making be at the client’s level of functioning so confidence can be built with successful decision-making experiences. Those decisions that the client has made should be noted. • Provide positive social reinforcement and other behavioral Reinforcement encourages positive behavior and enhances rewards for demonstration of adaptive problem solving and self-esteem. coping. Those things that the client finds rewarding should be listed here, with a schedule for use. Those kinds of behavior that are to be rewarded should also be listed. (continued) Copyright © 2002 F.A. Davis Company 674 COPING-STRESS TOLERANCE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Assist the client in identifying support systems and in developing Support system understanding promotes their appropriate support a plan for their use. This plan should be noted here. of the client. • Inform significant others of the relationship between the client’s Support system understanding promotes their appropriate support behavior and the traumatic event. Discuss with them their of the client. thoughts and feelings about the client’s behavior. The person responsible for these discussions should be noted here, along with the schedule for the discussion times. This should also include information about the importance of supporting the client in discussing the event and how this might be facilitated. The concerns the significant others have about their response to this sharing should be discussed as well as planning for the types of information they might be exposed to. • When the client develops a degree of comfort discussing the Promotes the development of adaptive coping within the support traumatic event, meetings between the client and significant system. others should be scheduled. Content of these meetings should include: � Opportunities for the client to share thoughts and feelings about the event � Opportunities for the significant others to share their thoughts and feelings about the client’s behavior � Sharing of thoughts and feelings related to other events in the relationship as they surface as important topics of discussion during the meetings � Sharing of caring thoughts and feelings with each other • Arrange for the client to attend support group meetings with Decreases the sense of social isolation, and decreases feelings of others who have experienced similar traumas. The times and deviance. Consensual validation from other group members days for these meetings should be noted here with any special enhances self-esteem, providing increased emotional resources arrangements that are needed to facilitate the client’s attendance, for coping. e.g., transportation to group meeting place. This could include veterans groups, groups for survivors of natural disasters, and victims’ groups. • Schedule client involvement in unit activities. Note here the Decreases social isolation, and provides opportunity to practice client’s responsibilities in these activities, with times the client new coping skills in a supportive environment. will be involved in the activity. Gerontic Health The nursing actions for a gerontic patient with this diagnosis are the same as those given for the adult health and mental health patient. Home Health See Psychiatric Health nursing actions for detailed interventions. If family violence is involved, refer to Chapter 9. ACTIONS/INTERVENTIONS RATIONALES • Ask the client to describe the precipitating event. Assists the nurse in understanding the client’s perception of the crisis and its impact. • Determine the client’s perception of the stress. • Assess sources of support, resources, and usual coping methods. • Identify which coping strategies that the client has previously Crisis can produce growth if effective skills are applied in future used have been effective and which have not. Discuss ways that situations. effective strategies can be used to cope with future crises.29 • Assist the client in implementing adaptive coping mechanisms. • Reinforce and encourage the use of healthy coping responses. Assists the nurse in mobilizing resources and reinforcing adaptive actions. Copyright © 2002 F.A. Davis Company POST-TRAUMA SYNDROME, RISK FOR AND ACTUAL 675 Post-Trauma Syndrome, Risk for and Actual FLOWCHART EVALUATION: EXPECTED OUTCOME Interview the patient and significant others. Has the patient returned to pretrauma behavior? Yes No Record data, e.g., reports self-destructive Reassess using initial assessment factors. thoughts are no longer a problem; impulse control has improved; irritability has decreased; infrequently discusses event. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., family reports “still short-tempered,” Did evaluation show another vacillating between withdrawal problem had arisen? Yes and hyperactivity. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company 676 COPING-STRESS TOLERANCE PATTERN Suicide, Risk for b. Terminal illness c. Chronic pain DEFINITION15 7. Social factors a. Loss of important relationships At risk for self-inflicted, life-threatening injury. b. Disrupted family life c. Grief or bereavement NANDA TAXONOMY: DOMAIN 11—SAFETY/ d. Poor support systems PROTECTION; CLASS 3—VIOLENCE e. Loneliness f. Hopelessness NIC: DOMAIN 4—SAFETY; CLASS U—CRISIS g. Helplessness MANAGEMENT h. Social isolation NOC: DOMAIN III—PSYCHOSOCIAL HEALTH; i. Legal or disciplinary problem CLASS O—SELF-CONTROL j. Cluster suicides DEFINING CHARACTERISTICS15 RELATED FACTORS15 The risk factors also serve as the related factors. 1. Behavioral factors a. History of prior suicide attempt b. Impulsiveness RELATED CLINICAL CONCERNS c. Buying a gun 1. Any chronic disorder, for example, rheumatoid arthritis, multi- d. Stockpiling medicines ple sclerosis, or chronic pain e. Making or changing a will 2. Psychiatric illness or disorder f. Giving away possessions 3. Chemical use or abuse g. Sudden emphatic recovery from a major depression 4. Recent, multiple losses h. Marked changes in behavior, attitude, or school performance 2. Verbal factors a. Threats of killing oneself b. States a desire to die or “end it all” HAVE YOU SELECTED 3. Situational factors THE CORRECT DIAGNOSIS? a. Living alone b. Retired Risk for Self-Mutilation This diagnosis refers c. Relocation or institutionalization to the patient causing self-injury; however, d. Economic instability there is no intent to kill oneself. e. Loss of autonomy or independence f. Presence of gun in home Risk for Violence, Self-Directed This g. Adolescents living in nontraditional settings: juvenile deten- diagnosis can be labeled as a combination of tion center, prison, halfway house, or group home Risk for Self-Mutilation and Risk for Suicide. 4. Psychological factors Using this diagnosis rather than Risk for a. Family history of suicides Suicide would not be a problem because the b. Alcohol and substance use or abuse interventions for both diagnoses are c. Psychiatric illness or disorder, for example, depression, schiz- essentially the same. ophrenia, and bipolar disorder d. Abuse in childhood e. Guilt EXPECTED OUTCOME f. Gay or lesbian youth 5. Demographic factors Will demonstrate a [percent] decrease in risk factors by [date]. a. Age: elderly, young adult males, or adolescents b. Race: Caucasian or Native American TARGET DATES c. Gender: male d. Divorced or widowed Because of the life-threatening consequences of this diagnosis, 6. Physical factors progress should be monitored on a daily basis. a. Physical illness NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health The Psychiatric Health nursing actions also serve as the Adult Health nursing actions. Copyright © 2002 F.A. Davis Company SUICIDE, RISK FOR 677 Child Health ACTIONS/INTERVENTIONS RATIONALES • Assess for all contributing factors, including the child’s or A holistic and complete assessment will provide the most thorough parental subjective data, objective data, primary and secondary database for individualized care. references. • Identify any threats or expression of related high-risk factors Verbalization of ideation must be taken seriously. suggesting low self-esteem or lack of self-worth. • Identify history of any past suicide ideation. Tendency for recurrence is often noted with one suicide ideation providing risk index. • Identify ways to enhance communication for the child and Communication will provide cues to how the client is feeling, with family to best express feelings on an ongoing basis. an avenue for dialogue. • Explore value conflicts and meaning these have for the client Freedom to explore thoughts about values will assist in noting and family. uniqueness of each individual, while attempting to also respect the family’s views. • Identify ways to assist the child and family to identify cues Knowledge is enhanced with recognition of patterns per individual suggestive of suicidal risk. and family. • Provide appropriate attention to role of medications if these are Knowledge about drugs will assist in safe, effective compliance ordered, with focus on desired effect, appropriate dosing and with regimen. timing, importance of parent’s securing supply in a safe place, expected side effects, possible toxicity, and ways to reduce toxicity vs. importance of maintenance of blood levels. • Ensure environmental safety as noted per adult plus frequent Client safety is paramount. surveillance every 10 min or constant as may be required. • Identify appropriate peer support group activities, and The sense of isolation is reduced with peers who may be able to encourage group activities. relate to similar feelings. • Collaborate with other members of health team, such as child Expertise will best provide for needs of the child and family. life specialist, child psychologist or psychiatrist. • Utilize developmentally appropriate strategies to encourage Expression of feelings may be facilitated through means other than ongoing expression of feelings and/or ways to cope with suicidal verbalization and must be considered paramount in the child with tendency. suicidal risk. • Identify with the child and family a plan to deal with the risk Input from the child and family will best reflect and demonstrate for suicide. the need for anticipatory planning in event of possible recurrence. • Identify a plan for gradual resumption of daily activities, such Prior planning lessens anxiety

and affords time to resume as school and extracurricular activities, well before actual activities per individual coping strategies. dismissal. • Identify a plan for follow-up in advance of dismissal. Appropriate follow-up planning lessens likelihood of crisis or recurrence before situational or precipitating factors can be controlled. Women’s Health The nursing interventions for a woman with this diagnosis are the same as those actions in Psychiatric Health. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Introduce self and call the client by name. Conditions that encourage feelings of anonymity facilitate aggressive behavior.34 • Frame suicide as one option or solution to the problem. Promotes a problem-solving approach without prompting a power struggle between the staff and the client around this option. • Inform the client about the limits of confidentiality. Plans to Honesty promotes the development of a trusting relationship. harm himself or herself or someone else must be shared with the treatment team and necessary authorities. • Protect the client from harm by: Provides an environment that promotes client safety. � Asking the client what in the environment could pose harm for them. � Removing sharp objects from environment. � Removing belts and strings from environment. (continued) Copyright © 2002 F.A. Davis Company 678 COPING-STRESS TOLERANCE PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES � Providing a one-to-one constant interaction if risk for self-harm is high. � Checking on the client’s whereabouts every 15 min if not on one-to-one observation. � Removing glass objects from environment. � Removing locks from room and bathroom doors. � Providing a shower curtain that will not support weight. � Providing staff to supervise client areas at times when clients would normally expect less supervision, such as change of shift. � Checking to see whether the client swallows medication. • Sit with the client [number] minutes [number] times each day. (Note person responsible for this here.) Use this time to: � Have the client tell his or her perspective of the situation, Facilitates the development of a trusting environment for open including feelings. expression of concerns.23 Communicates to the client that his or her welfare is important to the staff.35 � Commend the client’s strengths. Increases the client’s awareness of strengths, which promotes a context of change and alternative problem solutions, while providing hope.23,36 � Explore the client’s past attempts to cope with concerns. Facilitates understanding of the client’s perception of the problem. Change is dependent on problem perception.23 • If suicidal behavior is influenced by intoxication, consult with Intoxication with drugs and alcohol can have a negative impact on primary care provider for detoxification procedure. the client’s ability to make decisions.35 • If suicidal behavior is influenced by command hallucinations, Command hallucinations place clients at high risk for self-harm.35 provide one-to-one observation until the client no longer describes these thoughts. Refer to Disturbed Thought Process (Chap. 7) for detailed interventions for hallucinations. • Contract with the client to talk with staff member when he or Promotes the client’s sense of control by assuring the client that if she feels or thinks the risk for suicide is high. he or she needs help controlling his or her behavior, the staff has a specific plan to help. Assures the client of staff availability.35,37 • When the client is capable of group interactions, assign him or Facilitates the client’s development of social skills and social her to a support group. Note schedule for group interactions contacts.36 here. • Schedule regular times with primary nurse for the client to explore: (Note times and person responsible for these interactions here.) � Need to carry out this problem solution at this time. Removing the immediacy of this solution set can provide the client with time to develop alternative solutions. � Exploring past solutions. Assists in facilitating understanding of the client’s perception of the problem. � Exploring solution sets that enlist creative problem solving. Facilitates the client’s learning new problem-solving strategies. These might include what the client would tell a friend to do, Promotes the client’s sense of control. three wishes, generating a long list of solutions that are not assessed for their practicality in the initial problem-solving stages. � When solutions are generated, note the support the client needs from staff to implement these solutions here. � Develop with the client a plan to initiate new problem-solving strategies when problems arise after discharge. Provide the client with a written copy of this plan. • Develop with the client a system to reward the use of new Positive reinforcement encourages behavior. problem-solving strategies. Note the behavior that is to be rewarded and the reward system here. • Attend recreational activities with the client. Choose activities Provides the client with alternative outlets for anger or that have a high potential for client success. Note activities here aggression, while promoting a sense of belonging and self-worth.38 and person responsible for attending with the client. • Develop with the client a list of support groups in the Social isolation increases the risk for suicide.36,38 community that will be utilized after discharge. Note the support groups here with names of contact persons. • Arrange meeting with the client’s support system to provide Promotes connection with support system, and facilitates problem information about alternative coping strategies and develop solving.36 positive communication patterns. Note times and frequency of these meetings here. Copyright © 2002 F.A. Davis Company SUICIDE, RISK FOR 679 Gerontic Health NOTE: In the United States, the highest suicide rate is seen in the older, white male population. Older adults rarely threaten to commit suicide. Usually they successfully take action rather than discuss the possibility. With the “graying” of America comes a need for health care professionals to increase their own and public awareness of this problem. The Psychiatric Health section for this diagnosis provides information on nursing actions that can be used in conjunction with the following interventions. ACTIONS/INTERVENTIONS RATIONALES • Obtain information regarding risk factors associated with suicide A combination of these risk factors is frequently present in older in the elderly, such as loss of spouse in the past year, history of adults who commit suicide. depression, social isolation, physical decline, loss of independence, and terminal diagnosis.39 • Refer to social support services for assistance in meeting Introduces means of dealing with changing life circumstances. changing care needs.40 • Refer for hospice support if the older adult has been diagnosed Provides interdisciplinary resources and support for the older with a terminal illness and meets hospice admission criteria.40,41 client. • Question older adults about possible suicidal thoughts or Encourages the client to discuss feelings of possible suicidal plans.42–44 intent. • Refer the client for psychiatric assessment and treatment if risk Places the client in contact with necessary resources for treatment. for suicide is determined to be present.41,44 Home Health ACTIONS/INTERVENTIONS RATIONALES • Consult with and/or refer the patient to assistive resources such Utilization of existing services is an efficient use of resources. as caregiver support groups as needed. • Monitor the client and family closely for warning signs or risks Understanding helps promote a sense of control and order. for suicide. • Consider all threats seriously. • When a threat is made, do not leave the client alone for any Minimizes risk of a suicide attempt. period of time. • Ask direct questions about intent: Helps determine the seriousness and lethality of the suicide plan. � Have you thought about killing yourself? Indicates to the client that you take him or her seriously and are � Have you thought about how and when you might do this? willing to help. � What can I or we do to help you through this time? • Assist the family or caregivers in removing the most lethal Although it is not possible to remove all potentially destructive means of suicide, such as weapons and medications. items, removal of the most lethal items reduces the likelihood of an attempt or successful effort. • Develop a written “no-suicide contract” with the client; i.e., the Allows time for intervention should the client decide to attempt client agrees that he or she will not hurt or kill himself or herself suicide. Provides the client with a sense of responsibility to during a specific time period; that if such thoughts occur he or another and a sense that he or she is important to others. she will contact the nurse or other involved person; and if the contact person is not immediately available, the client will continue trying to reach him or her. Copyright © 2002 F.A. Davis Company 680 COPING-STRESS TOLERANCE PATTERN Suicide, Risk for FLOWCHART EVALUATION: EXPECTED OUTCOME Does the patient exhibit [percent] decrease in risk factors? Yes No Record data, e.g., states “Counseling Reassess using initial assessment factors. has helped”; has had family get rid of gun and medications; no longer wants to die, states “I really have a lot to live for.” Record RESOLVED. (May wish to use CONTINUE until patient discharged from your service.) Delete nursing diagnosis, expected outcome, target date, and No Is diagnosis validated? nursing actions. Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., states “Still feel down; don’t see a real future.” Did evaluation show another Record CONTINUE and change problem had arisen? Yes target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company CHAPTER 12 Value-Belief Pattern 1. SPIRITUAL DISTRESS, RISK FOR AND 2. SPIRITUAL WELL-BEING, READINESS ACTUAL 683 FOR ENHANCED 689 Pattern Description Pattern Assessment The nurse may care for patients who, because of health alterations, 1. Does the patient express anger toward a supreme being regard- experience disturbances in their individual value-belief systems. A ing his or her current condition? person’s value-belief system is the core of his or her existence, his a. Yes (Spiritual Distress) or her interconnectedness with his or her spiritual side as well as b. No (Spiritual Well-Being) his or her interconnectedness with the environment. This value- 2. Does the patient verbalize conflict about personal spiritual beliefs? belief system gives meaning and purpose to life. Some call this faith. a. Yes (Spiritual Distress) “Faith carries us forward when there is no longer reason to carry on. b. No (Spiritual Well-Being) It enables us to exist during the in-between times: between mean- 3. Does the patient indicate positive thoughts about spirituality? ings, amid dangers of radical discontinuity, even in the face of a. Yes (Readiness for Enhanced Spiritual Well-Being) death. Faith is a sine qua non of life, a primal force we cannot do b. No (Spiritual Distress) without.”1 Faith can be in many things—a superior being, the en- 4. Does the patient indicate comfort with self? vironment, self, family, or community. The nurse may care for pa- a. Yes (Readiness for Enhanced Spiritual Well-Being) tients who, because of their faith or value-belief system, cope and b. No even increase their spiritual well-being when faced with health al- terations. Other patients the nurse cares for may experience distur- bances in their individual value-belief system or faith because of Conceptual Information health alterations. These alterations may take a form ranging from The faith, belief, or value system of a person can be described as the being disturbed to being demolished. These disturbances can be predominating force (spirituality) that provides the vital direction manifested by the inability to practice formal religious directions, to that person’s existence. This predominating force can be a faith such as attending church or following a specific diet, to being to- in a supreme being or God, a belief in one’s self, or a belief in oth- tally unable to manage their own spiritual needs and live within a ers.2 By this, it is conceptualized that each person must find his or certain spiritual structure. Conversely, religion can affect physical her place in the world, nature, and in relationships with other be- or emotional well-being if the practice of the religion results in spir- ings. This faith, belief, or value system is exhibited by the individ- itual distress. An individual’s value-belief system can contribute to ual in the form of organized religion, attitudes, and actions related alterations in health, just as alterations in health can contribute to to the individual’s sense of what is right, cultural beliefs, and the in- disturbances in the individual’s values and

beliefs. The nurse must dividual’s internal motivations. individualize care to help enhance and support faith while mini- All persons have some philosophical orientation to life that assists mizing spiritual distress when meeting the specific needs of the in- in constructing their reality, regardless of whether or not they prac- dividual patient within his or her value-belief system. tice a formal religion. Spirituality is interwoven into a person’s cul- The value-belief pattern looks not only at how the individual re- tural background, beliefs, and individual value system. This spiritu- tains faith and enhances his or her value-belief system in times of ality is what gives life meaning and allows the person to function in stress but at how physical illness can interfere with the individual’s a more total manner. These beliefs and values influence a person’s be- ability to practice religion and maintain beliefs, values, and spiri- havior and attitudes toward what is right and what is wrong and with tual life, as well as how a person’s judgment and interpretation of the lifestyle he or she practices. Many authors3,4 stress that the nurse the meaning of life (faith) for himself or herself can affect or inter- must not only take into consideration the patient’s beliefs and value fere with health care practices. 681 Copyright © 2002 F.A. Davis Company 682 VALUE-BELIEF PATTERN system but must also recognize his or her own beliefs and values. This is a conformist stage, where peers and their values become The nurse must know about or develop resources to assist with un- most important. Influences from earlier stages are carried derstanding the different beliefs and religious practices of groups “within” as reference points by which beliefs, values, and actions encountered in practice settings. Further understanding and as- are valued, and actions are validated and sanctioned. sessment of a patient’s beliefs can be ascertained by asking ques- 4. Individuative-Reflexive The individual begins to construct and tions such as “Do you have a faith community?” or “Which beliefs maintain his or her own identity, autonomy, and faith, without re- and practices are important to you?”5 lying on others. The sense of self is now reciprocal with a faith out- Studies have shown that the value of specific rituals such as look or worldview that negotiates between self and significant oth- prayer to the individuals who practice them is not affected by the ers. One knows he or she is different from others, and his or her fact that they can or cannot be proved scientifically.6 The impact of views and faith are vulnerable to challenge and change. values and beliefs is best described by the following quote: 5. Paradoxical-Consolidative Many previous dimensions that were formally suppressed or ignored are integrated. One be- When as much emphasis is placed on the symbolic and intuitive as comes open to the voices of one’s most inner self. There is a com- on the analytical, consciousness develops more fully. The expansion ing to terms with one’s social unconsciousness: the myths, of consciousness is what life and, therefore, health is all about and norms, ideal images, and prejudices that have, until now, health can coexist with illness and even encompass it as a mean- ingful aspect.4 formed one’s life. One can see injustice, because of an expanded awareness of the demands of justice and the implications of This can be seen in those individuals who consider suffering, ill- those demands. ness, and even death as having “meaning in life” or as “God’s will.” 6. Universalizing The individual at this stage becomes a disci- Many individuals believe that the only value of life, and the source plined activist. He or she exhibits qualities that shake the usual of strength and power, is the will of the individual and that there is no criteria of normalcy. He or she leads and embraces strategies of need for assistance from the outside. This focus has been described as nonviolent suffering and of ultimate respect for life. “They often “a person’s authority within himself.”6 This focus may actually revolve become martyrs to the visions they incarnate.”2 around work, physical activity, or self 6—“I can do anything I want to Another study10 provides insights regarding the interactive when I want to.” Three predominant indicators have been listed that process of caring as it relates to spiritual needs. Trust, meaningful must be considered when judging the value of continued life: mental support systems, and a respect for personal beliefs were identified capacity, physical capacity, and pain.7 This would indicate that life, in by participants as central to care. and of itself, is not intrinsically valuable to the possessor of it; instead, Because of the conscious, subconscious, and unconscious com- it is the quality of conscious life that is important. ponents of the value-belief system, nurses must be continually alert In one phenomenological study8 of spirituality, the constituents for disruptions in the system. There is a need to be aware that every of spirituality, as reported by the study subjects, were described and individual expresses disruptions in spirituality differently.11 Some included (1) realization of humanity of self or valued other; (2) event withdraw, some become more religious, and some become angry of nonhuman intervention; (3) receiving divine intervention; (4) vis- and defiant. Nurses need to be cognizant of not only the patient’s ceral knowing; (5) willingness to sacrifice; (6) physical sensations; spiritual beliefs but also the stage of spiritual development in which (7) a personal experience; (8) a reality experience; (9) not easily ex- the patient and nurse are. This will affect and determine not only plained; and (10) different from or more than daily experience. In the needs and concerns of the patients but how the nurse will ap- 1981, Fowler1 described his faith development theory, which was proach the patient to care for those needs and concerns. This aware- influenced by the work of Piaget and Kolberg. Fowler describes faith ness of and respect for the impact and influence values and beliefs as not always religious in its content or context but “a person’s or have on the patient cannot be overemphasized in planning and pro- group’s way of moving into the force field of life. It is our way of find- viding high-quality care for the patient. ing coherence in and giving meaning to the multiple forces and re- lations that make up our lives.” Fowler described the experience of spirituality in different stages of the life cycle. He states that one tran- sitions from one stage to another, some fast and some slow, and that Developmental Considerations it is not a simple change of mind or even a conscious movement The geographic, social, political, and home environment in which from one phase to another, and that it can be a long and painful one lives has a major effect on how a person develops, how he or process. Six states of faith are recognized by Fowler: she will view health, and how spirituality, values, and beliefs are 1. Intuitive-Projective This stage is characterized by experienc- formulated. The values a person holds influence all facets of life. ing the world as a child, fluid and full of novelty, with a rudi- How one perceives the world about him or her, as well as his or her mentary awareness of self as the center of the universe. Preop- basic philosophy, guides all interactions with others and ultimately erational reasoning and judgment are employed by people in reflects a person’s individuality. this stage. There is no reasoning or logic to thought; therefore, Fowler, in describing his developmental stages of faith, states he the capacity for taking the role or perspective of others is ex- has found, regardless of chronologic age, adults and adolescents in tremely limited. stages 2 and 3 and some adults in all stages. But persons are usu- 2. Mythic-Literal People in this stage can separate real from unreal ally found in the various stages as shown in the parentheses at the on the basis of experience, and therefore the world becomes more end of each developmental stage in the following narrative. linear and orderly than in stage 1. This is accompanied by a pri- vate world of speculation, fantasy, and wonder. Bounds of the so- INFANT cial world widen, and the questioning of “good and evil” is begun. Often these thoughts, which can be reassuring, hopeful, or full of The infant is totally dependent on the parents and those about him or terror and fear, are symbolized in dreams and daydreams.1,9 her and is busy building trust or mistrust.12 Unable at this age to form 3. Synthetic-Conventional One begins to structure the world values or distinguish spirituality, the infant is a mirror image of those and the environment in interpersonal terms. The individual con- about him or her. The parent’s method of interaction, communica- structs an image of self as seen by others and becomes aware that tion, and fulfillment of the emotional and physiologic needs of the in- others are performing the same operations in their relationships. fant forms the basis for value development. (Fowler’s stage 1) Copyright © 2002 F.A. Davis Company SPIRITUAL DISTRESS, RISK FOR AND ACTUAL 683 TODDLER AND PRESCHOOLER Spiritual Distress Disruption in the life principle that pervades a person’s entire being and that integrates and transcends one’s bio- The toddler imitates those about him or her: parents, siblings, and logic and psychosocial nature. other adults. The toddler develops by mimicking observed behavior and receiving either positive or negative reinforcement. Values begin to form as the toddler begins to become aware of others and to inter- NANDA TAXONOMY: DOMAIN 10—LIFE act with those around him or her. Values become known to individ- PRINCIPLES; CLASS 3—VALUE/BELIEF/ACTION uals through the process of social cognition, which begins in early CONGRUENCE childhood. This arises not from objects nor the subject but from the NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING interaction between the subject and those objects.13 (Fowler’s stage 1) ASSISTANCE SCHOOL-AGE CHILD NOC: DOMAIN V—PERCEIVED HEALTH; CLASS U—HEALTH AND LIFE QUALITY The school-age child begins to be influenced by peers outside the family structure and begins to question and make choices. The DEFINING CHARACTERISTICS15 school-age child actively participates in his or her own moral de- velopment. Individual reasoning develops through various stages, A. Risk for Spiritual Distress (Risk Factors) beginning in the school-age years.14 Play is the major mechanism 1. Energy-consuming anxiety of learning throughout the school-age years. (Fowler’s stage 2) 2. Low self-esteem 3. Mental illness ADOLESCENT 4. Blocks to self-love The adolescent searches for his or her own identity and begins to 5. Poor relationships practice values that are separate and yet congruent with his or her 6. Physical or psychological stress family unit. The adolescent is constantly questioning, trying, and 7. Substance abuse searching for the “truth of life” and for his or her identity in the 8. Loss of loved one scheme of things. He or she sees values as being either “black or 9. Natural disasters white,” and there can be no overlapping. The adolescent is still 10. Situational losses struggling with his or her own independence and formulating his or 11. Maturational losses her own values, beliefs, and spirituality. (Fowler’s stages 2 and 3) 12. Inability to forgive B. Spiritual Distress 1. Expresses concern with meaning of life or death and/or YOUNG ADULT belief systems Young adults are constantly examining, reformulating, and chang- 2. Questions moral or ethical implications of therapeutic ing their values, beliefs, and spirituality. Often they change com- regimen pletely the values and beliefs they developed during adolescence, 3. Description of nightmares or sleep disturbances although it is important to note that they often keep the basic val- 4. Verbalizes inner conflict about beliefs ues and beliefs they learned during their young years with their 5. Verbalizes concern about relationship with deity families. (Fowler’s stages 3 and 4) 6. Unable to participate in usual religious practices 7. Seeks spiritual assistance ADULT 8. Questions meaning of suffering 9. Questions meaning of own existence Adults usually strengthen the values and beliefs they have formed ac- 10. Displacement of anger toward religious representatives cording to their life experiences. The adult is continually exploring and 11. Expresses anger toward God trying to see whether his or her value system fits within his or her 12. Alteration in behavior or

mood evidenced by anger, crying, lifestyle. They are busy teaching children the values and beliefs that they withdrawal, preoccupation, anxiety, hostility, apathy, and wish their children to adopt for their lives. (Fowler’s stages 4 and 5) so forth 13. Gallows humor (inappropriate humor in a grave situation) OLDER ADULT RELATED FACTORS15 Older adults find great solace in their spirituality and the values and beliefs they have formed through a lifetime. In general, the older A. Risk for Spiritual Distress adult continues to use the values, beliefs, and spiritual patterns The risk factors also serve as the related factors. adopted in adulthood.5 (Fowler’s stages 5 and 6) B. Spiritual Distress 1. Challenged belief and value system, for example, as a re- sult of moral or ethical implications of therapy or intense APPLICABLE NURSING DIAGNOSES suffering 2. Separation from religious or cultural ties Spiritual Distress, Risk for and Actual RELATED CLINICAL CONCERNS DEFINITIONS15 1. Cancer Risk for Spiritual Distress At risk for an altered sense of harmo- 2. Severe head injury, for example, brain death nious connectedness with all of life and the universe in which di- 3. Chronic illnesses, for example, rheumatoid arthritis or multiple mensions that transcend and empower the self may be disrupted. sclerosis Copyright © 2002 F.A. Davis Company 684 VALUE-BELIEF PATTERN 4. Mental retardation 7. Stillbirth, fetal demise, or miscarriage 5. Burns 8. Infertility 6. Sudden infant death syndrome (SIDS) HAVE YOU SELECTED THE CORRECT DIAGNOSIS? Ineffective Individual Coping Many individuals use live fully functional lives despite physical religion or beliefs as a means of bargaining in handicaps. If the patient mentions any of the unwanted life situations or denying their role in the defining characteristics of this diagnosis, then the situation by blaming it on a superior being. Others primary diagnosis is Spiritual Distress, which must will find their source of strength and hope from their be attended to before trying to intervene for beliefs in a superior being or God and are able to Ineffective Individual Coping. EXPECTED OUTCOME TARGET DATES Will describe at least [number] support systems to use when spiri- Because of the largely subconscious nature of spiritual beliefs and tual conflict arises by [date]. values, it is recommended the target date be at least 5 days from the date of diagnosis. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Assist the patient to identify and define his or her values, Clarifies values and beliefs, and helps the patient understand particularly in relation to health and illness, through the use impact of values and beliefs on health and illness. of value clarification techniques such as sentence completion, rank-ordering exercises, and completion of health-value scales. • Demonstrate respect for and acceptance of the patient’s values Spiritual values and beliefs are highly personal. A nurse’s attitude and spiritual system by not judging, moralizing, arguing, or can positively or negatively influence the therapeutic relationship. advising changes in values or religious practices. • Adapt nursing therapeutics as necessary to incorporate values Maintains and respects the patient’s preferences during and religious beliefs, e.g., diet, administration of blood or blood hospitalization. products, or rituals. • Schedule appropriate rituals as necessary, e.g., baptism, Provides comfort for the patient. confession, or communion. • Arrange visits from support persons, e.g., chaplain, pastor, Each offers good listening skills that promote comfort and reduce rabbi, priest, or prayer group, as needed. anxiety. • Provide privacy for religious practices and rituals as necessary. Allows for expression of religious practices. • Encourage the family to bring significant symbols to the patient, Promotes comfort. e.g., Bible, rosary, or icons, as needed. • Plan to spend at least 15 min twice a day at [times] with the Promotes mutual sharing, and builds a trusting relationship. patient to allow verbalization, questioning, counseling, and support on a one-to-one basis. • Assist the patient to develop problem-solving behavior through Involves the patient in self-management activities. Increases practice of problem-solving techniques at least twice daily at motivation. [times] during hospitalization. Child Health ACTIONS/INTERVENTIONS RATIONALES • Support the patient in attaining or maintaining spiritual integrity Openness affords trust as the child grapples with the meaning of according to specific identified needs and developmental level. such stressors as illness and death. Remember to pay attention to the parental dyad’s value-belief preferences: (continued) Copyright © 2002 F.A. Davis Company SPIRITUAL DISTRESS, RISK FOR AND ACTUAL 685 (continued) ACTIONS/INTERVENTIONS RATIONALES � Allow for appropriate privacy. � Allow time for self-reflection. � Allow time for prayer and practice of worship as permitted. � Support the child in expressing feelings about spiritual distress and related factors through use of open-ended questions and providing time for this at least twice a day at [times]. � Act as advocate for the child and family when they are expressing differing beliefs from that of the staff, institution, or significant others. • Answer value-belief-related questions honestly according to the Sensitivity to needs within legal domains regarding appropriate patient’s developmental level and after conferring with the standards of care honors the child’s rights and attaches value to parents. the family’s cultural wishes. Women’s Health ACTIONS/INTERVENTIONS RATIONALES • Allow the mother and family to express feelings at the Allows the family to receive religious and social support as a less-than-perfect pregnancy outcome:16 means of coping. � Stillborn or infant death: (1) Provide time for the mother and family to see, hold, and take pictures of the infant if so desired. (2) Provide quiet, private place where the mother and family can be with the infant. (3) Arrange for religious practices requested, e.g., baptism or other rituals. (4) Contact religious or cultural leader as requested by the mother or family. (5) Refer to appropriate support groups within the community. (6) Do legacy building, e.g., cap, bracelets, certificate of life, and footprints.17 � Spontaneous abortion: (1) Provide the patient with factual information regarding Assists in reducing guilt, blame, etc. etiology of spontaneous abortion. (2) Encourage verbal expressions of grief. (3) Allow expression of feelings such as anger. (4) Do legacy building, e.g., cap, bracelets, certificate of life, and footprints.17 (5) Provide information on miscarriage and grief. (6) Contact religious or cultural leader as requested by the patient. (7) Provide referrals to appropriate support groups within Provides information and support for the family. the community. � Less-than-perfect baby, e.g., sick baby or infant with anomaly: (1) Provide quiet, private place for the mother and family to visit with the infant. (2) Encourage verbalization of fears and asking of any question by providing time for one-to-one interactions at least twice a day at [times]. (3) Encourage touching and holding of the infant by the mother and family. (4) Teach methods of caring for the infant, e.g., special feeding techniques. (5) Teach methods of coping with the stress connected with caring for the infant, e.g., planned alone time for relaxation techniques. (6) Assign one staff member to care for both the mother and infant. (continued) Copyright © 2002 F.A. Davis Company 686 VALUE-BELIEF PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES (7) Contact religious or cultural leader as requested by the mother or family. (8) Provide the patient with information and referrals to Provides support and information, and assists with coping. appropriate support groups and community agencies. • Provide support for the woman facing an unwanted pregnancy: � Encourage questions and verbalization of the patient’s life Provides information about choices and consequences of each expectations by providing at least 15 min of one-to-one time choice, which can assist with decision making. Gives long-term at least twice a day at [times]. support by providing referrals. � Provide information on options available to the patient, e.g., adoption, abortion, or keeping the baby. � Assist the patient in identifying lifestyle adjustments that each decision could entail, e.g., dealing with guilt or finances. � Involve significant others and include the patient’s religious or cultural leader, if so desired by the patient, in discussion and problem-solving activities regarding lifestyle adjustments. • Assist the patient facing gynecologic surgery to express her Provides support and gives preoperative information, which assist perceptions of lifestyle adjustments: with postoperative recovery. � Provide explanation of surgical procedure and perioperative nursing care. � Provide factual information as to physiologic and psychological reactions she may experience. � Allow the patient to grieve loss of body image, e.g., inability to have a child. � Involve significant others in discussion and problem-solving activities regarding life cycle changes that could affect self-concept and interpersonal relationships, e.g., hot flashes, sexual relationships, or ability to have children. • Participate with the patient in religious support activities, e.g., Demonstrates visible support for the role these activities play in praying or reading religious literature aloud. the patient’s life. Psychiatric Health ACTIONS/INTERVENTIONS RATIONALES • Remove items from the environment that increase problem Environment will assist the client in demonstrating appropriate behavior (list specific items for each client, e.g., Bible or coping behaviors, which increases opportunities for succeeding religious pictures). with new coping behaviors. Success provides reinforcement, which encourages positive behavior and enhances self-esteem. • Restrict visitors who increase problem behavior for the client. Promotes the client’s sense of control. Discuss with the family and other frequent visitors the necessity of not discussing the problem ideas with the client. • Request consultation from religious leader who has had Meets the client’s spiritual needs in a constructive manner. education and experience in assisting clients to cope with this type of spiritual distress. • Do not discuss with the client belief systems that are related to These discussions only serve to reinforce the client’s problem behavior (state here specifically what that content is). misconceptions. • Do not argue with the client about religious belief system or This would reinforce the dysfunctional belief system. behaviors that evolve from this system. • Do not joke with the client about belief system or behavior that Protects the client’s self-esteem at a time when it is most evolves from this system. vulnerable. • Spend time with the client when themes of conversation are not Presence of the nurse, at this time, provides reinforcement for related to the problem behavior. this behavior, which encourages the positive behavior and enhances self-esteem. • Limit topics of conversation to daily activities or situations that Environmental structure helps the client focus away from problem do not include religious beliefs. areas, which supports his or her efforts to enlist more appropriate coping behaviors. • Provide activities that decrease client time alone to reflect on the Provides the client with opportunities to practice alternative coping problem beliefs. Suggested activities include: behaviors in a supportive environment. � Physical exercise such as walks, bicycle riding, swimming, or exercise classes � Group activities such as board games, meal preparation, sports, or arts and crafts Copyright © 2002 F.A. Davis Company SPIRITUAL DISTRESS, RISK FOR AND ACTUAL 687 Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Encourage use of reminiscence to aid the patient in examining Assists the patient in finding meaning in life experiences and ego life.18 integrity. • Discuss with the patient possible sources of spiritual distress, Enables the patient to identify problem areas and potential and use problem-solving process as indicated. correctable measures to ameliorate distress. Home Health ACTIONS/INTERVENTIONS RATIONALES ACTUAL • Involve the client and family in planning, implementing, and Family and client involvement enhances the effectiveness of the promoting spiritual well-being through: interventions. � Arranging family conferences to discuss spiritual values. � Assisting with mutual goal setting for the client and family to enhance spiritual well-being of the client and family, such as personal prayer, interactions with clergy, family, and nurses to find meaning during illness.19 � Assigning family members to specific tasks that assist in maintaining spiritual well-being, e.g., support person for the client, companionship in meeting mutual goals, prayer, meditation, reading Scripture, etc.16 � Interviewing designed to provide opportunities for expression of spiritual needs.19 • Assist the client to identify factors contributing to spiritual Identification of contributing factors provides the opportunity for distress, e.g., significant life experiences, treatment prescribed planning designed to decrease these factors. by health care team, or inability to perform spiritual rituals. • Assist the client and family in lifestyle adjustments that may be Lifestyle changes require change in behavior. Self-evaluation and required, e.g., diet, environmental changes, or hygiene practices. support facilitate these changes. • Assist the client and family in expressing spirituality in the Facilitates expression of spirituality and access to

spiritual support home in as normal a fashion as possible; e.g., help arrange for systems. priest or pastoral visits, help arrange for visits from church friends, respect schedules necessary for worship, prayer, or meditation. • Refer to appropriate assistive resources as indicated. Challenges to one’s value system may require long-term follow-up. Use of the network of existing community services provides for effective utilization of resources. RISK FOR • Assist the client in a search for meaning of the client’s life as it The search for meaning is a common task of the human has been lived. This can be accomplished by asking the client experience.20,21 questions, such as: � “If you had your life to live over again, what would you like to be different and what the same?” � “What does it mean to you that this has happened?” • Recognize that spiritual strength comes from many secular The concept of God is different to all people, and spirituality is sources, such as finding hope and relationships with other derived from sources unique to each individual.20,21 people. • Listen without judging when clients share spiritual concerns. Talking in itself is therapeutic, and nonjudgmental listening may Active listening requires attention to and focus on the client. enable a client to work through difficult spiritual issues. Silence, presence, and concentration are significant spiritual tools. • Accept the client no matter what his or her understanding or Enhances the trust relationship between nurse and the client. experience of God. • Respect the client’s wishes about when he or she chooses to Enhances the trust relationship between nurse and the client. discuss issues of spirituality.20,21 • Avoid giving advice, offering solutions, or platitudes.20,21 Often a client’s questions about spiritual issues are ways of beginning a difficult conversation, rather than a search for answers from a nurse. Copyright © 2002 F.A. Davis Company 688 VALUE-BELIEF PATTERN Spiritual Distress, Risk for and Actual FLOWCHART EVALUATION: EXPECTED OUTCOME Can the patient describe at least X number of support systems to use when spirituality conflict arises? Yes No Record data, e.g., has identified Sunday Reassess using initial assessment factors. School teacher and church youth director as usable support systems; both have visited and are willing to assist. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., has identified one support system—next-door Did evaluation show another neighbor who is church organist— problem had arisen? Yes not sure how neighbor can help or where to locate any other support systems. Record CONTINUE and change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company SPIRITUAL WELL-BEING, READINESS FOR ENHANCED 689 Spiritual Well-Being, Readiness for RELATED CLINICAL CONCERNS Enhanced 1. Any terminal diagnosis DEFINITION15 2. Any chronic disease diagnosis Process of developing or unfolding of mystery through harmonious interconnectedness that springs from inner strengths. HAVE YOU SELECTED THE CORRECT DIAGNOSIS? NANDA TAXONOMY: DOMAIN 10—LIFE PRINCIPLES; CLASS 2—BELIEFS Spiritual Distress This diagnosis indicates that the patient is experiencing significant NIC: DOMAIN 3—BEHAVIORAL; CLASS R—COPING problems with spirituality. Readiness for ASSISTANCE Enhanced Spiritual Well-Being indicates that NOC: DOMAIN IV—PERCEIVED HEALTH; the patient is making progress in resolving CLASS U—HEALTH AND LIFE QUALITY any such problems. DEFINING CHARACTERISTICS15 EXPECTED OUTCOME 1. Inner Strengths: A sense of awareness, self-consciousness, sacred source, unifying force, inner core, and transcendence Will exhibit majority [percent number] of defining characteristics 2. Unfolding Mystery: One’s experience about life’s purpose and for diagnosis by [date]. meaning, mystery, uncertainty, and struggles 3. Harmonious Interconnectedness: Harmony, relatedness, and TARGET DATES connectedness with self, others, Higher Power or God, and the environment The target date for this diagnosis will be highly individualized. An appropriate initial date to check progress would be 10 to 14 days. RELATED FACTORS15 None given. NURSING ACTIONS/INTERVENTIONS WITH RATIONALES Adult Health ACTIONS/INTERVENTIONS RATIONALES • Establish a trusting relationship. A trusting relationship assists the patient to express his or her feelings to the nurse. • Provide in-depth spiritual assessment. These are all spiritual care practices that enhance spirituality.22–24 • Convey technical competence. • Act as facilitator among the family, clergy, and other providers. • Be present: touch, make eye contact, and use appropriate facial expressions. • Treat the patient as a unique individual. • Inquire about religion, values, relationships, transcendence, Spirituality is expressed in all these areas.25 affective feeling, communication, and spiritual practices. • Support and enhance the patient’s spirituality. • Pray for and with the patient. These are all spiritual care practices. • Read Bible with the patient. • Refer to chaplain, clergy, or spiritual advisor. • Provide with religious materials. • Serve as a therapeutic presence. • Listen and talk to the patient. • If possible, allow the patient to interact and/or “care” for other Provides expansion of personal boundaries through connectedness. patients. Provides a sense of wholeness and well-being. Person may be “ill” and still be “healthy” in terms of spirituality, as spirituality provides the patient with the capacity for health through transcendence of ordinary boundaries and various modes of connectedness.26 (continued) Copyright © 2002 F.A. Davis Company 690 VALUE-BELIEF PATTERN (continued) ACTIONS/INTERVENTIONS RATIONALES • Encourage the patient to talk about and reflect on hopes, Solitude may liberate the spirit and lead to true knowledge of self, dreams, God, faith, religious beliefs, social support, acceptance, peace and joy, and an appreciation of life on a more profound health, forgiveness, hopelessness; provide privacy and personal level.27 time for reflection; assure presence of higher being. • Encourage family and friends’ interactions with the patient to express love and concern for the patient. • Have the patient express his or her health and well-being Expressions of self-transcendence may differ across individuals and through connectedness—intrapersonally, interpersonally, and life phases in general.26 Interactions within the person and with transpersonally. the environment generate conflicts that can provide the impetus for development through self-transcendence. Making meaning of life is integral to human development and enhancement of health.28 • Advocate for the patient’s spiritual beliefs with the health team. • Show respect and support of the patient’s beliefs and values.24 Shows respect and support of the patient’s beliefs and values.24 • Demonstrate compassion and acceptance. Be sensitive to the Spiritual nursing care needs to be based on a more universal patient’s spiritual needs. concept of inspiring rather than focusing around religious concepts.29 However, depending on the patient’s beliefs, religious concepts may be integral to care. • Assist the patient to meet own spiritual needs. Assist the patient to use spiritual resources to meet personal situation. • Encourage the patient to keep significant symbols nearby. Significant symbols can be a source of consolation and spiritual support.27 • Inform the patient and family where chapel or prayer room is A patient’s spiritual needs are complex and individual.24 located. • Be willing to cooperate with and/or facilitate the administration Shows respect for the patient’s spiritual values and needs.27 of the patient’s rituals. • Nurse should determine own values and spirituality. Awareness of nurse’s own feelings is helpful in guiding and/or controlling his or her actions.24 Child Health NOTE: Consider all actions listed for Adult Health, but modify them to be developmentally appro- priate. When the infant or child is incapable of expressing spiritual preferences or indices, refer the child to parents or staff or advocacy as deemed appropriate. ACTIONS/INTERVENTIONS RATIONALES • Allow 30 min each shift for expression of feelings about current Feelings regarding current status will provide opportunity to health status and/or offer structured observation of the infant, know spiritual factors valued. child, or parents to offer insight into thoughts relevant to current status. • Allow for component of play therapy to provide spiritual data. Play facilitates meaningful interaction for children and may best afford insights into thought processes. • Abide by the family’s wishes in times of spiritual need and as Trust will be afforded to enhance current spiritual well-being part of regular care to degree possible. when it is shown to have value. • Incorporate spirituality into local support system by encouraging Valuing of community potentials increases likelihood of spiritual donations of time, reading materials, videos, art supplies, etc., support, especially for young. with age-appropriate materials for all levels of development. Women’s Health ACTIONS/INTERVENTIONS RATIONALES NOTE: All the actions under Spiritual Distress can apply here as well as the following: • Allow the woman and her family to direct the spiritual care By allowing the patient to express her own beliefs and values, needed when possible. strengths, and relationships, great insight into how health care providers can provide high-quality care to the whole person can emerge. This can form the basis of care or support to patients. • Be available and willing to call whatever spiritual advisor the woman and family wish. (continued) Copyright © 2002 F.A. Davis Company SPIRITUAL WELL-BEING, READINESS FOR ENHANCED 691 (continued) ACTIONS/INTERVENTIONS RATIONALES • Provide quiet, noninterruptive space for discussion, prayer, or communication with spiritual advisor. • Allow the patient and family to participate in rituals as requested when possible. • Be open to spiritual awareness in both the patient’s life and in the nurse’s own life. This could be accomplished through being a participant in a dream-telling group.9 • Assess how the patient views her “sense of fit” in her world.30 • Assess the patient’s sources of strength and relationships that are important to her.30 • Encourage the woman to give voice to her story.30 • Encourage time for self-reflection and making connections. Psychiatric Health Refer to Adult Health interventions. Gerontic Health ACTIONS/INTERVENTIONS RATIONALES • Determine availability of religious services or ceremonies for the If the patient attends religious services, he or she may need patient. information about what services are offered. The number of active, participating church members is highest in the older adult group. • Coordinate, as needed, transportation to formal services or Aging physical changes may interfere with access to services. visits from religious representatives. • Provide time for religious activities or personal time for Depending on the care setting and care needs, it may be difficult meditation or contemplation. to incorporate activities or personal time, and the patient may be hesitant to make the need known. • Establish ongoing relationship with the patient that fosters trust Provides an opportunity to gradually reveal self and nurture and sharing. spiritual growth for the caregiver and the care recipient. • Encourage life review or reminiscing to assist the older patient Offers insight into coping ability and needs. in identification of past stressors and coping skills. • Discuss how aging has changed the patient, from his or her Enhances self-worth and problem-solving skills the older patient perspective, and what those changes have meant to the patient. possesses. Promotes developmentally appropriate reflection. • Discuss spiritual care needs with the patient, and identify Clergy are frequently used as personal counselors by older adults. preferred spiritual advisor, counselor, or resource for the patient. • Offer opportunities to pray with the older patient, if you are Health-related prayer is considered a source of comfort to many comfortable in so doing. older patients. Home Health ACTIONS/INTERVENTIONS RATIONALES • Involve the client and family in planning and implementing Family involvement enhances effectiveness of intervention. strategies to enhance spiritual well-being: � Identify values and beliefs. � Develop lifestyle choices that support values and beliefs. � Explore meaning of spirituality to self and family. � Identify actions and behaviors that express spirituality. Copyright © 2002 F.A. Davis Company 692 VALUE-BELIEF PATTERN Spiritual Well-Being, Readiness for Enhanced FLOWCHART EVALUATION: EXPECTED OUTCOME Does the patient exhibit stated percentage of defining characteristics? Yes No Record data, e.g., exhibits all of defining Reassess using initial assessment factors. characteristics. Record RESOLVED. Delete nursing diagnosis, expected outcome, target date, and nursing actions. No Is diagnosis validated? Record new assessment data. Record REVISE. Add new diagnosis, expected outcome, target date, and nursing actions. Yes Delete invalidated diagnosis. Start new evaluation process. Record data, e.g., exhibits only 1 of defining characteristics. List Did evaluation show another here. Record CONTINUE and problem had arisen? Yes change target date. Modify nursing actions as necessary. No Finished Copyright © 2002 F.A. Davis Company APPENDIX A Image/Text rights unavailable 693 Copyright © 2002 F.A. Davis Company APPENDIX B Admission

Assessment Form and Sample ADMISSION ASSESSMENT FORM Demographic Data Date: _____________ Time: ____________ Name: __________________________________________________________________________________ D.O.B.: ________________________________ Age: _________________ Sex: ______________________ Primary Significant Other: _________________________________ Telephone #: _____________________ Name of Primary Information Source: _________________________________________________________ Admitting Medical Diagnosis: _______________________________________________________________ Vital Signs Temperature: ________ F __ C __ ; Oral __ Rectal __ Axillary __ Tympanic __ Pulse Rate: Radial _____ Apical _____ ; Regular __ Irregular __ Respiratory Rate: ______ Abdominal __ Diaphragmatic __ Blood Pressure: Left arm _______ ; Right arm _______ ; Sitting __ Standing __ Lying down __ Weight: _______ pounds, _______ kilograms; Height: ___ feet ___ inches, _____ meters Do you have any allergies? No __ Yes __ What? _______________________________________________ (Check reactions to medications, foods, cosmetics, insect bites, etc.) Review admission CBC, urinalyses, and chest x-ray. Note any abnormalities here: ________________________________________________________________________________________ Health Perception–Health Management Pattern SUBJECTIVE 1. How would you describe your usual health status? Good __ Fair __ Poor __ 2. Are you satisfied with your usual health status? Yes ___ No ___ Source of dissatisfaction _________________________________________________________________ 3. Tobacco use? No ___ Yes ___ Number of packs per day? _____________________________________ 4. Alcohol use? No ___ Yes ___ How much and what kind? ______________________________________ 694 Copyright © 2002 F.A. Davis Company APPENDIX B 695 5. Street drug use? No ___ Yes ___ What and how much? _____________________________________ 6. Any history of chronic diseases? No ___ Yes ___ Describe ____________________________________ ____________________________________________________________________________________ 7. Immunization History: Tetanus ______ ; Pneumonia ______ ; Influenza ______ ; MMR ______ ; Polio ______ ; Hepatitis B ______ ; Hib ______ 8. Have you sought any health care assistance in the past year? No ___ Yes ___ If yes, why? __________________________________________________________________________ 9. Are you currently working? Yes ___ No ___ How would you rate your working conditions (e.g., safety, noise, space, heating, cooling, water, ventilation)? Excellent ____ Good ____ Fair ____ Poor ____ Describe any problem areas __________________ ____________________________________________________________________________________ 10. How would you rate living conditions at home? Excellent ___ Good ___ Fair ___ Poor ___ Describe any problem areas ______________________________________________________________ 11. Do you have any difficulty securing any of the following services? Grocery store? Yes ___ No ___ ; Pharmacy? Yes ___ No ___ ; Health care facility? Yes ___ No ___ ; Transportation? Yes ___ No ___ ; Telephone (for police, fire, ambulance, etc.)? Yes ___ No ___ If any difficulties, note referral here _______________________________________________________ 12. Medications (over-the-counter and prescriptive) NAME DOSAGE AMT. TIMES/DAY REASON TAKING AS ORDERED _____________________________________________________________________ Yes ___ No ___ _____________________________________________________________________ Yes ___ No ___ _____________________________________________________________________ Yes ___ No ___ _____________________________________________________________________ Yes ___ No ___ _____________________________________________________________________ Yes ___ No ___ _____________________________________________________________________ Yes ___ No ___ _____________________________________________________________________ Yes ___ No ___ _____________________________________________________________________ Yes ___ No ___ 13. Have you followed the routine prescribed for you? Yes ___ No ___ Why not? ____________________________________________________________________________ 14. Did you think this prescribed routine was the best for you? Yes ___ No ___ What would be better? _________________________________________________________________ 15. Have you had any accidents/injuries/falls in the past year? No ___ Yes ___ Describe _____________________________________________________________________________ 16. Have you had any problems with cuts healing? No ___ Yes ___ Describe__________________________ ____________________________________________________________________________________ 17. Do you exercise on a regular basis? No ___ Yes ___ Type and Frequency __________________________ ____________________________________________________________________________________ 18. Have you experienced any ringing in the ears? Right ear: Yes ___ No ___ Left ear: Yes ___ No ___ 19. Have you experienced any vertigo? Yes ___ No ___ How often and when? _________________________ ____________________________________________________________________________________ 20. Do you regularly use seat belts? Yes ____ No ____ 21. For infants and children, are car seats used regularly? Yes ____ No ____ 22. Do you have any suggestions or assistance requests for improving your health? No ___ Yes _________________________________________________________________________ 23. Do you do (breast/testicular) self-examination? No ___ Yes ___ How often? ___________________________________________________________________________ 24. Were you or your family able to meet all your therapeutic needs? Yes ___ No ___ 25. Are you scheduled for surgery? Yes ___ No ___ 26. Have you recently had surgery? No ___ Yes ___ Date __________ Copyright © 2002 F.A. Davis Company 696 APPENDIX B OBJECTIVE 1. Mental Status (Indicate assessment with an X) a. Oriented ___ Disoriented ___ Length of time __________ Time: Yes ___ No ___ Length of time __________ Place: Yes ___ No ___ Length of time __________ Person: Yes ___ No ___ Length of time __________ b. Sensorium Alert ___ ; Drowsy ___ ; Lethargic ___ ; Stuporous ___ ; Comatose ___ ; Cooperative ___ ; Combative ___ ; Delusions ___ ; Fluctuating levels of consciousness? Yes ___ No ___ Appropriate response to stimuli? Yes ___ No ___ c. Memory Recent: Yes ___ No ___ ; Remote: Yes ___ No ___ ; Past 4 hours: Yes ___ No ___ d. Is there a disruption of the flow of energy surrounding the person? Yes ___ No ___ Change in color? Yes ___ No ___ ; Change in temperature? Yes ___ No ___ ; Field? Yes ___ No ___ ; Movement? Yes ___ No ___ ; Sound? Yes ___ No ___ e. Responds to simple directions? Yes ___ No ___ 2. Vision a. Visual Acuity: Both eyes 20/___ Right 20/___ Left 20/___ Not assessed ___ b. Pupil Size: Right: Normal ___ Abnormal ___ ; Left: Normal ___ Abnormal ___ Description of abnormalities ____________________________________________________________ c. Pupil Reaction: Right: Normal ___ Abnormal ___ ; Left: Normal ___ Abnormal ___ Description of abnormalities ____________________________________________________________ d. Wears glasses? Yes ___ No ___ ; Contact lenses? Yes ___ No ___ 3. Hearing: Not assessed ___ a. Right ear: WNL ___ Impaired ___ Deaf ___ ; Left ear: WNL ___ Impaired ___ Deaf ___ b. Hearing aid? Yes ___ No ___ 4. Taste a. Sweet: Normal ___ Abnormal ___ Describe ________________________________________________ b. Sour: Normal ___ Abnormal ___ Describe _________________________________________________ c. Tongue Movement: Normal ___ Abnormal ___ Describe ______________________________________ d. Tongue Appearance: Normal ___ Abnormal ___ Describe ____________________________________ 5. Touch a. Blunt: Normal ___ Abnormal ___ Describe ________________________________________________ b. Sharp: Normal ___ Abnormal ___ Describe ________________________________________________ c. Light Touch Sensation: Normal ___ Abnormal ___ Describe __________________________________ d. Proprioception: Normal ___ Abnormal ___ Describe ________________________________________ e. Heat: Normal ___ Abnormal ___ Describe _______________________________________________ f. Cold: Normal ___ Abnormal ___ Describe _______________________________________________ g. Any numbness? No ___ Yes ___ Describe ________________________________________________ h. Any tingling? No ___ Yes ___ Describe __________________________________________________ 6. Smell a. Right Nostril: Normal ___ Abnormal ___ Describe _________________________________________ b. Left Nostril: Normal ___ Abnormal ___ Describe __________________________________________ 7. Assess Cranial Nerves: Normal ___ Abnormal ____ Describe deviations ____________________________________________________________________ 8. Cerebellar Exam (Romberg, balance, gait, coordination, etc.): Normal ___ Abnormal ___ Describe _____________________________________________________________________________ 9. Assess Reflexes: Normal ___ Abnormal ___ Describe _________________________________________ _____________________________________________________________________________________ Copyright © 2002 F.A. Davis Company APPENDIX B 697 10. Throat: Enlarged tonsils? No ___ Yes ___ Location __________________________________________ Tenderness? No ___ Yes ___ Exudate on tonsils? No ___ Yes ___ Color _________________________ Uvula midline? No ___ Yes ___ 11. Neck: Any enlarged lymph nodes? No ___ Yes ___ Location and size ____________________________ ____________________________________________________________________________________ 12. General Appearance a. Hair _____________________________________________________________________________ b. Skin _____________________________________________________________________________ Does the patient exhibit any eczema? No ___ Yes ___ Where? _________________________________ c. Nails ____________________________________________________________________________ d. Body Odor ________________________________________________________________________ 13. Does the patient have a history of multiple surgeries or a history of reaction to latex? No ___Yes ___ Which one? ___ Multiple surgeries ___ Reaction to latex 14. Is the patient’s surgical incision healing properly? N/A ___ Yes ___ No ___ Describe ___________________________________________________________________________ Nutritional-Metabolic Pattern SUBJECTIVE 1. Any weight gain in last 6 months? No ___ Yes ___ Amount ___________________________________ 2. Any weight loss in last 6 months? No ___ Yes ___ Amount ____________________________________ 3. Would you describe your appetite as: Good ___ Fair ___ Poor ___ 4. Do you have any food intolerances? No ___ Yes ___ Describe __________________________________ ____________________________________________________________________________________ 5. Do you have any dietary restrictions? (Check for those that are a part of a prescribed regimen as well as those that patient restricts voluntarily; for example, to prevent flatus.) No ___ Yes ___ What__________________________________________________________________ 6. Describe an average day’s food intake for you (meals and snacks). ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 7. Describe an average day’s fluid intake for you. _______________________________________________ ____________________________________________________________________________________ 8. Describe food likes and dislikes. __________________________________________________________ ____________________________________________________________________________________ 9. Would you like to: Gain weight? ___ Lose weight? ___ Neither ___ 10. Any problems with: a. Nausea? No ___ Yes ___ Describe _____________________________________________________ b. Vomiting? No ___ Yes ___ Describe ____________________________________________________ c. Swallowing? No ___ Yes ___ Describe __________________________________________________ d. Chewing? No ___ Yes ___ Describe ____________________________________________________ e. Indigestion? No ___ Yes ___ Describe __________________________________________________ 11. Would you describe your usual lifestyle as: Active ___ Sedate ___ 12. Do you have any chronic health problems? No ___ Yes ___ Describe ____________________________ ____________________________________________________________________________________ For breastfeeding mothers only: 13. Do you have any concerns about breastfeeding? No ___ Yes ___ Describe ____________________________________________________________________________ Copyright © 2002 F.A. Davis Company 698 APPENDIX B 14. Are you having any problems with breastfeeding? No ___ Yes ___ Describe ___________________________________________________________________________ OBJECTIVE 1. Skin Examination a. Warm ____ Cool ____ Moist ____ Dry ____ b. Lesions? No ___ Yes ___ Describe _____________________________________________________ c. Rash? No ___ Yes ___ Describe _______________________________________________________ d. Turgor: Firm ____ Supple ____ Dehydrated ____ Fragile ____ e. Color: Pale ____ Pink ____ Dusky ____ Cyanotic ____ Jaundiced ____ Mottled ____ Other ____________________________________________________________________________ 2. Mucous Membranes a. Mouth (1) Moist ____ Dry ____ (2) Lesions? No ___ Yes ___ Describe _________________________________________________ (3) Color: Pale ____ Pink ____ (4) Teeth: Normal ___ Abnormal ___ Describe _____________________________________________ (5) Dentures? No ___ Yes ___ Upper ____ Lower ____ Partial ____ (6) Gums: Normal ___ Abnormal ___ Describe __________________________________________ (7) Tongue: Normal ___ Abnormal ___ Describe _________________________________________ b. Eyes (1) Moist ____ Dry ____ (2) Color of conjunctivae: Pale ____ Pink ____ Jaundiced ____ (3) Lesions? No ___ Yes ___ Describe _________________________________________________ 3. Edema a. General? No ___ Yes ___ Describe _________________________________________________________________________ __________________________________________________________________________________ Abdominal Girth: _______inches; Not measured ____ b. Periorbital? No ___ Yes ___ Describe ____________________________________________________ c. Dependent? No ___ Yes ___ Describe ___________________________________________________ Ankle Girth: Right _____ inches; Left _____ inches; Not measured ____ 4. Thyroid: Normal ____ Abnormal ____ Describe ____________________________________________ 5. Jugular vein distention? No ___ Yes ___ 6. Gag Reflex: Present ___ Absent ___ 7. Can the patient move self easily (turning, walking)? Yes ___ No ___ Describe limitations ___________________________________________________________________ 8. Upon admission was the patient dressed appropriately for the weather? Yes ___ No ___ Describe ____________________________________________________________________________ For breastfeeding mothers only: 9. Breast Exam: Normal ____ Abnormal ____ Describe __________________________________________ ____________________________________________________________________________________ 10. Weigh the infant. Is the infant’s weight within normal limits? Yes ___ No ___ Elimination Pattern SUBJECTIVE 1. What is your usual frequency of bowel movements? __________________________________________ a. Have to strain to have bowel movement? No ___ Yes ___ Copyright © 2002 F.A. Davis Company APPENDIX B 699 b. Same time each day? No ___ Yes ___ 2. Has the number of bowel movements changed in the past week? No ___ Yes ___ Increased ___ Decreased ___ 3. Character of stool: a. Consistency: Hard ____ Soft ____ Liquid ____ b. Color: Brown ____ Black ____ Yellow ____ Clay colored____ c. Bleeding with bowel movements? No ___ Yes ___ 4. History of constipation? No ___ Yes ___ How often ________________________________ Use bowel movement aids (laxatives, suppositories, diet)? No ___ Yes ___ Describe _____________________________________________________________________________ 5. History of diarrhea? No ___ Yes ___ When __________________________________________________ 6. History of incontinence? No ___ Yes ___ Related to increased abdominal pressure (coughing, laughing, sneezing)? No ___ Yes ___ 7. History of recent travel? No ___ Yes ___ Where ______________________________________________ 8. Usual voiding pattern: a. Frequency (times/day) ________ Decreased ___ Increased ___ b. Change in awareness of need to void? No ___ Yes ___ Increased ___ Decreased ___ c. Change in urge to void? No ___ Yes ___ Increased ___ Decreased ___ d. Any change in amount? No ___ Yes ___ Decreased ___ Increased ___ e. Color: Yellow ____ Smoky ____ Dark ____ f. Incontinence? No ___Yes ___ When ____________________________________________________ Difficulty holding voiding when urge to void develops? No ____ Yes ____ Have time to get to bathroom? Yes ____ No ____ How often does problem of reaching the bathroom occur? ___________________________________ g. Retention? No ___ Yes ___ Describe ____________________________________________________ h. Pain/burning? No ___ Yes ___ Describe __________________________________________________ i. Sensation of bladder spasms? No ___ Yes ___ When ________________________________________ OBJECTIVE 1. Auscultate abdomen. a. Bowel Sounds: Normal ____ Increased ____ Decreased ____ Absent ____ 2.

Palpate abdomen. a. Tender? No ___ Yes ___ Where? _______________________________________________________ b. Soft? Yes ___ No ___ ; Firm? Yes ___ No ___ c. Masses? No ___ Yes ___ Describe _______________________________________________________ d. Distention (include distended bladder)? No ___ Yes ___ Describe _____________________________ ___________________________________________________________________________________ e. Overflow urine when bladder palpated? Yes ___ No ___ 3. Rectal Exam a. Sphincter tone: Describe ______________________________________________________________ b. Hemorrhoids? No ___ Yes ___ Describe _________________________________________________ c. Stool in rectum? No ___ Yes ___ Describe ________________________________________________ d. Impaction? No ___ Yes ___ Describe ____________________________________________________ e. Occult blood? No ___ Yes ___ 4. Ostomy present? No ___ Yes ___ Location __________________________________________________ Copyright © 2002 F.A. Davis Company 700 APPENDIX B Activity-Exercise Pattern SUBJECTIVE 1. Using the following Functional Level Classification, have the patient rate each area of self-care. (Code adapted by NANDA from Jones, E, et al: Patient Classification for Long-Term Care: Users’ Manual, HEW Publication No. HRA-74-3107. November, 1974.) 0  Completely independent 1  Requires use of equipment or device 2  Requires help from another person for assistance, supervision, or teaching 3  Requires help from another person and equipment or device 4  Dependent, does not participate in activity Feeding _____; Bathing/hygiene _____; Dressing/grooming _____; Toileting _____; Ambulation _____; Care of home ______; Shopping ____; Meal preparation _____; Laundry _____; Transportation _____ 2. Oxygen use at home? No ___ Yes ___ Describe ______________________________________________ 3. How many pillows do you use to sleep on? ______ 4. Do you frequently experience fatigue? No ___ Yes ___ Describe _________________________________ _____________________________________________________________________________________ 5. How many stairs can you climb without experiencing any difficulty (can be individual number or number of flights)? ___________________________________________________________________________ 6. How far can you walk without experiencing any difficulty? ____________________________________ 7. Any history of falls? No ___ Yes ___ How often? ____________________________________________ 8. Has assistance at home for care of self and maintenance of home? No ___ Yes ___ Who _______________________________________________________________________________ If no, would like to have or believes needs to have assistance? No ___ Yes ___ With what activities? __________________________________________________________________ 9. Occupation (if retired, former occupation) ________________________________________________ 10. Describe your usual leisure time activities/hobbies. __________________________________________ ____________________________________________________________________________________ 11. Any complaints of weakness or lack of energy? No ___ Yes ___ Describe ____________________________________________________________________________ 12. Any difficulties in maintaining activities of daily living? No ___ Yes ___ Describe ____________________________________________________________________________ 13. Any problems with concentration? No ___ Yes ___ Describe ____________________________________________________________________________ 14. If in wheelchair, do you have any problems manipulating the wheelchair? No ___ Yes ___ Describe ____________________________________________________________________________ 15. Can you move yourself from site to site with no problems? Yes ___ No ____ Describe ____________________________________________________________________________ OBJECTIVE 1. Cardiovascular a. Cyanosis? No ___ Yes ____ Where? ____________________________________________________ b. Pulses: Easily palpable? Carotid: Yes ___ No ___; Jugular: Yes ___ No ___; Temporal: Yes ___ No ___; Radial: Yes ___ No ___; Femoral: Yes ___ No ___; Popliteal: Yes ___ No ___; Post tibial: Yes ___ No ___; Dorsalis pedis: Yes ___ No ___ c. Extremities (1) Temperature: Cold ___ Cool ___ Warm ___ Hot ___ (2) Capillary Refill: Normal ___ Delayed ___ Copyright © 2002 F.A. Davis Company APPENDIX B 701 (3) Color: Pink ___ Pale ___ Cyanotic ___ Other ___ Describe _______________________________________________________________________ (4) Homans’ sign? No ___ Yes ___ (5) Nails: Normal ___ Abnormal ___ Describe _____________________________________________ (6) Hair Distribution: Normal ___ Abnormal ___ Describe __________________________________ _______________________________________________________________________________ (7) Claudication? No ___ Yes ___ Describe ______________________________________________ d. Heart: PMI Location _________________________________________________________________ (1) Abnormal rhythm? No ___ Yes ___ Describe __________________________________________ _______________________________________________________________________________ (2) Abnormal sounds? No ___ Yes ___ Describe __________________________________________ _______________________________________________________________________________ 2. Respiratory a. Rate ________ ; Depth: Shallow ___ Deep ___ Abdominal ___ Diaphragmatic ___ b. Have the patient cough. Any sputum? No ___ Yes ___ Describe ______________________________ ___________________________________________________________________________________ c. Fremitus? No ___ Yes ___ d. Any chest excursion? No ___ Yes ___ Equal ___ Unequal ___ e. Auscultate chest. Any abnormal sounds (rales, rhonchi)? No ___ Yes ___ Describe ___________________________________________________________________________ f. Have the patient walk in place for 3 minutes (if permissible): (1) Any shortness of breath after activity? No ___ Yes ___ (2) Any dyspnea? No ___ Yes ___ (3) BP after activity _____/______ in (right/left) arm (4) Respiratory rate after activity ________ (5) Pulse rate after activity _______ 3. Musculoskeletal a. Range of motion: Normal ____ Limited ____ Describe ______________________________________ b. Gait: Normal ____ Abnormal ____ Describe ______________________________________________ c. Balance: Normal ____ Abnormal ____ Describe ___________________________________________ d. Muscle Mass/Strength: Normal ____ Increased ____ Decreased ____ Describe ___________________________________________________________________________ e. Hand Grasp: Right: Normal ____ Decreased ____ Left: Normal ____ Decreased ____ f. Toe Wiggle: Right: Normal ____ Decreased ____ Left: Normal ____ Decreased ____ g. Posture: Normal ____ Kyphosis ____ Lordosis ____ h. Deformities? No ___ Yes ___ Describe ___________________________________________________ i. Missing limbs? No ___ Yes ___ Where ___________________________________________________ j. Uses mobility assistive devices (walker, crutches, etc.)? No ___ Yes ___ Describe ___________________________________________________________________________ k. Tremors? No ___ Yes ___ Describe _____________________________________________________ l. Traction or casts present? No ___ Yes ___ Describe ________________________________________ m. Easily turns in bed? Yes ___ No ___ Describe _____________________________________________ 4. Spinal cord injury? No ___ Yes ___ Level ___________________________________________________ 5. Paralysis present? No ___ Yes ___ Where ___________________________________________________ 6. Conduct developmental assessment. Normal ____ Abnormal ____ Describe _______________________ ______________________________________________________________________________________ 7. Responds appropriately to stimuli? Yes ___ No ___ Describe ____________________________________ ______________________________________________________________________________________ 8. Are there any abnormal movements? No ___ Yes ___ Describe __________________________________ ____________________________________________________________________________________ Copyright © 2002 F.A. Davis Company 702 APPENDIX B 9. Frequent walking in hall? No ___ Yes ___ 10. Episodes of trespassing or getting lost? No ___ Yes ___ Sleep-Rest Pattern SUBJECTIVE 1. Usual sleep habits: Hours/night ______ ; Naps? No ___ Yes ___ a.m. ____ p.m. ____ Feel rested? Yes ___ No ___ Describe ______________________________________________________ 2. Any problems: a. Difficulty going to sleep? No ___ Yes ___ b. Awakening during night? No ___ Yes ___ c. Early awakening? No ___ Yes ___ d. Insomnia? No ___ Yes ___ Describe _____________________________________________________ 3. Methods used to promote sleep: Medication? No ___ Yes ___ Name ______________________________ Warm fluids? No ___ Yes ___ What _______________________________________________________ Relaxation techniques? No ___ Yes ___ OBJECTIVE None Cognitive-Perceptual Pattern SUBJECTIVE 1. Pain a. Location (have the patient point to area) _________________________________________________ b. Intensity (have the patient rank on scale of 0–10) ________ c. Radiation? No ____ Yes ____ To where? _________________________________________________ d. Timing (how often; related to any specific events) __________________________________________ ____________________________________________________________________________________ e. Duration __________________________________________________________________________ f. What do you do to relieve pain at home? _________________________________________________ g. When did pain begin? ________________________________________________________________ 2. Decision Making a. Find decision making: Easy ____ Moderately easy ____ Moderately difficult ____ Difficult____ b. Inclined to make decisions: Rapidly ____ Slowly ____ Delay ____ c. Difficulty choosing between options? Yes ___ No ___ Describe ________________________________ ____________________________________________________________________________________ 3. Knowledge Level a. Can define what current problem is? Yes ___ No ___ b. Can restate current therapeutic regimen? Yes ___ No ___ OBJECTIVE 1. Review sensory and mental status completed in Health Perception–Health Management Pattern. 2. Any overt signs of pain? No ___ Yes ___ Describe ____________________________________________ 3. Any fluctuations in intercranial pressure? Yes ___ No ___ Copyright © 2002 F.A. Davis Company APPENDIX B 703 Self-Perception and Self-Concept Pattern SUBJECTIVE 1. What is your major concern at the current time? _____________________________________________ _____________________________________________________________________________________ 2. Do you think this admission will cause any lifestyle changes for you? No ___ Yes ___ What? _______________________________________________________________________________ 3. Do you think this admission will result in any body changes for you? No ___ Yes ___ What? _______________________________________________________________________________ 4. My usual view of myself is: Positive ____ Neutral ____ Somewhat negative ____ 5. Do you believe you will have any problems dealing with your current health situation? No ___ Yes ___ Describe ________________________________________________________________ 6. On a scale of 0–5, rank your perception of your level of control in this situation _________ 7. On a scale of 0–5, rank your usual assertiveness level ________ 8. Have you recently experienced a loss? No ___ Yes ___ Describe _________________________________ _____________________________________________________________________________________ OBJECTIVE 1. During assessment, the patient appears: Calm ____ Anxious ____ Irritable ____ Withdrawn ____ Restless ______ 2. Did any physiologic parameters change: Face reddened? No ___ Yes ___ Voice volume changed? No ___ Yes ___ Louder ____ Softer ____ Voice quality changed? No___ Yes___ Quavering ____ Hesitation ____ Other _______________________________________________________________________________ 3. Body language observed _________________________________________________________________ 4. Is current admission going to result in a body structure or function change for the patient? No ___ Yes ___ Unsure at this time ____ 5. Is the patient expressing any fears about dying? No ___ Yes ___ 6. Is the patient expressing worries about the impact of his or her death on his or her family and/or friends? No ___ Yes ___ N/A ___ Role-Relationship Pattern SUBJECTIVE 1. Does the patient live alone? Yes ___ No ____With whom ______________________________________ 2. Is the patient married? Yes ___ No ___ ; Children? No ___ Yes ___ ; # of children __________________ Age(s) of children __________________________ Were any of the children premature? No ___ Yes ___ Describe __________________________________ _____________________________________________________________________________________ 3. How would you rate your parenting skills: Not applicable ____ No difficulty with ____ Average ____ Some difficulty with ____ Describe _____________________________________________________________________________ _____________________________________________________________________________________ 4. Any losses (physical, psychological, social) in past year? No ___ Yes ___ Describe _____________________________________________________________________________ 5. How is the patient handling this loss at this time? ____________________________________________ _____________________________________________________________________________________ Copyright © 2002 F.A. Davis Company 704 APPENDIX B 6. Do you believe this admission will result in any type of loss? No ___ Yes ___ Describe ____________________________________________________________________________ 7. Has the patient recently received a diagnosis related to a chronic physical or mental illness? No ___ Yes ___ 8. Is the patient verbally expressing sadness? No ___ Yes ___ 9. Ask both the patient and family: Do you think this admission will cause any significant changes in (the patient’s) usual family role? No ___ Yes ___ Describe _________________________________________ ____________________________________________________________________________________ 10. How would you rate your usual social activities? Very active ____ Active ____ Limited ____ None ____ 11. How would you rate your comfort in social situations? Comfortable ____ Uncomfortable ____ 12. What activities/jobs, etc., do you like to do? ________________________________________________ ____________________________________________________________________________________ 13. What activities/jobs, etc., do you dislike doing? _____________________________________________ ____________________________________________________________________________________ 14. Does the person use alcohol or drugs? No ___ Yes ___ Kind ___________________________________ Amount ________________ 15. Is the patient in the role of primary caregiver for another person? No ___ Yes ___ OBJECTIVE 1. Speech Pattern a. Is English the patient’s native language? Yes ___ No ___ Native language is ______________ ; Interpreter needed? No ___ Yes ___ b. During interview have you noted any speech problems? No ___ Yes ___ Describe __________________________________________________________________________ 2. Family Interaction a. During interview have you observed any dysfunctional family interactions? No ___ Yes ___ Describe ___________________________________________________________________________ b. If the patient is a child, is there any physical or emotional evidence of physical or psychosocial abuse? No ___ Yes ___ Describe ______________________________________________________________ c. If the patient is a child, is there evidence of attachment behaviors between the parents and child? Yes ___ No ___ Describe _____________________________________________________________ d. Any signs or symptoms of alcoholism? No ___ Yes ___ Describe_______________________________ Sexuality-Reproductive Pattern SUBJECTIVE Female 1. Date of LMP __________ ; Any pregnancies? Para _____ Gravida _____ Menopause? No ___ Yes ___ Year _______ 2. Use birth control measures? No ___ N/A ___ Yes ___ Type ______________________________________ 3. Any history of vaginal discharge, bleeding, lesions? No ___ Yes ___ Description ____________________________________________________________________________ 4. Pap smear annually? Yes ___ No ___ Date of last pap smear __________ 5. Date of last mammogram ___________________ 6. History of STD (sexually transmitted disease)? No ___ Yes ___ Describe ___________________________ _____________________________________________________________________________________ Copyright © 2002 F.A. Davis Company APPENDIX B 705 If admission secondary to rape: 7. Is the patient describing numerous physical symptoms? No ___ Yes ___ Describe ____________________________________________________________________________ 8. Is the patient exhibiting numerous emotional reactions? No ___ Yes ___ Describe __________________ ____________________________________________________________________________________ 9. What has been your primary coping mechanism to handle this rape episode? _____________________ ____________________________________________________________________________________ 10. Have you talked to persons from the rape crisis center? Yes ___ No ___ If no, want you to contact them for her? No ___ Yes ___ If yes, was this contact of assistance? No ___ Yes ___ Male 1. Any history of prostate problems? No ___ Yes ___ Describe ___________________________________ ____________________________________________________________________________________ 2. Any history of penile discharge, bleeding, lesions? No ___ Yes ___ Describe ______________________ ____________________________________________________________________________________ 3. Date of last prostate exam _______________________

4. History of STD (sexually transmitted disease)? No ___ Yes ___ Describe _________________________ ____________________________________________________________________________________ Both 1. Are you experiencing any problems in sexual functioning? No ___ Yes ___ Describe ____________________________________________________________________________ 2. Are you satisfied with your sexual relationship? Yes ___ No ___ Describe ________________________ ____________________________________________________________________________________ 3. Do you believe this admission will have any impact on sexual functioning? No ___ Yes ___ Describe ____________________________________________________________________________ OBJECTIVE Review admission physical exam for results of pelvic and rectal exams. If results not documented, nurse should perform exams. Check history to see whether admission resulted from a rape. Coping–Stress Tolerance Pattern SUBJECTIVE 1. Have you experienced any stressful or traumatic events in the past year in addition to this admission? No ___ Yes ___ Describe _______________________________________________________________ ____________________________________________________________________________________ 2. How would you rate your usual handling of stress? Good ____ Average ____ Poor ____ 3. What is the primary way you deal with stress or problems? ____________________________________ ____________________________________________________________________________________ 4. Have you or your family used any support or counseling groups in the past year? No ___ Yes ___ Group Name ___________________________________________________________ Was support group helpful? Yes ___ No ___ Additional comments _____________________________ ____________________________________________________________________________________ 5. What do you believe is the primary reason behind the need for this admission? ____________________________________________________________________________________ 6. How soon, after first noting symptoms, did you seek health care assistance? ____________________________________________________________________________________ Copyright © 2002 F.A. Davis Company 706 APPENDIX B 7. Are you satisfied with the care you have been receiving at home? Yes ___ No ___ Comments ___________________________________________________________________________ _____________________________________________________________________________________ 8. Ask primary caregiver: What is your understanding of the care that will be needed when the patient goes home? _______________________________________________________________________________ _____________________________________________________________________________________ OBJECTIVE 1. Observe behavior. Are there any overt signs of stress (e.g., crying, wringing of hands, clenched fists, etc.)? Describe _____________________________________________________________________________ 2. Ask the family or primary caregiver if the patient has threatened to kill himself or herself. No ___ Yes ___ 3. Ask the family or primary caregiver if they have noticed any marked changes in the patient’s behavior, attitude, or school performance? No ___ Yes ___ Value-Belief Pattern SUBJECTIVE 1. Satisfied with the way your life has been developing? Yes ___ No ___ Comments ___________________________________________________________________________ 2. Will this admission interfere with your plans for the future? No ___ Yes ___ How? _______________________________________________________________________________ 3. Religion: Protestant ____ Catholic ____ Jewish ____ Islam ____ Buddhist ____ Other _______________________________________________________________________________ 4. Will this admission interfere with your spiritual or religious practices? No ___ Yes ___ How? ________________________________________________________________________________ 5. Any religious restrictions to care (diet, blood transfusions)? No ___ Yes ___ Describe _____________________________________________________________________________ 6. Would you like to have your (pastor, priest, rabbi, hospital chaplain) contacted to visit you? No ___ Yes ___ Who? __________________________________________________________________ 7. Have your religious beliefs helped you deal with problems in the past? No ___ Yes ___ Comments ____________________________________________________________________________ OBJECTIVE 1. Observe behavior. Is the patient exhibiting any signs of alterations in mood (e.g., anger, crying, withdrawal, etc.)? No ___ Yes ___ Describe__________________________________________________ General 1. Is there any information we need to have that I have not covered in this interview? No ___ Yes ___ Comments ______________________________________________________________ 2. Do you have any questions you need to ask me concerning your health, plan of care, or this agency? No ___ Yes ___ Questions _______________________________________________________________ _____________________________________________________________________________________ 3. What is the first problem you would like to have assistance with? _________________________________ _____________________________________________________________________________________ Copyright © 2002 F.A. Davis Company APPENDIX B 707 Mr. Fred Carson Mr. Fred Carson is a 63-year-old man who has been admitted with a medical diagnosis of hyperglycemia sec- ondary to diabetes mellitus. He was first diagnosed as having adult onset diabetes 2 years ago. Upon admission Mr. Carson’s vital signs are temperature 101.4F orally, pulse 98, respiration 20, blood pres- sure 98/70. Mr. Carson is 5 feet 9 inches tall and weighs 230 pounds. He states he has gained 20 pounds over the past 6 weeks. His fasting glucose is 200 mg/dL. His hemoglobin level is 20 g/dL, with a hematocrit of 56 vol/dL. Mr. Carson tells you he regulates his insulin according to what he eats and eats whatever he is hungry for. You find, in interviewing Mr. Carson, that he has been drinking 3–4 “iced tea glasses” of water every hour stating, “I’m always thirsty.” He has been voiding at least once an hour. His urine specimen is dilute and a very pale yellow. Mr. Carson’s urine glucose, as measured by a Clinitest, is 4
. In the past 2 hours Mr. Carson voided 1500 mL in addition to the urine specimen, and his intake has been 500 mL. Mr. Carson says he doesn’t pay any attention to his urine tests—“They’re just a waste of time”—but, he adds, “I’ve been peeing a lot more that past few days. Does this mean I’m not behaving?” Mr. Carson states he was taught about his diabetes but thinks “They were just try- ing to scare me. I don’t think I really have diabetes. Kids develop that—not old codgers like me. I only check in with the doctor when I feel like it. He wants me to come in every other month, but I think he’s just trying to get more money.” When asked to discuss what he was taught regarding his diabetes, Mr. Carson relates a high level of understanding of his prescribed regimen. You find out this is Mr. Carson’s fourth admission over the last 8 months. All of the admissions have been due to complications secondary to the diabetes. He exhibits anger on each admission and refuses to have home health nurses visit him. In examining Mr. Carson’s skin you find that his toenails and fingernails are dry, thick, and brittle. Both his skin and mucous membranes are dry in spite of the amount of fluid Mr. Carson indicates he was drinking prior to ad- mission. His extremities are shiny and cool to the touch, and his legs become cyanotic when they are kept in a de- pendent position. When elevated, his legs become pale, and color is very slow to return when his legs are returned to a neutral position. His pedal pulses are difficult to locate and diminished in volume. He has a 10 cm
size le- sion on his left shin, and you can see that the lesion has begun to impact the muscle tissue. Mr. Carson tells you he hit his leg on a table 3 weeks ago. You note 3 round scars with atrophied skin on his right leg and 1 similar scar on his left leg. Mr. Carson describes a sensation of “pins and needles when walking, but if I stop it goes away.” SAMPLE ADMISSION ASSESSMENT Demographic Data Date: 10/25/92 Time: 9:25 a.m. Name: CARSON, FRED D.O.B.: 6/10/29 Age: 63 Sex: MALE Primary Significant Other: WIFE—RUTH CARSON Telephone #: 806-745-5689 Name of Primary Information Source: PATIENT Admitting Medical Diagnosis: HYPERGLYCEMIA SECONDARY TO INSULIN-DEPENDENT DIABETES Vital Signs Temperature 101.4 F X C Oral X Rectal Axillary Tympanic Pulse Rate: Radial 98 Apical ; Regular X Irregular Respiratory Rate: 20 Abdominal ____ Diaphragmatic X Copyright © 2002 F.A. Davis Company 708 APPENDIX B Blood Pressure: Left arm 98/60 ; Right arm 100/64 ; Sitting X Standing ___ Lying down ___ Weight: 230 pounds, ______ kilograms; Height: 5 feet 9 inches, ____ meters Do you have any allergies? No X Yes ___ What?________________________________________________ (Check reactions to medications, foods, cosmetics, insect bites, etc.) Review admission CBC, urinalyses, and chest x-ray. Note any abnormalities here: FASTING GLUCOSE 200 MG/DL; HGB 20 G/DL; HCT 56 VOL/DL; Health Perception–Health Management Pattern SUBJECTIVE 1. How would you describe your usual health status? Good ___ Fair X Poor ___ 2. Are you satisfied with your usual health status? Yes ____ No X Source of dissatisfaction “I’M ALWAYS THIRSTY.” 3. Tobacco use? No X Yes ____ Number of packs per day _____________________________________ 4. Alcohol use? No X Yes ____ How much and what kind _____________________________________ 5. Street drug use? No X Yes ____ What ___________________________________________________ 6. Any history of chronic diseases? No ____ Yes X What “THE DOCTOR SAYS I HAVE DIABETES, BUT I DON’T BELIEVE IT. KIDS DEVELOP THAT, NOT OLD CODGERS LIKE ME.” 7. Immunization History: Tetanus 1960 ; Pneumonia NO ; Influenza NO ; MMR HAD DISEASES AS CHILD ; Polio NO ; Hepatitis B NO ; Hib NO 8. Have you sought any health care assistance in the past year? No ____ Yes X If yes, why? “I’M THIRSTY ALL THE TIME.” “SORES ON MY LEGS.” FOUR ADMISSIONS IN PAST 8 MONTHS FOR COMPLICATIONS OF DIABETES. 9. Are you currently working? Yes ____ No RETIRED How would you rate your working conditions (e.g., safety, noise, space, heating, cooling, water, ventilation)? Excellent ____ Good ____ Fair ____ Poor ____ Describe any problem areas ______________________ ____________________________________________________________________________________ 10. How would you rate living conditions at home? Excellent X Good ___ Fair ___ Poor ___ Describe any problem areas “NEED ANOTHER BATHROOM. WE HAVE ONLY ONE AND I NEED TO PEE ALL THE TIME.” 11. Do you have any difficulty securing any of the following services? Grocery store? Yes ____ No X ; Pharmacy? Yes ____ No X ; Health care facility? Yes ____ No X ; Transportation? Yes ____ No X ; Telephone (for police, fire, ambulance, etc.)? Yes ____ No X If any difficulties, note referral here _______________________________________________________ 12. Medications (over-the-counter and prescriptive) NAME DOSAGE AMT. TIMES/DAY REASON TAKING AS ORDERED INSULIN REGULATES ACCORD. 1–3 TIMES DIABETES Yes ____ No X TO URINE TESTS _____________________________________________________________________ Yes ___ No ___ _____________________________________________________________________ Yes ___ No ___ _____________________________________________________________________ Yes ___ No ___ _____________________________________________________________________ Yes ___ No ___ _____________________________________________________________________ Yes ___ No ___ 13. Have you followed the routine prescribed for you? Yes ____ No X Why not? “I TAKE THE INSULIN, BUT I DON’T LIKE THE DIET.” Copyright © 2002 F.A. Davis Company APPENDIX B 709 14. Did you think this prescribed routine was the best for you? Yes ____ No X What would be better? “I EAT WHAT I WANT.” 15. Have you had any accidents/injuries/falls in the past year? No ____ Yes X Describe “I HIT MY LEG ON THE TABLE A FEW WEEKS AGO.” 16. Have you had any problems with cuts healing? No ____ Yes X Describe “THIS SORE HAS BEEN HERE SINCE I HIT IT 3 WEEKS AGO (POINTS TO LT SHIN). THESE SCARS ARE FROM SORES THAT TOOK AGES TO HEAL (POINTS TO RT LEG).” 17. Do you exercise on a regular basis? No X Yes ___ Type and Frequency “I USED TO WALK EVERY AFTERNOON, BUT SINCE I HAVE TO PEE SO MUCH I CAN’T LEAVE THE HOUSE.” 18. Have you experienced any ringing in the ears? Right: Yes ____ No X Left: Yes ____ No X 19. Have you experienced any vertigo? Yes ____ No X How often and when? _______________________ ____________________________________________________________________________________ 20. Do you regularly use seat belts? Yes ____ No X 21. For infants and children, are car seats used regularly? Yes ____ No ____ 22. Do you have any suggestions or assistance requests for improving your health? No ____ Yes X What? “I WANT TO STOP PEEING SO MUCH.” 23. Do you do (breast/testicular) self-examination? No X Yes ____ How often? __________________________________________________________________________ 24. Were you or your family able to meet all your therapeutic needs? Yes X No ____ 25. Are you scheduled for surgery? Yes ____ No X 26. Have you recently had surgery? No X Yes ____ Date__________ OBJECTIVE 1. Mental Status (Indicate assessment with an X) a. Oriented X Disoriented ____ Length of time__________ Time: Yes X No ____ Length of time__________ Place: Yes X No ____ Length of time__________ Person: Yes X No ____ Length of time__________ b. Sensorium Alert ___ ; Drowsy X ; Lethargic ___ ; Stuporous ___ ; Comatose ___ ; Cooperative X ; Combative ___ ; Delusions ___ ; Fluctuating levels of consciousness? Yes ___ No X Appropriate response to stimuli? Yes X No ____ c. Memory Recent? Yes X No ___ ; Remote? Yes X No ___ ; Past 4 hours? Yes ____ No ____ d. Is there a disruption of the flow of energy surrounding the person? Yes X No ___ Change in color? Yes ____ No X ; Change in temperature? Yes ____ No X ; Field? Yes ____ No X ; Movement? Yes ____ No X ; Sound? Yes ____ No X e. Responds to simple directions?

Yes X No ____ 2. Vision a. Visual Acuity: Both eyes 20/____ Right 20/____ Left 20/____ Not assessed X b. Pupil Size: Right: Normal X Abnormal ___ ; Left: Normal X Abnormal ___ Description of abnormalities___________________________________________ c. Pupil Reaction: Right: Normal X Abnormal ___ ; Left: Normal X Abnormal ____ Description of abnormalities NONE d. Wears glasses? Yes X No ___ ; Contact lenses? Yes ____ No X 3. Hearing: Not assessed ____ a. Right: WNL X Impaired ___ Deaf __ ; Left: WNL X Impaired ___ Deaf ___ b. Hearing aid? Yes ____ No X Copyright © 2002 F.A. Davis Company 710 APPENDIX B 4. Taste a. Sweet: Normal ____ Abnormal ____ Describe NOT EXAMINED b. Sour: Normal ____ Abnormal ____ Describe NOT EXAMINED c. Tongue Movement: Normal X Abnormal ____ Describe MIDLINE d. Tongue Appearance: Normal X Abnormal ____ Describe PINK, NO LESIONS OR EXUDATE 5. Touch a. Blunt: Normal X Abnormal ____ Describe RESPONDS TO TOUCH ON ALL EXTREMITIES WITH FLAT TONGUE DEPRESSOR b. Sharp: Normal ____ Abnormal X Describe DIMINISHED RESPONSE ON LT FOOT c. Light Touch Sensation: Normal ____ Abnormal X Describe HYPERESTHESIA LT ANKLE AND RT LEG d. Proprioception: Normal X Abnormal ____ Describe _____________________________________ e. Heat: Normal ____ Abnormal X Describe DIMINISHED RESPONSE LT FOOT f. Cold: Normal ____ Abnormal X Describe DIMINISHED RESPONSE LT FOOT g. Any numbness? No ____ Yes X Describe BILATERALLY IN FEET WHEN WALKING h. Any tingling? No ____ Yes X Describe “PINS AND NEEDLES IN FEET” WHEN WALKING 6. Smell a. Right Nostril: Normal X Abnormal ____ Describe _______________________________________ b. Left Nostril: Normal X Abnormal ____ Describe ________________________________________ 7. Assess Cranial Nerves: Normal X Abnormal ____ Describe deviations____________________________________________________________________ 8. Cerebellar Exam (Romberg, balance, gait, coordination, etc.): Normal __ Abnormal X Describe ROMBERG ABSENT, BALANCE GOOD, DOES NOT BEAR FULL WEIGHT ON LT FOOT 9. Assess Reflexes: Normal X Abnormal ____ Describe _______________________________________ ____________________________________________________________________________________ 10. Throat: Enlarged tonsils? No X Yes ____ Location NORMAL Tenderness? No X Yes ____ Exudate on tonsils? No X Yes ____ Color ________ Uvula midline? No ____ Yes X 11. Neck: Any enlarged lymph nodes? No X Yes ____ Location and size ___________________________ ____________________________________________________________________________________ 12. General Appearance a. Hair BROWN, THINNING b. Skin PALE PINK, DRY, DECREASED TURGOR Eczema? No X Yes ____ c. Nails TOENAILS AND FINGERNAILS DRY, THICK, AND BRITTLE d. Body Odor NONE 13. History of multiple surgeries? No X Yes ____; Reaction to latex? No X Yes____ 14. Incisions healing well? No ____ Yes ____ N/A X Nutritional-Metabolic Pattern SUBJECTIVE 1. Any weight gain in last 6 months? No ____ Yes X Amount 20 LBS IN LAST 6 WEEKS 2. Any weight loss in last 6 months? No X Yes ____ Amount ___________________________________ 3. Would you describe your appetite as: Good X Fair ____ Poor ____ 4. Do you have any food intolerances? No X Yes ____ Describe ________________________________ ____________________________________________________________________________________ 5. Do you have any dietary restrictions? (Check for those that are a part of a prescribed regimen as well as those that patient restricts voluntarily; for example, to prevent flatus.) No ____ Yes X What “SPECIAL DIET MY WIFE FIXES ME FOR DIABETES.” Copyright © 2002 F.A. Davis Company APPENDIX B 711 6. Describe an average day’s food intake for you (meals and snacks). BREAKFAST: 3 PANCAKES WITH LOW SUGAR SYRUP, JUICE, BLACK COFFEE, SAUSAGE; LUNCH: SANDWICH, MILK OR SUGAR-FREE SOFT DRINK, POTATO CHIPS, FRUIT, “SOMETIMES A LITTLE CAKE OR PIE”; DINNER: CASSEROLE, ICED TEA, ROLLS WITH BUTTER, VEGETABLES AND DESSERT (“SURE DO LIKE MY ICE CREAM”). SNACKS: COOKIES AND JUICE. 7. Describe an average day’s fluid intake for you. “I DRINK ALL THE TIME,” AT LEAST 4 LARGE GLASSES PER HOUR. 8. Describe food likes and dislikes LIKES: MEAT, DESSERTS, AND POTATOES; DISLIKES: VEGETABLES AND LOW SUGAR “STUFF” 9. Would you like to: Gain weight ____ Lose weight X Neither ____ 10. Any problems with: a. Nausea? No X Yes ____ Describe ____________________________________________________ b. Vomiting? No X Yes ____ Describe __________________________________________________ c. Swallowing? No X Yes ____ Describe ________________________________________________ d. Chewing? No X Yes ____ Describe __________________________________________________ e. Indigestion? No X Yes ____ Describe _________________________________________________ 11. Would you describe your usual lifestyle as: Active ___ Sedate X 12. Any chronic health problems? No ____ Yes X Describe DIABETES MELLITUS For breastfeeding mothers only: 13. Do you have any concerns about breastfeeding? No ____ Yes ____ Describe ___________________________________________________________________________ 14. Are you having any problems with breastfeeding? No ____ Yes ____ Describe ___________________________________________________________________________ OBJECTIVE 1. Skin Examination a. Warm ___ Cool X Moist ___ Dry X b. Lesions? No ____ Yes X Describe 10 CM
LT SHIN SEVERAL CM DEEP; RED 3 ROUND SCARS WITH ATROPHIED SKIN ON RT LEG; 1 ON LT LEG. c. Rash? No X Yes ____ Describe ______________________________________________________ d. Turgor: Firm ____ Supple ____ Dehydrated X Fragile ____ e. Color: Pale ____ ; Pink ____ ; Dusky ____ ; Cyanotic ____ ; Jaundiced ____ ; Mottled ____ ; Other PINK EXCEPT FOR LEGS. LEGS ARE CYANOTIC IN DEPENDENT POSITION; PALE WHEN ELEVATED. 2. Mucous Membranes a. Mouth (1) Moist ___ Dry X (2) Lesions? No X Yes ____ Describe_________________________________________________ (3) Color: Pale X Pink ____ (4) Teeth: Normal X Abnormal ____ Describe _________________________________________ (5) Dentures? No ____ Yes ____ Upper ____ Lower ____ Partial X (6) Gums: Normal X Abnormal ____ Describe _________________________________________ (7) Tongue: Normal X Abnormal ____ Describe ________________________________________ b. Eyes (1) Moist ____ Dry X (2) Color of conjunctivae: Pale ____ Pink X Jaundiced ____ (3) Lesions? No X Yes ____ Describe _________________________________________________ 3. Edema a. General? No X Yes ____ Describe ____________________________________________________ _________________________________________________________________________________ Abdominal Girth: _______inches; Not measured X Copyright © 2002 F.A. Davis Company 712 APPENDIX B b. Periorbital? No X Yes ____ Describe __________________________________________________ c. Dependent? No ____ Yes X Describe BILATERAL ANKLES AND FEET WHEN DEPENDENT; LEGS SHINY; NO PITTING. Ankle Girth: Right _____inches; Left _____inches; Not measured X 4. Thyroid: Normal X Abnormal ____ Describe ______________________________________________ 5. Jugular vein distention? No X Yes ____ 6. Gag Reflex: Present X Absent ____ 7. Can the patient move self easily (turning, walking)? Yes ____ No X Describe limitations DOES NOT BEAR FULL WEIGHT ON LEG; TURNING OK. 8. Upon admission was the patient dressed appropriately for the weather? Yes X No ___ Describe ____________________________________________________________________________ For breastfeeding mothers only: 9. Breast Exam: Normal ____ Abnormal ____ Describe _________________________________________ ____________________________________________________________________________________ 10. Weigh the infant. Is the infant’s weight within normal limits? Yes ____ No ____ Elimination Pattern SUBJECTIVE 1. What is your usual frequency of bowel movements? ABOUT 3 TIMES PER WEEK a. Have to strain to have BM? No X Yes ____ b. Same time each day? No X Yes ____ 2. Has the number of bowel movements changed in the past week? No X Yes ____ Increased ____ Decreased ____ 3. Character of stool: a. Consistency: Hard ____ Soft X Liquid ____ b. Color: Brown X Black ____ Yellow ____ Clay colored ____ c. Bleeding with bowel movements? No X Yes ____ 4. History of constipation? No X Yes ____ How often ________________________________________ Use bowel movement aids (laxatives, suppositories, diet)? No X Yes ____ Describe ____________________________________________________________________________ 5. History of diarrhea? No X Yes ____ When ________________________________________________ 6. History of incontinence? No X Yes ____ Related to increased abdominal pressure (coughing, laughing, sneezing)? No ___Yes ___ 7. History of recent travel? No X Yes ____Where? ____________________________________________ 8. Usual voiding pattern: a. Frequency (times/day) FOR PAST 3 DAYS, 3–4/HOUR Decreased ___ Increased X b. Change in awareness of need to void? No ____ Yes X Increased ____ Decreased X c. Change in urge to void? No ____ Yes X Increased X Decreased ____ d. Any change in amount? No ____ Yes X Decreased ____ Increased X e. Color: Yellow VERY PALE Smoky ____ Dark ____ f. Incontinence? No ____ Yes X When “IF TOO FAR FROM BATHROOM.” Difficulty holding voiding when urge to void develops? No ____ Yes X Have time to get to bathroom? Yes ____ No X How often does problem reaching bathroom occur? EVERY VOIDING g. Retention? No X Yes ____ Describe ___________________________________________________ h. Pain or burning? No X Yes ____ Describe ______________________________________________ i. Sensation of bladder spasms? No X Yes ____ When? _____________________________________ Copyright © 2002 F.A. Davis Company APPENDIX B 713 OBJECTIVE 1. Auscultate abdomen. a. Bowel Sounds: Normal X Increased ____ Decreased ____ Absent ____ 2. Palpate abdomen. a. Tender? No X Yes ____ Where? ______________________________________________________ b. Soft? Yes X No ____; Firm? Yes ____ No X c. Masses? No X Yes ____ Describe _____________________________________________________ d. Distention (include distended bladder)? No X Yes ____ Describe ____________________________ __________________________________________________________________________________ e. Overflow urine when bladder palpated? Yes ____ No X 3. Rectal Exam a. Sphincter tone: Describe WITHIN NORMAL LIMITS b. Hemorrhoids? No X Yes ____ Describe ________________________________________________ c. Stool in rectum? No ____ Yes X Describe HEME NEGATIVE d. Impaction? No X Yes ____ Describe ___________________________________________________ e. Occult blood? No X Yes ____ 4. Ostomy present? No X Yes ____ Location _________________________________________________ Activity-Exercise Pattern SUBJECTIVE 1. Using the following Functional Level Classification, have the patient rate each area of self-care. (Code adapted by NANDA from Jones, E, et al: Patient Classification for Long-Term Care: Users’ Manual, HEW Publication No. HRA-74-3107. November, 1974.) 0  Completely independent 1  Requires use of equipment or device 2  Requires help from another person, for assistance, supervision, or teaching 3  Requires help from another person and equipment or device 4  Dependent, does not participate in activity Feeding 0 ; Bathing-hygiene 0 ; Dressing-grooming 0 ; Toileting 0 ; Ambulation 0 ; Care of home WIFE ; Shopping WIFE ; Meal preparation WIFE ; Laundry WIFE ; Transportation 0 . 2. Oxygen use at home? No X Yes ____ Describe ____________________________________________ 3. How many pillows do you use to sleep on? 1 4. Do you frequently experience fatigue? No ____ Yes X Describe “I’M TIRED AFTER GOING TO THE BATHROOM SO MUCH.” 5. How many stairs can you climb without experiencing any difficulty (can be individual number or number of flights)? 1 FLIGHT 6. How far can you walk without experiencing any difficulty? 1 BLOCK; “MY FOOT HURTS IF I TRY TO WALK TOO FAR.” 7. Any history of falls? No X Yes ____ How often?____________________________________________ 8. Has assistance at home for care of self and maintenance of home? No ____ Yes X Who WIFE If no, would like to have or believes needs to have assistance? No ____ Yes ____ With what activities? __________________________________________________________________ 9. Occupation (if retired, former occupation) MAIL CARRIER 10. Describe your usual leisure time activities-hobbies. GARDENING, FISHING, READING 11. Any complaints of weakness or lack of energy? No ____ Yes X Describe GOING TO THE BATHROOM SO MUCH “WEARS ME OUT.” Copyright © 2002 F.A. Davis Company 714 APPENDIX B 12. Any difficulties in maintaining activities of daily living? No ____ Yes X Describe “ALL I DO IS DRINK AND PEE.” 13. Any problems with concentration? No X Yes ____ Describe __________________________________ ____________________________________________________________________________________ 14. If in wheelchair, do you have any problems manipulating the wheelchair? No ____Yes ____ N/A X Describe ____________________________________________________________________________ 15. Can you move yourself from site to site with no problems? No ____ Yes X Describe ____________________________________________________________________________ OBJECTIVE 1. Cardiovascular a. Cyanosis? No ____ Yes X Where? LEGS WHEN DEPENDENT b. Pulses: Easily palpable? Carotid: Yes X No ___; Jugular: Yes X No ___; Temporal: Yes X No ___; Radial: Yes X No ___; Femoral: Yes X No ___; Popliteal: Yes X No ___; Post tibial: Yes___ No X ; Dorsalis pedis: Yes___ No X c. Extremities: (1) Temperature: Cold ____ Cool X Warm ____ Hot ____ (2) Capillary Refill: Normal ____ Delayed X (3) Color: Pink ____ Pale X Cyanotic X Other ____ Describe: PALE WHEN RAISED; CYANOTIC WHEN DEPENDENT (4) Homans’ sign? No X Yes ____ (5) Nails: Normal ____ Abnormal X Describe TOENAILS AND FINGERNAILS DRY, THICK, BRITTLE (6) Hair Distribution: Normal X Abnormal ____ Describe ________________________________ ____________________________________________________________ (7) Claudication? No ____ Yes X Describe NUMBNESS AND TINGLING IN FEET d. Heart: PMI Location 4TH ICS LCL (1) Abnormal rhythm? No X Yes ____ Describe ________________________________________ ______________________________________________________________________________ (2) Abnormal sounds? No X Yes ____ Describe ________________________________________ ______________________________________________________________________________ 2. Respiratory a. Rate 20/MIN ; Depth: Shallow ____ Deep X Abdominal ____ Diaphragmatic X b. Have the patient

cough. Any sputum? No X Yes ____ Describe _____________________________ _________________________________________________________________________________ c. Fremitus? No X Yes ____ d. Any chest excursion? No X Yes ____ Equal ____ Unequal ____ e. Auscultate chest: Any abnormal sounds (rales, rhonchi)? No X Yes ____ Describe __________________________________________________________________________ f. Have the patient walk in place for 3 minutes (if permissible): (1) Any shortness of breath after activity? No X Yes ____ (2) Any dyspnea? No X Yes ____ (3) BP after activity 108 / 74 in (right; left) arm (4) Respiratory rate after activity 25 (5) Pulse rate after activity 110 3. Musculoskeletal a. Range of motion: Normal ____ Limited X Describe LIMITED IN LOWER EXTREMITIES Copyright © 2002 F.A. Davis Company APPENDIX B 715 b. Gait: Normal ____ Abnormal X Describe DOES NOT BEAR FULL WEIGHT ON LEFT ANKLE c. Balance: Normal X Abnormal ____ Describe ___________________________________________ d. Muscle Mass/Strength: Normal ____ Increased ____ Decreased X Describe ATROPHY IN BOTH LEGS, ESPECIALLY IN AREA OF WOUNDS e. Hand Grasp: Right: Normal X Decreased ____ Left: Normal X Decreased ____ f. Toe Wiggle: Right: Normal X Decreased ____ Left: Normal X Decreased ____ g. Posture: Normal X Kyphosis ____ Lordosis ____ h. Deformities? No X Yes ____ Describe _________________________________________________ i. Missing limbs? No X Yes ____ Where? ________________________________________________ j. Uses mobility assistive devices (walker, crutches, etc.)? No X Yes ____ Describe _________________________________________________________________________ k. Tremors? No X Yes ____ Describe ____________________________________________________ l. Traction or casts present? No X Yes ____ Describe _______________________________________ m. Easily turns in bed? No ____ Yes X 4. Spinal cord injury? No X Yes ____ Level ________________________________________________ 5. Paralysis present? No X Yes ____ Where? ________________________________________________ 6. Conduct developmental assessment. Normal ____ Abnormal ____ Describe NOT DONE ___________________________________________________________________________________ 7. Responds appropriately to stimuli? Yes X No ____ Describe _________________________________ ___________________________________________________________________________________ 8. Are there any abnormal movements? No X Yes ____ Describe _______________________________ ___________________________________________________________________________________ 9. Frequent locomotion? Yes ____ No X 10. Episodes of trespassing or getting lost? Yes ____ No X Sleep-Rest Pattern SUBJECTIVE 1. Usual sleep habits: Hours/night 6 ; Naps? No ___ Yes X a.m. ___ p.m. X Feel rested? Yes X No ____ Describe ___________________________________________________ 2. Any problems: a. Difficulty going to sleep? No X Yes____ b. Awakening during night? No ____ Yes X (TO GO TO THE BATHROOM) c. Early awakening? No X Yes____ d. Insomnia? No X Yes ____ Describe __________________________________________________ 3. Methods used to promote sleep: Medication? No X Yes ____ Name ___________________________ Warm fluids? No X Yes ____ What? ____________________________________________________ Relaxation techniques? No X Yes ____ OBJECTIVE None Copyright © 2002 F.A. Davis Company 716 APPENDIX B Cognitive-Perceptual Pattern SUBJECTIVE 1. Pain a. Location (have the patient point to area ) LEFT SHIN b. Intensity (have the patient rank on scale of 0–10) 5 c. Radiation? No ____ Yes X To where UP LEG d. Timing (how often; related to any specific events) “ACHES ALL THE TIME”; INCREASED PAIN WITH WALKING OR IF TOUCH WOUND. e. Duration AS ABOVE f. What do you do to relieve pain at home? ELEVATE, TAKE AN ADVIL g. When did pain begin? “TWO WEEKS AGO” 2. Decision Making a. Find decision making: Easy X Moderately easy ____ Moderately difficult ____ Difficult ____ b. Inclined to make decisions: Rapidly X Slowly ____ Delay ____ c. Difficulty choosing between options? Yes ____ No X Describe ______________________________ __________________________________________________________________________________ 3. Knowledge level a. Can define what current problem is? Yes X No ____ b. Can restate current therapeutic regimen? Yes X No ____ OBJECTIVE 1. Review sensory and mental status completed in Health Perception–Health Management Pattern. 2. Any overt signs of pain? No ____Yes X Describe WINCES WHEN TRIES TO BEAR WEIGHT ON LEFT LEG 3. Any fluctuations in intercranial pressure? Yes ____ No X Self-Perception and Self-Concept Pattern SUBJECTIVE 1. What is your major concern at the current time? “I’M TIRED OF DOING NOTHING BUT DRINKING AND PEEING.” 2. Do you think this admission will cause any lifestyle changes for you? No ___ Yes X What? “HELP ME GET BETTER.” 3. Do you think this admission will result in any body changes for you? No ___ Yes X What? “HEAL MY LEG.” 4. My usual view of myself is: Positive X Neutral ___ Somewhat negative ___ 5. Do you believe you will have any problems dealing with your current health situation? No X Yes ___ Describe _____________________________________________________________________________ 6. On a scale of 0–5, rank your perception of your level of control in this situation 4 7. On a scale of 0–5, rank your usual assertiveness level 5 8. Have you recently experienced a loss? No X Yes ___ Describe _________________________________ _____________________________________________________________________________________ Copyright © 2002 F.A. Davis Company APPENDIX B 717 OBJECTIVE 1. During assessment, the patient appears: Calm ____ Anxious ____ Irritable X Withdrawn ____ Restless ____ 2. Did any physiologic parameters change: Face reddened? No X Yes ____ Voice volume changed? No X Yes ____ Louder ____ Softer ____ Voice quality changed? No X Yes ____ Quavering____ Hesitation____ Other ______________________________________________________________________________ 3. Body language observed GUARDS LEFT SHIN 4. Is current admission going to result in a body structure or function change for the patient? No ____ Yes ____ Unsure at this time X 5. Is the patient expressing any fears about dying? Yes ____ No X 6. Is the patient expressing worries about the impact of his or her death on his or her family and/or friends? Yes ____ No X Role-Relationship Pattern SUBJECTIVE 1. Does the patient live alone? Yes ____ No X Lives with: WIFE 2. Is the patient married? Yes X No ___; Children? No X Yes ____; # of children___ Age(s) of children__________________________ Were any of the children premature? No ____ Yes ____ Describe N/A ____________________________________________________________________________________ 3. How would you rate your parenting skills: Not applicable X No difficulty with ____ Average ____ Some difficulty with ____ Describe ________________________ ____________________________________________________________________________________ 4. Any losses (physical, psychological, social) in past year? No ____ Yes X Describe EARLY RETIREMENT 5. How is the patient handling this loss at this time? “DOING FINE, JUST NEED TO GET FEET IN SHAPE SO I CAN DO WHAT I WANT NOW THAT I HAVE THE TIME.” 6. Do you believe this admission will result in any type of loss? No X Yes ____ Describe ____________________________________________________________________________ 7. Has the patient recently received a diagnosis related to a chronic physical or mental illness? No X Yes____ 8. Is the patient verbally expressing sadness? No X Yes ____ 9. Ask both the patient and family: Do you think this admission will cause any significant changes in (the patient’s) usual family role? No X Yes ____ Describe ________________________________________ ____________________________________________________________________________________ 10. How would you rate your usual social activities? Very active ____ Active X Limited ____ None ____ 11. How would you rate your comfort in social situations? Comfortable X Uncomfortable ___ 12. What activities/jobs, etc., do you like to do? GARDENING, FISHING, PLAYING CARDS AND DOMINOES 13. What activities/jobs, etc., do you dislike doing? ANY HOUSEWORK OR COOKING AND HAVING TO PEE ALL THE TIME 14. Does the person use alcohol or drugs? No X Yes ____ Kind____________ Amount__________ 15. Is the patient in the role of primary caregiver for another person? No X Yes ____ Copyright © 2002 F.A. Davis Company 718 APPENDIX B OBJECTIVE 1. Speech Pattern a. Is English the patient’s native language? Yes X No ____ Native language is______________; Interpreter needed? No X Yes ____ b. During interview have you noted any speech problems? No X Yes ____ Describe __________________________________________________________________________ 2. Family Interaction a. During interview have you observed any dysfunctional family interactions? No X Yes ____ Describe _________________________________________________________________________ b. If the patient is a child, is there any physical or emotional evidence of physical or psychosocial abuse? No ____ Yes ____ Describe __________________________________________________________ _________________________________________________________________________________ c. If the patient is a child, is there evidence of attachment behaviors between the parents and child? Yes ____ No ____ Describe N/A d. Any signs or symptoms of alcoholism? No X Yes ____ Describe ____________________________ _________________________________________________________________________________ Sexuality-Reproductive Pattern SUBJECTIVE Female 1. Date of LMP__________; Any pregnancies? Para_____ Gravida_____ Menopause? No ____ Yes ____ Year_______ 2. Use birth control measures? No____ N/A ____ Yes ____ Type _________________________________ 3. Any history of vaginal discharge, bleeding, lesions? No ____ Yes ____ Describe ___________________________________________________________________________ 4. Pap smear annually? Yes ____ No ____ Date of last pap smear__________ 5. Date of last mammogram_________ 6. History of STD (sexually transmitted disease)? No ____ Yes ____ Describe _______________________ ____________________________________________________________________________________ If admission secondary to rape: 7. Is the patient describing numerous physical symptoms? No ____ Yes ____ Describe ___________________________________________________________________________ 8. Is the patient exhibiting numerous emotional reactions? No ____ Yes ____ Describe ___________________________________________________________________________ 9. What has been your primary coping mechanism to handle this rape episode? _____________________ ____________________________________________________________________________________ 10. Have you talked to persons from the rape crisis center? Yes ____ No ____ If no, does the patient want you to contact them for her? No ____ Yes ____ If yes, was this contact of assistance? No ____ Yes ____ Male 1. Any history of prostate problems? No X Yes ____ Describe __________________________________ ____________________________________________________________________________________ 2. Any history of penile discharge, bleeding, lesions? No X Yes ____ Describe _____________________ ____________________________________________________________________________________ 3. Date of last prostate exam? LAST ADMISSION 4. History of STD (sexually transmitted disease)? No X Yes ____ Describe ________________________ ____________________________________________________________________________________ Copyright © 2002 F.A. Davis Company APPENDIX B 719 Both 1. Are you experiencing any problems in sexual functioning? No ____ Yes X Describe IMPOTENCY FOR PAST SEVERAL MONTHS 2. Are you satisfied with your sexual relationship? Yes ____ No X Describe IMPOTENT 3. Do you believe this admission will have any impact on sexual functioning? No ____Yes X Describe “GET MY DIABETES UNDER CONTROL AND PROBLEM WILL BE HELPED.” OBJECTIVE Review admission physical exam for results of pelvic and rectal exams. If results not documented, nurse should perform exams. Check history to see whether admission resulted from a rape. Coping–Stress Tolerance Pattern SUBJECTIVE 1. Have you experienced any stressful or traumatic events in the past year in addition to this admission? No ____ Yes X Describe NUMEROUS ADMISSIONS AND I MISS WORK SOME 2. How would you rate your usual handling of stress: Good ____Average X Poor ____ 3. What is the primary way you deal with stress or problems? YELL OR AVOID SITUATION. “I DON’T LIKE TO TALK ABOUT IT.” 4. Have you or your family used any support or counseling groups in the past year? No X Yes ____ Group Name ___________________________________________________________ Was support group helpful? Yes ____ No ____ Additional comments ____________________________ _____________________________________________________________________________________ 5. What do you believe is the primary reason behind the need for this admission? “TO GET MY DIABETES UNDER CONTROL AGAIN; I GUESS I’M A SLOW LEARNER.” 6. How soon, after first noting symptoms, did you seek health care assistance? 3 WEEKS 7. Are you satisfied with the care you have been receiving at home? Yes X No ____ Comments “MY WIFE HAS ALWAYS TAKEN GOOD CARE OF ME AND I DIDN’T WANT TO HAVE THOSE PEOPLE (V.N.A.) COMING TO MY HOUSE.” 8. Ask primary caregiver: What is your understanding of the care that will be needed when the patient goes home? WIFE NOT PRESENT AT THIS TIME _____________________________________________________________________________________ OBJECTIVE 1. Observe behavior. Are there any overt signs of stress (e.g., crying, wringing of hands, clenched fists, etc.)? Describe CLENCHED FISTS _____________________________________________________________________________________ 2. Has the patient threatened to kill himself or herself? Yes ____ No X 3. Ask the family: Has the patient demonstrated any marked changes in behavior, attitude or school performance? Yes ____ No X Copyright © 2002 F.A. Davis Company 720 APPENDIX B Value-Belief Pattern SUBJECTIVE 1. Are you satisfied with the way your life has been developing? Yes ____ No X Comments “WAS O.K. UNTIL THIS DIABETES DEVELOPED.” 2. Will this admission interfere with your plans for the future? No X Yes ____ How? _______________________________________________________________________________ 3. Religion: Protestant X Catholic ____ Jewish ____ Islam ____ Buddhist ____ 4. Will this admission interfere with your spiritual or religious practices? No X Yes ____ How? _______________________________________________________________________________ 5. Any religious restrictions to care (diet, blood transfusions)? NO 6. Would you like to have your (pastor, priest, rabbi, hospital chaplain) contacted to visit you? No X Yes ____ Which? _______________________________________________________________ 7. Have your religious beliefs helped you to deal with problems in the past? No

__Yes X Comments NONE OBJECTIVE 1. Observe behavior. Is the patient exhibiting any signs of alterations in mood (e.g., anger, crying, withdrawal, etc.)? No ____ Yes X What CLENCHED FISTS General 1. Is there any information we need to have that I have not covered in this interview? No X Yes ____ Comments _____________________________________________________________ 2. Do you have any questions you need to ask me concerning your health, plan of care, or this agency? No X Yes ____ Questions _____________________________________________________________ _____________________________________________________________________________________ 3. What is the first problem you would like to have assistance with? STOP ME FROM HAVING TO GO TO THE BATHROOM ALL THE TIME Copyright © 2002 F.A. Davis Company REFERENCES Chapter 1 2. Kneeshaw, M, and Lunney, M: Nursing diagnosis: Not for individuals only. Geriatr Nurs 37:246, 1989. 3. Rosenstock, I: Historical origins of the health belief model. In Becker, M 1. Gordon, M: Nursing Diagnoses: Process and Application, ed 3. Mosby–Year (ed): The Health Belief Model and Personal Behavior. Charles B. Slack, Tho- Book, St. Louis, 1994. rofare, NJ, 1974. 2. Iyer, PW, Taptich, BJ, and Bernocchi-Losey, D: Nursing Process and Nurs- 4. Ridenour, N: Health beliefs, preventive behavioral intentions and knowl- ing Diagnosis, ed 3. WB Saunders, Philadelphia, 1995. edge of gonorrhea: Predictors of recidivism? In Monograph 1983, Pro- 3. Doenges, ME, and Moorhouse, MF: Nurse’s Pocket Guide: Nursing Diag- ceedings of 2nd Annual Sigma Theta Tau Conference, The World of Work: nosis with Interventions, ed 6. FA Davis, Philadelphia, 1998. Research in Nursing Practice. Sigma Theta Tau, Indianapolis, IN, 1983. 4. Alfaro, R: Applying Nursing Diagnosis and Nursing Process: A Step-by-Step 5. Fleury, J: The application of motivational theory to cardiovascular risk re- Approach. Lippincott-Raven, Philadelphia, 1998. duction. 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Acid-base balance, metabolic, 88 therapeutic regimen, ineffective family with adolescents, 636–637 Acquired roles, 521 management of, 62 health perception–health management Actions. See specific nursing diagnosis walking, impaired, 256 pattern, 20 Activities of daily living (ADL), 224. See also wheelchair mobility, impaired, 364 hearing development, 384 Activity-exercise pattern NANDA taxonomy, Nursing Interventions nutritional-metabolic pattern, 90–91 Activity-exercise pattern Classification, Nursing Outcomes proprioception, 384 activity intolerance, 231–238 Classification, 231 role-relationship pattern, 524–525 airway clearance, ineffective, 239–245 nursing actions/interventions self-perception/self-concept pattern, assessment of, 224–226 adult health, 232 455–456 autonomic dysreflexia, 246–250 child health, 233 sexuality-reproductive pattern, 613 bed mobility, impaired, 251–255 expected outcome, 231, 238 sleep-rest pattern, 369 breathing pattern, ineffective, 256–261 flowchart evaluation, 238 smell sense development, 384 cardiac output, decreased, 262–269 gerontic health, 236–237 teen parenting, 529 conceptual information, 226 home health, 237 teen pregnancy, 613 delayed development, risk for, 301–307 psychiatric health, 235–236 touch sense development, 384 description of, 10, 11t, 224 target dates, 231 value-belief pattern, 683 developmental considerations women’s health, 233–235 visual development, 384 adolescents, 229 related factors, 231 Adult failure to thrive adults, 230 risk for, 231 characteristics of, 92 infants, 226–227 Adaptive capacity, intracranial, decreased clinical concerns, 92 older adults, 230 characteristics of, 385 definition of, 92 preschoolers, 227–228 clinical concerns, 385 differential diagnosis, 92 school-age children, 228–229 definition of, 385 dentition, impaired, 119 toddlers, 227–228 differential diagnosis, 386 NANDA taxonomy, Nursing Interventions young adults, 229–230 NANDA taxonomy, Nursing Interventions Classification, Nursing Outcomes disproportionate growth, risk for, Classification, Nursing Outcomes Classification, 92 301–307 Classification, 385 nursing actions/interventions disuse syndrome, risk for, 270–274 nursing actions/interventions adult health, 93 diversional activity, deficient, 275–279 adult health, 386–388 expected outcome, 92, 96 dysfunctional ventilatory weaning child health, 388 flowchart evaluation, 96 response, 280–284 expected outcome, 386, 390 gerontic health, 94 falls, risk for, 285–288 flowchart evaluation, 390 home health, 94–95 fatigue, 289–293 gerontic health, 389 psychiatric health, 93–94 gas exchange, impaired, 294–300 home health, 389 target dates, 92 growth and development, delayed, psychiatric health, 389 women’s health, 93 301–307 target dates, 386 related factors, 92 home maintenance, impaired, 308–312 women’s health, 388–389 Adults infant behavior, disorganized, 313–317 related factors, 385 activity-exercise pattern, 230 peripheral neurovascular dysfunction, risk Adjustment, impaired cognitive-perceptual pattern, 384–385 for, 318–321 characteristics of, 637 coping–stress tolerance pattern, 636 physical mobility, impaired, 322–330 clinical concerns, 637 elimination pattern, 194 self-care deficit, 330–336 definition of, 637 health perception–health management spontaneous ventilation, impaired, differential diagnosis, 637 pattern, 20 337–340 caregiver role strain, 527 hearing development, 385 tissue perfusion, ineffective, 341–349 relocation stress syndrome, 570 nursing actions/interventions for. See transfer ability, impaired, 350–355 NANDA taxonomy, Nursing Interventions specific nursing diagnosis walking, impaired, 356–359 Classification, Nursing Outcomes nutritional-metabolic pattern, 91 wandering, 360–363 Classification, 637 older. See Older adults wheelchair mobility, impaired, 364–366 nursing actions/interventions proprioception, 385 Activity intolerance adult health, 638 role-relationship pattern, 525 actual, 231 child health, 638 self-perception/self-concept pattern, 456 characteristics of, 231 expected outcome, 637, 644 sexuality-reproductive pattern, 613 clinical concerns, 231 flowchart evaluation, 644 sleep-rest pattern, 369 definition of, 231 gerontic health, 643 smell sense development, 385 differential diagnosis, 231 home health, 643 taste development, 385 bed mobility, impaired, 251 psychiatric health, 640–643 touch sense development, 385 disuse syndrome, risk for, 270 target dates, 637 value-belief pattern, 683 diversional activity, deficient, 275 women’s health, 639–640 visual development, 384–385 energy field disturbance, 21 related factors, 637 young. See Young adults health maintenance, ineffective, 27 Admission assessment form and sample, 694 Affective disorder, postpartum, 639–640 home maintenance, impaired, 308 Adolescents “Affiliated individuation,” 456 injury, risk for, 43 activity-exercise pattern, 229 Afterload, definition of, 263 physical mobility, impaired, 322 cognitive-perceptual pattern, 384 Airway clearance, ineffective self-care deficit, 331 coping–stress tolerance pattern, 635–636 characteristics of, 239 sleep pattern, disturbed, 376 elimination pattern, 194 clinical concerns, 239 733 Copyright © 2002 F.A. Davis Company 734 INDEX Airway clearance—Continued Apgar score, 383 flowchart evaluation, 255 definition of, 239 Apnea of infancy, 368 gerontic health, 253–254 differential diagnosis, 239 Aspiration, risk for home health, 254 aspiration, risk for, 97 characteristics of, 97 psychiatric health, 253 breathing pattern, ineffective, 256 clinical concerns, 97 target dates, 251 gas exchange, impaired, 294 definition of, 97 women’s health, 253 NANDA taxonomy, Nursing Interventions differential diagnosis, 97 Bedrest, prolonged, system problems Classification, Nursing Outcomes NANDA taxonomy, Nursing Interventions associated with, 226 Classification, 239 Classification, Nursing Outcomes Belief pattern. See Value-belief pattern nursing actions/interventions Classification, 97 Birthing process. See Childbirth adult health, 240–241 nursing actions/interventions Bladder-retraining program, 193 child health, 241–242 adult health, 98 Body image expected outcome, 239, 245 child health, 98–99 developmental considerations flowchart evaluation, 245 expected outcome, 97, 101 adolescents, 456 gerontic health, 243 flowchart evaluation, 101 adults, 456 home health, 243–244 gerontic health, 100 toddlers and preschoolers, 455 psychiatric health, 243 home health, 100 disturbed target dates, 239 psychiatric health, 99 characteristics of, 465 women’s health, 242 target dates, 97 clinical concerns, 465 related factors, 239 women’s health, 99 definition of, 465 Alarm reaction, 634 related factors, 97 differential diagnosis, 465 Alcoholism. See also Family processes, Assessment of patient nutrition, imbalanced, less than body dysfunctional: alcoholism admission assessment form and sample, requirements, 157 nursing actions/interventions, 537–540 694 personal identity, disturbed, 497 Allergy response, latex. See Latex allergy data grouping, 4 self-esteem disturbance, 508 response data sources and types, 3 NANDA taxonomy, Nursing Alzheimer’s Association, 530 essential skills, 3–4 Interventions Classification, Anticipatory grieving. See Grieving, Assimilation, in Piaget’s theory of cognitive Nursing Outcomes Classification, anticipatory development, 382 465 Anxiety Auditory deficit, nursing nursing actions/interventions acute attack, 459 actions/interventions, 432, 437 adult health, 466 characteristics of, 456–457 Auscultation, 3 child health, 466–467 clinical concerns, 457 Autonomic dysreflexia expected outcome, 465, 470 death. See Death anxiety actual, 246 flowchart evaluation, 470 definition of, 456 characteristics of, 246 gerontic health, 469 developmental considerations clinical concerns, 246 home health, 469 adolescents, 455 definition of, 246 psychiatric health, 468–469 infants, 453–454 differential diagnosis, 247 target dates, 465 school-age children, 455 NANDA taxonomy, Nursing Interventions women’s health, 467–468 toddlers and preschoolers, 454–455 Classification, Nursing Outcomes related factors, 465 differential diagnosis, 457 Classification, 246 pregnancy and, 467–468 breastfeeding, ineffective, 110 nursing actions/interventions surgery and,

467 constipation, 200 adult health, 247–248 Body system approach, to patient death anxiety, 471 child health, 248 assessment, 3–4 decisional conflict, 400 expected outcome, 247, 250 Body temperature, imbalanced, risk for diarrhea, 206 flowchart evaluation, 250 characteristics of, 102 fear, 476 gerontic health, 248 clinical concerns, 102 grieving home health, 249 definition of, 102 anticipatory, 544 psychiatric health, 248 differential diagnosis, 102 dysfunctional, 551 target dates, 247 hyperthermia, 140 hopelessness, 484 women’s health, 248 hypothermia, 145 individual coping, ineffective, 662 related factors, 246 infection, risk for, 37 post-trauma syndrome, 671 risk for, 246 thermoregulation, ineffective, 178 powerlessness, 501 Autonomy, 62, 227, 612 NANDA taxonomy, Nursing Interventions mild or moderate, 459–460 Classification, Nursing Outcomes NANDA taxonomy, Nursing Interventions Classification, 102 Classification, Nursing Outcomes “Bad me,” 452 nursing actions/interventions Classification, 456 Bathing, toddlers and preschoolers, 227 adult health, 102–103 nursing actions/interventions Bathing-hygiene self-care deficit, 330 child health, 103–104 adult health, 458 Battered women. See Domestic violence expected outcome, 102, 106 child health, 459 Bed mobility, impaired flowchart evaluation, 106 expected outcome, 458, 464 characteristics of, 251 gerontic health, 105 flowchart evaluation, 464 clinical concerns, 251 home health, 105 gerontic health, 463 definition of, 251 psychiatric health, 104–105 home health, 463 differential diagnosis, 251 target dates, 102 midlife women, 461 NANDA taxonomy, Nursing Interventions women’s health, 104 postpartum period, 460–461 Classification, Nursing Outcomes related factors, 102 during pregnancy and childbirth, 460 Classification, 251 Bottle mouth syndrome, 90 psychiatric health, 461–463 nursing actions/interventions Bowel elimination target dates, 458 adult health, 251–253 enema use, 192–193 women’s health, 459–461 child health, 253 problems of related factors, 457 expected outcome, 251, 255 constipation. See Constipation Copyright © 2002 F.A. Davis Company INDEX 735 diarrhea. See Diarrhea Nursing Outcomes Classification, adults, 230 incontinence. See Bowel incontinence 115 infants, 227 process of, 192–193 nursing actions/interventions older adults, 230 Bowel incontinence adult health, 115 school-age children, 228–229 characteristics of, 195 child health, 116 toddlers and preschoolers, 228 clinical concerns, 195 expected outcome, 115, 118 young adults, 229–230 definition of, 195 flowchart evaluation, 118 effects of prolonged bedrest, 226 differential diagnosis, 195 home health, 117 function of, 342 constipation, 200 psychiatric health, 117 tissue perfusion. See Tissue perfusion, fluid volume, deficient, 123 target dates, 115 ineffective NANDA taxonomy, Nursing Interventions women’s health, 116 Care plan, 2–3 Classification, Nursing Outcomes related factors, 115 documentation of, 2–3, 14 Classification, 195 pain, 415–416 valuation of, 13–14 nursing actions/interventions Breathing pattern, ineffective Caregiver. See also Parent to your parents; adult health, 196 characteristics of, 256 Parental role child health, 196 clinical concerns, 256 resources for, 530 expected outcome, 196, 198 definition of, 256 Caregiver Network, Inc., 530 flowchart evaluation, 198 differential diagnosis, 256 Caregiver role strain gerontic health, 197 airway clearance, ineffective, 239 actual, 526 home health, 197 dysfunctional ventilatory weaning characteristics of, 526 psychiatric health, 197 response, 280 clinical concerns, 527 target dates, 196 gas exchange, impaired, 294 definition of, 526 women’s health, 196 spontaneous ventilation, impaired, 337 differential diagnosis, 527 related factors, 195 NANDA taxonomy, Nursing Interventions NANDA taxonomy, Nursing Interventions Brain death, 339 Classification, Nursing Outcomes Classification, Nursing Outcomes Breast milk, 89 Classification, 256 Classification, 526 Breastfeeding nursing actions/interventions nursing actions/interventions caloric intake of woman, 88 adult health, 256–257 adult health, 527–528 effective child health, 257–258 child health, 528 characteristics of, 107 expected outcome, 256, 261 expected outcome, 527, 533 definition of, 107 flowchart evaluation, 261 flowchart evaluation, 533 differential diagnosis, 107 gerontic health, 259–260 gerontic health, 531–532 NANDA taxonomy, Nursing home health, 260 home health, 532 Interventions Classification, psychiatric health, 259 psychiatric health, 530–531 Nursing Outcomes Classification, target dates, 256 target dates, 527 107 women’s health, 258 women’s health, 528–529 nursing actions/interventions related factors, 256 related factors, 526–527 expected outcome, 107, 109 Brown adipose tissue, 90 risk for, 526 flowchart evaluation, 109 Bulbar synchronizing portion, of medulla, The Caregiver’s Handbook, 530 home health, 108 367 Cataplexy, 367 target dates, 107 Cerebral blood flow, inadequate. See Tissue women’s health, 107–108 perfusion, ineffective related factors, 107 Cardiac output Charting by Exception, 8–9 ineffective definition of, 262 Childbirth. See also Postpartum period; characteristics of, 110 decreased Pregnancy clinical concerns, 110 characteristics of, 262 anxiety during, 460 definition of, 110 clinical concerns, 262 fear during, 479 differential diagnosis, 110 definition of, 262 Children, nursing actions/interventions for. breastfeeding, effective, 107 differential diagnosis, 262 See specific nursing diagnosis breastfeeding, interrupted, 115 autonomic dysreflexia, 247 Choosing, definition of, 11t infant feeding pattern, ineffective, fatigue, 289 Chyme, 192 150 fluid volume, excess, 129 Circadian rhythm, 367 NANDA taxonomy, Nursing gas exchange, impaired, 294 Cognition, definition of, 382 Interventions Classification, Nursing tissue perfusion, ineffective, 341 Cognitive dissonance, 382 Outcomes Classification, 110 NANDA taxonomy, Nursing Cognitive-perceptual pattern nursing actions/interventions Interventions Classification, adaptive capacity, intracranial, decreased, adult health, 111 Nursing Outcomes Classification, 385–390 child health, 111 262 assessment of, 381–382 expected outcome, 110, 114 nursing actions/interventions conceptual information, 382 flowchart evaluation, 114 adult health, 263–264 confusion, 391–399 home health, 113 child health, 264–265 decisional conflict, 400–405 psychiatric health, 112 expected outcome, 262, 269 description of, 10, 11t, 381 target dates, 110 flowchart evaluation, 269 developmental considerations women’s health, 111–112 gerontic health, 267–268 adolescents, 384 related factors, 110 home health, 268 adults, 384–385 interrupted psychiatric health, 266–267 infants, 382–383 characteristics of, 115 target dates, 262 older adults, 384–385 clinical concerns, 115 women’s health, 265–266 preschoolers, 383 definition of, 115 related factors, 262 school-age children, 384 differential diagnosis, 115 Cardiovascular system toddlers, 383–384 NANDA taxonomy, Nursing developmental considerations environmental interpretation syndrome, Interventions Classification, adolescents, 229 impaired, 406 Copyright © 2002 F.A. Davis Company 736 INDEX Cognitive-perceptual pattern—Continued NANDA taxonomy, Nursing Interventions flowchart evaluation, 475 knowledge, deficient, 410–415 Classification, Nursing Outcomes gerontic health, 473 memory, impaired, 416–420 Classification, 199 home health, 474 pain, 421–430 nursing actions/interventions psychiatric health, 473 sensory perception, disturbed, 431–439 adult health, 201–202 target dates, 471 thought process, disturbed, 440–446 child health, 202 women’s health, 472 unilateral neglect, 447–450 expected outcome, 200, 205 Decisional conflict Cognitive theory, 382 flowchart evaluation, 205 characteristics of, 400 Colic, 194 gerontic health, 204 clinical concerns, 400 Collaborative action, 6 home health, 204 definition of, 400 Communicating, definition of, 11t psychiatric health, 204 differential diagnosis, 400 Communication, verbal. See Verbal target dates, 200 NANDA taxonomy, Nursing Interventions communication, impaired women’s health, 203–204 Classification, Nursing Outcomes Community coping perceived, 199–200 Classification, 400 characteristics of, 645 related factors, 199–200 nursing actions/interventions clinical concerns, 645 risk for, 199–200 adult health, 400 definition of, 645 Continue, definition of, 9 child health, 401 differential diagnosis, 645 Contractility (heart), definition of, 263 expected outcome, 400, 405 health maintenance, ineffective, 27 Control, loci of, 502 flowchart evaluation, 405 ineffective, 645–646 Convection, loss of body heat, 89 gerontic health, 403 NANDA taxonomy, Nursing Interventions Coping home health, 403–404 Classification, Nursing Outcomes community. See Community coping psychiatric health, 402–403 Classification, 645 defensive, 661 target dates, 400 nursing actions/interventions definition of, 633–634 women’s health, 401 adult health, 645 effective, 635 related factors, 400 child health, 645 family. See Family coping Defecation reflex, 192 expected outcome, 645, 649 individual. See Individual coping, Defensive coping, 661 flowchart evaluation, 649 ineffective Definition (symbolic interaction), 522 gerontic health, 647–648 Coping-stress tolerance pattern Delayed development, risk for home health, 648 adjustment, impaired, 637–644 characteristics of, 301 psychiatric health, 647 assessment of, 633–634 clinical concerns, 301 target dates, 645 community coping, 645–649 definition of, 301 women’s health, 646–647 conceptual information, 634–635 differential diagnosis, 302 readiness for enhanced, 645–647 description of, 10, 11t, 633 NANDA taxonomy, Nursing Interventions related factors, 645 developmental considerations Classification, Nursing Outcomes Compliance, 62 adolescents, 635–636 Classification, 301 Conduction, loss of body heat, 89 adults, 636 nursing actions/interventions Conflict. See Decisional conflict; Parental infants, 635 adult health, 302 role conflict preschoolers, 635 child health, 302–303 Confusion school-age children, 635 expected outcome, 302, 307 acute, 391 toddlers, 635 gerontic health, 305 characteristics of, 391 young adults, 636 home health, 305–306 chronic, 391 family coping psychiatric health, 303–304 clinical concerns, 391 compromised and disabled, 650–656 target dates, 302 definition of, 391 readiness for enhanced, 657–660 women’s health, 303 differential diagnosis, 391 individual coping, ineffective, 661–669 related factors, 301 environmental interpretation syndrome, older adults, 636 Delirium, nursing actions/interventions, impaired, 406 post-trauma syndrome, 670–675 444 memory, impaired, 416 suicide, risk for, 676–680 Delusions, nursing actions/interventions, NANDA taxonomy, Nursing Interventions Credé’s maneuver, 193 442–444 Classification, Nursing Outcomes Crying, in infants, 523 Dementia, nursing actions/interventions, Classification, 391 “Cues to action,” 16, 17f 443–444 nursing actions/interventions Current data, 3 Denial, ineffective, 661 adult health, 391–392 Cybernetics, 502 Dental health child health, 392–393 older adults, 91 expected outcomes, 391, 398–399 school-age children, 90 flowchart evaluations, 398–399 DAR (Data, Action, and Response), 8 toddlers, 90 gerontic health, 395–396 Data collection, 9 young adults, 91 home health, 396–397 assessment of patient, 3 Dentition, impaired psychiatric health, 393–395 Data grouping, 4 characteristics of, 119 target dates, 391 Database, definition of, 7 clinical concerns, 119 women’s health, 393 Death anxiety definition of, 119 related factors, 391 characteristics of, 471 differential diagnosis, 119 Constipation clinical concerns, 471 NANDA taxonomy, Nursing Interventions characteristics of, 199 definition of, 471 Classification, Nursing Outcomes definition of, 199 differential diagnosis, 471 Classification, 119 differential diagnosis, 200 nursing actions/interventions nursing actions/interventions bowel incontinence, 195 adult health, 471–472 adult health, 119–120 diarrhea, 206 child health, 472 child health, 120 urinary incontinence, 212 expected outcome, 471, 475 expected outcome, 119, 122 Copyright © 2002 F.A. Davis Company INDEX 737 flowchart evaluation, 122 nursing actions/interventions Edema, 129 gerontic health, 120–121 adult health, 270–271 Eldercare Locator, 530 home health, 121 child health, 271 Eldercare Navigator, 530 psychiatric health, 120 expected outcome, 270, 274 Elderly. See Older adults target dates, 119 flowchart evaluation, 274 Electrolytes, 88 women’s health, 120 gerontic health, 273 Elimination, definition of, 192 related factors, 119 home health, 273 Elimination pattern Descriptors, NANDA, 693 psychiatric health, 271–272 assessment of, 191–192 DETERMINE, nutritional checklist for older target dates, 270 bowel. See Bowel elimination adults, 91 women’s health, 271 bowel incontinence, 195–198 Development, delayed. See Growth and related factors, 270 conceptual information, 192–193 development, delayed Diversional activity, deficient constipation, 199–205 Diagnosis. See also specific nursing diagnoses characteristics of, 275 description of, 10, 11t, 191 definition of, 4 clinical concerns, 275 developmental considerations nursing, 4 definition of, 275–279 adolescents, 194 statements, 4–5 differential diagnosis, 275 adults, 194 Diarrhea NANDA taxonomy, Nursing Interventions infants, 193–194 characteristics of, 206 Classification, Nursing Outcomes older adults, 195 clinical concerns, 206 Classification, 275 preschoolers, 194 definition of, 206 nursing actions/interventions school-age children, 194 differential diagnosis, 206 adult health, 275–276 toddlers, 194 bowel incontinence, 195 child health, 276 young adults, 194 constipation, 200 expected outcome, 275, 279 diarrhea, 206–210 fluid volume, deficient, 123 flowchart evaluation, 279 urinary incontinence, 211–218 nutrition, imbalanced, less than body gerontic health, 278 urinary retention, 219–223 requirements, 157 home health, 278 Enactive mode, in Piaget’s theory of NANDA taxonomy, Nursing Interventions psychiatric health, 277–278 cognitive development, 382 Classification, Nursing Outcomes target dates, 275 Enema, 192–193 Classification, 206 women’s health, 276–277 Energy field disturbance nursing actions/interventions related factors, 275 characteristics of, 21 adult health, 207 Divorce, nursing actions/interventions, clinical concerns, 21 child health, 208 493 definition of, 21 expected outcome, 206, 210 Documentation, of care plan, 2–3, 14 differential diagnosis, 21 flowchart evaluation, 210 Domestic violence. See also Rape; Rape- NANDA taxonomy, Nursing Interventions gerontic health, 209 trauma syndrome Classification, Nursing Outcomes home health, 209 nursing actions/interventions Classification, 21 psychiatric health, 208 fear, 478–479 nursing actions/interventions target dates, 206 hopelessness, 485 adult health, 22 women’s health, 208 powerlessness, 504 child health, 22–23 precursor to labor, 208 social isolation, 586–587 expected outcome, 22, 26 related factors, 206 violence, risk for, 604–605 flowchart evaluation, 26 Diet. See Nutritional-metabolic pattern Dressing, by toddlers and preschoolers, gerontic health, 24–25 Disorganized infant behavior. See Infants, 227–228 home health, 25 behavior, disorganized Dressing-grooming self-care deficit, psychiatric health, 23–24 Disproportionate growth, risk for 330 target dates, 22 characteristics of, 301 “Due to,” 4 women’s health, 23 clinical concerns, 301 Duodenocolic reflex, 192 Environmental interpretation syndrome, definition of, 301 Dysfunctional grieving. See Grieving, impaired differential diagnosis, 302 dysfunctional characteristics of, 406 NANDA taxonomy, Nursing Interventions Dysfunctional ventilatory weaning response clinical concerns, 406 Classification, Nursing Outcomes (DVWR) definition of, 406 Classification, 301 characteristics of, 280 differential diagnosis, 406 nursing actions/interventions clinical concerns, 280 NANDA taxonomy, Nursing Interventions adult health, 302 definition of, 280 Classification, Nursing Outcomes child health, 302–303 differential diagnosis, 280 Classification, 406 expected outcome, 302, 307 NANDA taxonomy, Nursing Interventions nursing actions/interventions gerontic health, 305 Classification, Nursing Outcomes adult health, 406 home

health, 305–306 Classification, 280 child health, 407 psychiatric health, 303–304 nursing actions/interventions expected outcome, 406, 409 target dates, 302 adult health, 281 flowchart evaluation, 409 women’s health, 303 child health, 281–282 gerontic health, 408 related factors, 301 expected outcome, 280, 284 home health, 408 Disuse syndrome, risk for flowchart evaluation, 284 psychiatric health, 407–408 characteristics of, 270 gerontic health, 283 target dates, 406 clinical concerns, 270 home health, 283 women’s health, 407 definition of, 270 target dates, 280 related factors, 406 differential diagnosis, 270 women’s health, 282 Etiology, in diagnostic statement, 4 NANDA taxonomy, Nursing Interventions related factors, 280 Evaluation, as part of nursing process, 9 Classification, Nursing Outcomes Dysreflexia, autonomic. See Autonomic action following data collection, 9 Classification, 270 dysreflexia data collection, 9 Copyright © 2002 F.A. Davis Company 738 INDEX Evaporation, loss of body heat, 89 home health, 654–655 definition of, 534 “As evidenced by,” 4 psychiatric health, 652–654 differential diagnosis, 535 Exchanging, definition of, 11t target dates, 651 NANDA taxonomy, Nursing Exercise pattern. See Activity-exercise pattern women’s health, 652 Interventions Classification, Expected outcome, 5 related factors, 650 Nursing Outcomes Classification, Expiratory reserve volume, definition of, disabled 534 240t characteristics of, 650 nursing actions/interventions External locus of control, 502 clinical concerns, 650 adult health, 535–536 Exteroceptor, 382 definition of, 650 child health, 536 Extracellular fluid, 88 differential diagnosis, 651 expected outcome, 535, 543 Extremities, tissue perfusion. See Tissue caregiver role strain, 527 flowchart evaluation, 543 perfusion, ineffective family coping, readiness for gerontic health, 541 enhanced, 657 home health, 541–542 family processes, dysfunctional: psychiatric health, 538 Failure to thrive alcoholism, 535 target dates, 535 adult. See Adult failure to thrive family processes, interrupted, 535 women’s health, 536–537 infant, 454 health maintenance, ineffective, 27 related factors, 535 Faith, 681–682. See also Value-belief pattern home maintenance, impaired, 308 interrupted developmental stages of, 682–683 parental role conflict, 563 characteristics of, 534–535 Falls, risk for parenting, impaired, 563 clinical concerns, 535 characteristics of, 285 self-care deficit, 331 definition of, 534 clinical concerns, 285 therapeutic regime, ineffective differential diagnosis, 535 definition of, 285 management of, 62 family coping, readiness for differential diagnosis, 285 violence, risk for, 603 enhanced, 657 NANDA taxonomy, Nursing Interventions NANDA taxonomy, Nursing Interven - health maintenance, ineffective, 27 Classification, Nursing Outcomes tions Classification, Nursing home maintenance, impaired, Classification, 285 Outcomes Classification, 650 308 nursing actions/interventions nursing actions/interventions parent, infant, and child attachment, adult health, 286 adult health, 651 impaired, risk for, 557 child health, 286 child health, 651–652 parental role conflict, 563 expected outcome, 285, 288 expected outcome, 651, 656 parenting, impaired, 563 flowchart evaluation, 288 flowchart evaluation, 656 role performance, ineffective, 574 gerontic health, 287 gerontic health, 654 self-care deficit, 331 home health, 287 home health, 654–655 NANDA taxonomy, Nursing psychiatric health, 287 psychiatric health, 652–654 Interventions Classification, target dates, 285 target dates, 651 Nursing Outcomes Classification, women’s health, 286 women’s health, 652 534 related factors, 285 related factors, 650 nursing actions/interventions Family readiness for enhanced adult health, 535–536 definitions of, 522 characteristics of, 657 child health, 536 relationships within, 522 clinical concerns, 657 expected outcome, 535, 543 types of, 636 definition of, 657 flowchart evaluation, 543 Family coping differential diagnosis, 657 gerontic health, 541 compromised family coping, compromised, 651 home health, 541–542 characteristics of, 650 family coping, disabled, 651 psychiatric health, 538–541 clinical concerns, 650 health maintenance, ineffective, target dates, 535 definition of, 650 27 women’s health, 536–537 differential diagnosis, 652 NANDA taxonomy, Nursing related factors, 535 caregiver role strain, 527 Interventions Classification, Family with adolescents, 636–637 family coping, readiness for Nursing Outcomes Classification, Family with young children, 636 enhanced, 657 657 Fatigue family processes, dysfunctional: nursing actions/interventions characteristics of, 289 alcoholism, 535 adult health, 657 clinical concerns, 289 family processes, interrupted, 535 child health, 657–658 definition of, 289 home maintenance, impaired, 308 expected outcome, 657, 660 differential diagnosis, 289 parental role conflict, 563 flowchart evaluation, 660 energy field disturbance, 21 parenting, impaired, 563 gerontic health, 659 sleep deprivation, 370 self-care deficit, 331 home health, 659 sleep pattern, disabled, 376 therapeutic regime, ineffective psychiatric health, 658–659 experiential, 226 management of, 62 target dates, 657 muscular, 226 violence, risk for, 603 women’s health, 658 NANDA taxonomy, Nursing Interventions NANDA classification, Nursing related factors, 657 Classification, Nursing Outcomes Interventions Classification, Family in later life, 636 Classification, 289 Nursing Outcomes Classification, Family life cycle, 636–637 nursing actions/interventions 650 Family processes adult health, 289–290 nursing actions/interventions dysfunctional, differential diagnosis, child health, 290 adult health, 651 therapeutic regimen, ineffective expected outcome, 289, 293 child health, 651–652 management of, 62 flowchart evaluation, 293 expected outcome, 651, 656 dysfunctional: alcoholism gerontic health, 292 flowchart evaluation, 656 characteristics of, 534–535 home health, 292 gerontic health, 654 clinical concerns, 535 psychiatric health, 291–292 Copyright © 2002 F.A. Davis Company INDEX 739 target dates, 289 related factors, 123 nursing actions/interventions women’s health, 290–291 risk for, 123 adult health, 294–296 related factors, 289 excess child health, 296 Fear characteristics of, 129 expected outcome, 294, 300 characteristics of, 476 clinical concerns, 129 flowchart evaluation, 300 clinical concerns, 476 definition of, 129 gerontic health, 298 definition of, 476 differential diagnosis, 129 home health, 298–299 developmental considerations adaptive capacity, intracranial, psychiatric health, 297–298 adolescents, 455 decreased, 386 target dates, 294 adults, 456 diarrhea, 206 women’s health, 297 infants, 453–454 fluid volume, imbalanced, risk for, related factors, 294 school-age children, 455 136 Gastrocolic reflex, 192 toddlers and preschoolers, 455 urinary incontinence, 212 Gastrointestinal tract differential diagnosis, 476 NANDA taxonomy, Nursing description of, 192 anxiety, 457 Interventions Classification, tissue perfusion. See Tissue perfusion, grieving Nursing Outcomes Classification, ineffective anticipatory, 544 129 Gender identity, 611–613 dysfunctional, 551 nursing actions/interventions Gender orientation, 613 hopelessness, 484 adult health, 130 Gender preference, 613 nutrition, imbalanced, less than body child health, 130–131 Gender role, development of, 611–612 requirements, 157 expected outcome, 129, 135 General-adaptation syndrome (GAS), NANDA taxonomy, Nursing Interventions flowchart evaluation, 135 634 Classification, Nursing Outcomes gerontic health, 133 Generalized resistance resources (GRR), Classification, 476 home health, 133–134 634–635 nursing actions/interventions psychiatric health, 132–133 macrosociocultural, 635 adult health, 477 target dates, 129 Gerontic health. See Older adults child health, 477–478 women’s health, 131–132 Glove powder, 54 expected outcome, 476, 483 related factors, 129 “Good me,” 452 flowchart evaluation, 483 imbalanced, risk for Grieving gerontic health, 481 clinical concerns, 136 anticipatory home health, 481–482 definition of, 136 characteristics of, 544 psychiatric health, 479–481 differential diagnosis, 136 clinical concerns, 544 target dates, 476 NANDA taxonomy, Nursing Interven - definition of, 544 women’s health, 478–479 tions Classification, Nursing Out - differential diagnosis, 544 related factors, 476 comes Classification, 136 death anxiety, 471 Feces, 192 nursing actions/interventions sorrow, chronic, 591 Feeding, by toddlers and preschoolers, 228 adult health, 136–137 NANDA taxonomy, Nursing Feeding self-care deficit, 330 child health, 137–138 Interventions Classification, Feeling, definition of, 11t expected outcome, 136, 139 Nursing Outcomes Classification, Fetal demise, nursing actions/interventions flowchart evaluation, 138 544 decisional conflict, 402 gerontic health, 138 nursing actions/interventions sorrow, chronic, 592–593 home health, 138 adult health, 544 Flatulence, 193 psychiatric health, 138 child health, 544–545 Fluid volume target dates, 136 expected outcome, 544, 550 definition of, 88 women’s health, 138 flowchart evaluation, 550 deficient risk factors, 136 gerontic health, 548–549 actual, 123 FOCUS charting, 8 home health, 549 characteristics of, 123 Food Guide Pyramid, 87 psychiatric health, 547–548 clinical concerns, 123 Functional health patterns, 10, 11t target dates, 544 definitions of, 123 approach to patient assessment, 4 women’s health, 545–546 differential diagnosis, 123 data types, 10 dysfunctional airway clearance, ineffective, 239 description of, 10, 11t characteristics of, 551 constipation, 200 Functional residual capacity, definition of, clinical concerns, 551 diarrhea, 206 240t definition of, 551 fluid volume, imbalanced, risk for, Functional urinary incontinence, 211 differential diagnosis, 551 136 adjustment, impaired, 637 urinary incontinence, 212 anxiety, 457 NANDA taxonomy, Nursing Gas exchange, impaired individual coping, ineffective, 662 Interventions Classification, characteristics of, 294 nutrition, imbalanced, less than body Nursing Outcomes Classification, clinical concerns, 294 requirements, 157 123 definition of, 294 post-trauma syndrome, 671 nursing actions/interventions differential diagnosis, 294 NANDA taxonomy, Nursing adult health, 124–125 airway clearance, ineffective, 239 Interventions Classification, child health, 125 breathing pattern, ineffective, 256 Nursing Outcomes Classification, expected outcome, 123, 128 dysfunctional ventilatory weaning 551 flowchart evaluation, 128 response, 280 nursing actions/interventions gerontic health, 127 fluid volume, excess, 129 adult health, 551 home health, 127 spontaneous ventilation, impaired, 337 child health, 552 psychiatric health, 127 NANDA taxonomy, Nursing Interventions expected outcome, 551, 556 target dates, 123 Classification, Nursing Outcomes flowchart evaluation, 556 women’s health, 125–126 Classification, 294 gerontic health, 554 Copyright © 2002 F.A. Davis Company 740 INDEX Grieving—Continued older adults, 20–21 constipation, 204 home health, 554–555 preschoolers, 19 death anxiety, 474 psychiatric health, 553–554 school-age children, 19–20 decisional conflict, 403–404 target dates, 551 toddlers, 18–19 delayed development, risk for, 305–306 women’s health, 552–553 energy field disturbance, 21–26 dentition, impaired, 121 related factors, 551 health maintenance, ineffective, 27–32 diarrhea, 209 Grooming, by toddlers and preschoolers, health-seeking behaviors, 33–36 disproportionate growth, risk for, 227–228 infection, risk for, 37–41 305–306 Growth and development, delayed injury, risk for, 42–50 disuse syndrome, risk for, 273 characteristics of, 301 latex allergy response, 51–56 diversional activity, deficient, 278 clinical concerns, 301 perioperative-positioning injury, risk for, dysfunctional ventilatory weaning definition of, 301 71–74 response, 283 differential diagnosis, 302 protection, ineffective, 75–80 energy field disturbance, 25 NANDA taxonomy, Nursing Interventions surgical recovery, delayed, 81–85 environmental interpretation syndrome, Classification, Nursing Outcomes therapeutic regimen impaired, 408 Classification, 301 effective management of, 57–60 falls, risk for, 287 nursing actions/interventions ineffective management of, 61–70 family coping adult health, 302 Health Promotion Model, 16, 17f compromised, 654–655 child health, 302–303 Health-seeking behaviors disabled, 654–655 expected outcome, 302, 307 characteristics of, 33 readiness for enhanced, 659 flowchart evaluation, 307 clinical concerns, 33 family processes gerontic health, 305 definition of, 33 dysfunctional: alcoholism, 541–542 home health, 305–306 differential diagnosis, 33 interrupted, 541–542 psychiatric health, 303–304 NANDA taxonomy, Nursing Interventions fatigue, 292 target dates, 302 Classification, Nursing Outcomes fear, 481–482 women’s health, 303 Classification, 33 fluid volume related factors, 301 nursing actions/interventions deficient, 127 Gynecologic pain, nursing adult health, 33–34 excess, 133–134 actions/interventions, 424–425 child health, 34 imbalanced, risk for, 138 expected outcome, 33, 36 gas exchange, impaired, 298–299 flowchart evaluation, 36 grieving Hallucinations, nursing gerontic health, 35 anticipatory, 549 actions/interventions, 437, home health, 35 dysfunctional, 554–555 442–444 psychiatric health, 34–35 growth and development, delayed, Hardiness, description of, 635 target dates, 33 305–306 Head-to-toe approach, to patient women’s health, 34 health maintenance, ineffective, 31 assessment, 3 Healthy People 2010, 18 health-seeking behaviors, 35 Health Belief Model, 16, 17f Hearing home maintenance, impaired, 311 Health maintenance, ineffective deficit, nursing actions/interventions, 432, hopelessness, 489 characteristics of, 27 437 hyperthermia, 143 clinical concerns, 27 developmental considerations hypothermia, 148 definition of, 27 adolescents, 384 individual coping, ineffective, 668 differential diagnosis, 27 adults and older adults, 385 infant behavior, disorganized, 316 knowledge, deficient, 410 infants, 383 infant feeding pattern, ineffective, 151 nutrition, imbalanced Heart rate, cardiac output and, 262 infection, risk for, 40 less than body requirements, 157 Helicobacter pylori infection, 93 injury, risk for, 48–49 more than body requirements, 166 Historical data, 3 knowledge, deficient, 414 thought process, disturbed, 440 Home health, nursing actions/interventions latex allergy response, 55 NANDA taxonomy, Nursing Interventions activity intolerance, 237 loneliness, risk for, 495 Classification, Nursing Outcomes adaptive capacity, intracranial, decreased, memory, impaired, 418–419 Classification, 27 389 nausea, 155 nursing actions/interventions adjustment, impaired, 643 nutrition, imbalanced adult health, 28–29 adult failure to thrive, 94–95 less than body requirements, 164 child health, 29 airway clearance, ineffective, 243–244 more than body requirements, 171 expected outcome, 28, 32 anxiety, 463 pain, 428–429 flowchart evaluation, 32 aspiration, risk for, 100 parent, infant, and child attachment, gerontic health, 31 autonomic dysreflexia, 249 impaired, risk for, 559 home health, 31 bed mobility, impaired, 254 parental role conflict, 568 psychiatric health, 30 body image, disturbed, 469 parenting, impaired, 568 target dates, 28 body temperature, imbalanced, risk for, perioperative-positioning injury, risk for, women’s health, 29–30 105 73 related factors, 27 bowel incontinence, 197 peripheral neurovascular dysfunction, risk Health perception–health management breastfeeding for, 320 pattern effective, 108 personal identity, disturbed, 499 assessment of, 15–16 ineffective, 113 physical mobility, impaired, 327–328 conceptual information, 16–18, 17f interrupted, 117 post-trauma syndrome, 674 description of, 10, 11t, 15 breathing pattern, ineffective, 260 powerlessness, 505–506 developmental considerations cardiac output, decreased, 268 protection, ineffective, 79 adolescents, 20 caregiver role strain, 532 rape-trauma syndrome, 619 adults, 20 community coping, 648 relocation stress syndrome, 572 infants, 18–19 confusion, 396–397 role performance, ineffective,

578 Copyright © 2002 F.A. Davis Company INDEX 741 self-care deficit, 335 Classification, Nursing Outcomes Immunization self-esteem disturbance, 513 Classification, 484 adolescents, 20 self-mutilation behavior, 517–518 nursing actions/interventions adults, 20 sensory perception, disturbed, 438 adult health, 485 infants and toddlers, 18–19 sexual dysfunction, 625–626 child health, 485 older adults, 20–21 sexuality patterns, ineffective, 631 expected outcome, 484, 490 preschoolers, 19 sleep deprivation, 373 flowchart evaluation, 490 school-age children, 20 sleep pattern, disturbed, 379 gerontic health, 488 Incest, nursing actions/interventions, 616 social interaction, impaired, 583 home health, 489 Incontinence social isolation, 589 psychiatric health, 486–488 bowel. See Bowel incontinence sorrow, chronic, 594 target dates, 484 urinary. See Urinary incontinence spiritual distress, 687 women’s health, 486 Independent nursing action, 6 spiritual well-being, readiness for related factors, 484 Individual coping, ineffective enhanced, 691 Human response patterns, 10–11, 11t characteristics of, 661 spontaneous ventilation, impaired, 339 Hygiene, toddlers and preschoolers, 227 clinical concerns, 661 suicide, risk for, 679 Hypersomnia, 367–368 defensive coping, 661 surgical recovery, delayed, 84 Hyperthermia definition of, 661 swallowing, impaired, 176 characteristics of, 140 differential diagnosis, 662 therapeutic regimen clinical concerns, 140 activity intolerance, 231 effective management of, 59 definition of, 140 adjustment, impaired, 637 ineffective management of, 68–69 differential diagnosis, 140 anxiety, 457 thermoregulation, ineffective, 179 body temperature, imbalanced, risk for, breastfeeding, ineffective, 110 thought process, disturbed, 444–445 102 caregiver role strain, 527 tissue integrity, impaired, 189 hypothermia, 145 constipation, 200 tissue perfusion, ineffective, 348 infection, risk for, 37 decisional conflict, 400 transfer ability, impaired, 354 thermoregulation, ineffective, 178 diarrhea, 206 unilateral neglect, 448–449 NANDA taxonomy, Nursing Interventions grieving urinary incontinence, 216–217 Classification, Nursing Outcomes anticipatory, 544 urinary retention, 222 Classification, 140 dysfunctional, 551 verbal communication, impaired, 600 nursing actions/interventions health maintenance, ineffective, 27 violence, risk for, 608–609 adult health, 140–141 home maintenance, impaired, 308 walking, impaired, 358 child health, 141–142 powerlessness, 501 wandering, 362 expected outcome, 140, 144 relocation stress syndrome, 570 wheelchair mobility, impaired, 365 flowchart evaluation, 144 self-care deficit, 331 Home maintenance, impaired gerontic health, 143 self-esteem disturbance, 508 characteristics of, 308 home health, 143 self-mutilation behavior, 516 clinical concerns, 308 psychiatric health, 142–143 sleep deprivation, 370 definition of, 308 target dates, 140 sleep pattern, disturbed, 376 differential diagnosis, 308 women’s health, 142 sorrow, chronic, 591 health maintenance, ineffective, 27 related factors, 140 spiritual distress, 684 health-seeking behaviors, 33 Hypothermia therapeutic regimen, ineffective injury, risk for, 43 characteristics of, 145 management of, 62 therapeutic regime, ineffective clinical concerns, 145 ineffective denial, 661 management of, 62 definition of, 145 NANDA taxonomy, Nursing Interventions NANDA taxonomy, Nursing Interventions differential diagnosis, 145 Classification, Nursing Outcomes Classification, Nursing Outcomes body temperature, imbalanced, risk for, Classification, 661 Classification, 308 102 nursing actions/interventions nursing action/interventions hyperthermia, 140 adult health, 662 adult health, 309 thermoregulation, ineffective, 178 child health, 663 child health, 309 NANDA taxonomy, Nursing Interventions expected outcome, 662, 669 expected outcome, 308, 312 Classification, Nursing Outcomes flowchart evaluation, 669 flowchart evaluation, 312 Classification, 145 gerontic health, 668 gerontic health, 311 nursing actions/interventions home health, 668 home health, 311 adult health, 145–146 psychiatric health, 664–668 psychiatric health, 310–311 child health, 147 target dates, 662 target dates, 308 expected outcome, 145, 149 women’s health, 663–664 women’s health, 309–310 flowchart evaluation, 149 related factors, 661 related factors, 308 gerontic health, 148 Infants. See also Neonates; Toddlers Homosexual family, 522 home health, 148 activity-exercise pattern, 226–227 Hope, 453–454 newborn, 147 behavior, disorganized Hopelessness psychiatric health, 147 actual, 313 characteristics of, 484 target dates, 145 characteristics of, 313 clinical concerns, 484 women’s health, 147 clinical concerns, 313 definition of, 453, 484 related factors, 145 definition of, 313 developmental considerations NANDA taxonomy, Nursing adults, 456 Interventions Classification, infants, 454 Iconic mode, in Piaget’s theory of cognitive Nursing Outcomes Classification, school-age children, 455 development, 382 313 toddlers and preschoolers, 455 Image disturbances. See Body image, nursing actions/interventions differential diagnosis, 484 disturbed; Self-esteem disturbance adult health, 314 NANDA taxonomy, Nursing Interventions Immobility, definition of, 226 child health, 314–315 Copyright © 2002 F.A. Davis Company 742 INDEX Infants—Continued Infertility, nursing actions/interventions, 485 powerlessness, 501 expected outcome, 313, 317 Informed consent, 62 social interaction, impaired, flowchart evaluation, 317 Injury, risk for 580 home health, 316 characteristics of, 42 social isolation, 585 psychiatric health, 316 clinical concerns, 43 therapeutic regimen, ineffective target dates, 313 definition of, 42 management of, 62 women’s health, 315–316 differential diagnosis, 43 NANDA taxonomy, Nursing Interventions readiness for enhanced organized falls, risk for, 285 Classification, Nursing Outcomes behavior, 313 perioperative-positioning injury, risk Classification, 410 related factors, 313 for, 71 nursing actions/interventions risk for, 313 NANDA taxonomy, Nursing Interventions adult health, 410–411 cognitive-perceptual pattern, 382 Classification, Nursing Outcomes child health, 411–412 coping–stress tolerance pattern, 635 Classification, 42 expected outcome, 410, 415 death, nursing actions/interventions, 685 nursing actions/interventions flowchart evaluation, 415 elimination pattern, 193–194 adult health, 44 gerontic health, 414 failure to thrive, 454 child health, 45 home health, 414 feeding pattern, ineffective expected outcome, 43, 50 psychiatric health, 413 characteristics of, 150 flowchart evaluation, 50 target dates, 410 clinical concerns, 150 gerontic health, 47–48 women’s health, 412–413 definition of, 150 home health, 48–49 related factors, 410 differential diagnosis, 150 psychiatric health, 47 breastfeeding, interrupted, 115 target dates, 43 NANDA taxonomy, Nursing women’s health, 46 Labor Interventions Classification, perioperative-positioning. See Periopera- pain, nursing actions/interventions, Nursing Outcomes Classification, tive-positioning injury, risk for 425–426 150 related factors, 43 preterm, 233–234 nursing actions/interventions risk factors for Landau reflex, 383 child health, 150–151 poisoning, 42 Latex allergy response expected outcome, 150, 152 suffocation, 42 characteristics of, 51 flowchart evaluation, 152 trauma, 42–43 clinical concerns, 51 home health, 151 Inspection, 3 definition of, 51 target dates, 150 Inspiratory capacity, definition of, 240t differential diagnosis, 51 women’s health, 151 Inspiratory reserve volume, definition of, 240t NANDA taxonomy, Nursing Interventions related factors, 150 Institutional family, 522 Classification, Nursing Outcomes health perception–health management Internal locus of control, 502 Classification, 51 pattern, 18–19 Interoceptor, 382 nursing actions/interventions hearing development, 383 Interpretation (symbolic interaction), 522 adult health, 51–53 less-than-perfect, 402, 685–686 Interstitial fluid, 88 child health, 53–54 nursing actions/interventions for. See Interventions. See specific nursing diagnosis expected outcome, 51, 56 specific nursing diagnosis Intracellular fluid, 88 flowchart evaluation, 56 nutritional-metabolic pattern, 89–90 Intracranial pressure, increased, 385–390 gerontic health, 55 proprioception, 383 Intravascular fluid, 88 home health, 55 role-relationship pattern, 522–523 Intravenous therapy, nutritional, 159–160 psychiatric health, 55 self-perception/self-concept pattern, target dates, 51 453–454 women’s health, 54–55 sexuality-reproductive pattern, 612 Joining of families through marriage, 636 related factors, 51 sleep-rest pattern, 368 Joint Commission on Accreditation of risk for, 51 smell sense development, 383 Healthcare Organizations Laxatives, 193 taste sense development, 383 ( JCAHO), plan of care statement, Learning, 382 touch sense development, 383 2–3 Less-than-perfect infant, nursing value-belief pattern, 682–683 actions/interventions visual development, 382–383 decisional conflict, 402 Infection, risk for Kidney, tissue perfusion. See Tissue spiritual distress, 685–686 characteristics of, 37 perfusion, ineffective Loneliness, risk for clinical concerns, 37 Kin network, 522 clinical concerns, 491 definition of, 37 Kinesthesia deficit, nursing actions/interven- definition of, 491 differential diagnosis, 37 tions, 433–434, 436 differential diagnosis, 492 protection, ineffective, 75 Kinship system, 522 NANDA taxonomy, Nursing Interventions surgical recovery, delayed, 81 Kleine-Levin syndrome, 368 Classification, Nursing Outcomes NANDA taxonomy, Nursing Interventions Knowing, definition of, 11t Classification, 491 Classification, Nursing Outcomes Knowledge, deficient nursing actions/interventions Classification, 37 characteristics of, 410 adult health, 491–492 nursing actions/interventions clinical concerns, 410 child health, 492 adult health, 37–38 definition of, 410 expected outcome, 492, 496 child health, 38 differential diagnosis, 410 flowchart evaluation, 496 expected outcome, 37, 41 decisional conflict, 400 gerontic health, 495 flowchart evaluation, 41 fear, 476 home health, 495 gerontic health, 40 health maintenance, ineffective, 27 psychiatric health, 493–495 home health, 40 home maintenance, impaired, 308 target dates, 492 psychiatric health, 39 injury, risk for, 43 women’s health, 492–493 target dates, 37 nutrition, imbalanced, more than body risk factors, 491 women’s health, 38–39 requirements, 166 Low self-esteem. See Self-esteem disturbance Copyright © 2002 F.A. Davis Company INDEX 743 Lungs, capacity and volume measurements, nursing actions/interventions differential diagnosis, 157 240t adult health, 153 adult failure to thrive, 92 child health, 154 constipation, 200 expected outcome, 153, 156 delayed development, risk for, 302 Macrosociocultural generalized resistance flowchart evaluation, 156 dentition, impaired, 119 resources, 635 gerontic health, 154 diarrhea, 206 Magical thinking, 384, 523–524 home health, 155 disproportionate growth, risk for, Malnutrition, 88 psychiatric health, 154 302 Maternal exsanguinations, 138 target dates, 153 fatigue, 289 Maternal touch, 435–436 women’s health, 154 fluid volume, deficient, 123 Meconium, 194 related factors, 153 growth and development, delayed, Memory, impaired Near miss sudden infant death syndrome 302 characteristics of, 416 (near miss SIDS), 368 infant feeding pattern, ineffective, clinical concerns, 416 Neglect, unilateral. See Unilateral neglect 150 definition of, 416 Neonates. See also Infants infection, risk for, 37 differential diagnosis, 416 hypothermia, 147 physical mobility, impaired, 322 confusion, 391 role-relationship pattern, 522–523 swallowing, impaired, 174 environmental interpretation syndrome, Nervous system, developmental NANDA taxonomy, Nursing Interven - impaired, 406 considerations tions Classification, Nursing Out - wandering, 360 adolescents, 229 comes Classification, 157 NANDA taxonomy, Nursing Interventions infants, 227 nursing actions/interventions Classification, Nursing Outcomes school-age children, 228–229 adult health, 159–160 Classification, 416 Non-rapid eye movement (NREM) sleep, child health, 160–161 nursing actions/interventions 367, 369 expected outcome, 157, 165 adult health, 416 Noncompliance, 61–62 flowchart evaluation, 165 child health, 417 differential diagnosis, knowledge, gerontic health, 164 expected outcome, 416, 420 deficient, 410 home health, 164 flowchart evaluation, 420 Nonshivering thermogenesis, 147 psychiatric health, 163–164 gerontic health, 418 North American Nursing Diagnosis target dates, 157 home health, 418–419 Association (NANDA) diagnosis, women’s health, 161–162 psychiatric health, 417–418 4–5 related factors, 157 target dates, 416 descriptors, 693 more than body requirements women’s health, 417 Nose breather, 227 actual, 166 related factors, 416 “Not me,” 452 characteristics of, 166 Metabolic acidosis, 88, 147, 192 Nuclear dyad, 522 clinical concerns, 166 Metabolic pattern. See Nutritional-metabolic Nuclear family, 522 definition of, 166–172 pattern Nursing actions. See also specific nursing differential diagnosis, 166 Metabolism, effects of prolonged bedrest, diagnosis fluid volume, excess, 129 226 definition of, 6 physical mobility, impaired, 322 Minimum daily requirements (MDR), 87 difference from physician orders, 6 NANDA taxonomy, Nursing Mobility. See also Activity-exercise pattern examples of, 7 Interventions Classification, definition of, 226 Nursing diagnosis, 4 Nursing Outcomes Classification, impaired definition of, 4 166 bed. See Bed mobility, impaired Nursing models, 9–10 nursing actions/interventions physical. See Physical mobility, Nursing process adult health, 167–169 impaired care plan child health, 169 wheelchair. See Wheelchair mobility, planning of care and, 2–3 expected outcome, 166, 172 impaired valuation of, 13–14 flowchart evaluation, 172 Moro response, 383 components of gerontic health, 170 Moving, definition of, 11t assessment, 3–4 home health, 171 Mucous membrane integrity, 88–89 diagnosis, 4 psychiatric health, 170 Musculoskeletal system documentation, 7–9 target dates, 166 developmental considerations evaluation, 9 women’s health, 170 adolescents, 229 nursing actions, 6–7 related factors, 166 adults, 230 planning, 5–6 risk for, 166 infants, 227 conceptual frameworks Nutritional-metabolic pattern older adults, 230 diagnostic divisions, 11–13, 12–13t adult failure to thrive, 92–96 school-age children, 228–229 functional health patterns, 10, 11t aspiration, risk for, 97–101 young adults, 229 human response patterns, 10–11, 11t assessment of, 86–87 effects of prolonged bedrest, 226 nursing models, 9–10 body temperature, imbalanced, risk for, Mutilation behavior. See Self-mutilation definition of, 1–2 102–106 behavior flowchart, 10f breastfeeding planning of care, 2–3 effective, 107–109 purpose of, 1 ineffective, 110–114 Narcolepsy, 367 standards of care, 2t interrupted, 115–118 Nausea Nursing standards, 2, 2t conceptual information, 87 characteristics of, 153 Nutrition, definition of, 87 dentition, impaired, 119–122 clinical concerns, 153 Nutrition, imbalanced description of, 10, 11t, 86 definition of, 153 less than body requirements developmental considerations NANDA taxonomy, Nursing Interventions characteristics of, 157 adolescents, 90–91 Classification, Nursing Outcomes clinical concerns, 157 adults, 91 Classification, 153 definition of, 157 infants, 89–90 Copyright © 2002 F.A. Davis Company 744 INDEX Nutritional-metabolic pattern—Continued NANDA taxonomy, Nursing Interventions Parenting, impaired older adults, 91–92 Classification, Nursing Outcomes actual, 561 preschoolers, 90 Classification, 421 characteristics of, 561 school-age children, 90 nursing actions/interventions clinical concerns, 562 toddlers, 90 adult health, 422–423 definition of, 561 young adults, 91 child health, 423–424 differential diagnosis, 563 fluid volume expected outcome, 421, 430 breastfeeding deficient, 123–128 flowchart evaluation, 430 effective, 107 excess, 129–135 gerontic health, 428 ineffective, 110 imbalanced, risk for, 136–139 gynecologic pain, 424–425 family coping hyperthermia, 140–144 home health, 428–429 compromised, 651 hypothermia, 145–149 labor pain and nursing, 425–426 disabled, 651 infant feeding pattern, ineffective, postpartum pain, 425–426 fear, 476 150–152 psychiatric health, 426–427 fluid

volume, deficient, 123 nausea, 153–156 target dates, 421 parent, infant, and child attachment, nutrition, imbalanced women’s health, 424–425 impaired, risk for, 557 less than body requirements, 157–165 related factors, 421 violence, risk for, 603 more than body requirements, Palpation, 3 NANDA taxonomy, Nursing Interventions 166–172 Parachute reflex, 383 Classification, Nursing Outcomes swallowing, impaired, 173–177 Parataxic mode, 452 Classification, 561 thermoregulation, ineffective, 178–180 Parent to your parents, nursing nursing actions/interventions tissue integrity, impaired, 181–190 actions/interventions adult health, 563 caregiver role strain, 529–530 child health, 563–564 family processes expected outcome, 563, 569 Objective data, 3 dysfunctional: alcoholism, 537 flowchart evaluation, 569 Older adults interrupted, 537 gerontic health, 567 activity-exercise pattern, 230 Parent, infant, and child attachment, home health, 568 cognitive-perceptual pattern, 384–385 impaired, risk for psychiatric health, 566–567 coping–stress tolerance pattern, 636 clinical concerns, 557 target dates, 563 elimination pattern, 195 definition of, 557 women’s health, 564–566 health perception–health management differential diagnosis, 557 related factors, 562 pattern, 20–21 NANDA taxonomy, Nursing Interventions risk for, 561 hearing development, 385 Classification, Nursing Outcomes Parturition. See Childbirth nursing actions/interventions for. See Classification, 557 Pelvic relaxation, 196 specific nursing diagnosis nursing actions/interventions Perceiving, definition of, 11t, 381 nutritional-metabolic pattern, 91–92 adult health, 557 Perception. See also Cognitive-perceptual proprioception, 385 child health, 557–558 pattern role-relationship pattern, 525 expected outcome, 557, 560 alterations in. See Sensory perception, self-perception/self-concept pattern, 456 flowchart evaluation, 560 disturbed sexuality-reproductive pattern, 613 home health, 559 definition of, 382 sleep-rest pattern, 369 target dates, 557 Percussion, 3 smell sense development, 385 women’s health, 558 Perfusion. See also Tissue perfusion, taste development, 385 related factors, 557 ineffective touch sense development, 385 risk factors, 557 definition of, 342 value-belief pattern, 683 Parental role Periodic limb movement disorder, 369 visual development, 384–385 nursing actions/interventions Perioperative-positioning injury, risk for Olfactory deficit, nursing caregiver role strain, 528–529 characteristics of, 71 actions/interventions, 434 family processes clinical concerns, 71 Ondine’s curse syndrome, 368 dysfunctional: alcoholism, 536–537 definition of, 71 Oral mucous membrane, impaired, 181–190 interrupted, 536–537 differential diagnosis, 71 differential diagnosis self-esteem disturbance, 510–511 NANDA taxonomy, Nursing Interventions fluid volume, deficient, 123 single parent, 492–493 Classification, Nursing Outcomes infection, risk for, 37 Parental role conflict Classification, 71 nutrition, imbalanced, less than body characteristics of, 561–562 nursing actions/interventions requirements, 157 clinical concerns, 562 adult health, 71–72 swallowing, impaired, 174 definition of, 561 child health, 73 tissue integrity, impaired, 182 differential diagnosis, 563 expected outcome, 71, 74 Overweight, 88 NANDA taxonomy, Nursing Interventions flowchart evaluation, 74 Classification, Nursing Outcomes gerontic health, 73 Classification, 561 home health, 73 Pain nursing actions/interventions psychiatric health, 73 acute, 421 adult health, 563 target dates, 71 characteristics of, 421 child health, 563–564 women’s health, 73 chronic, 421 expected outcome, 563, 569 related factors, 71 clinical concerns, 421 flowchart evaluation, 569 Peripheral neurovascular dysfunction, risk for definition of, 421 gerontic health, 567 characteristics of, 318 differential diagnosis, 421 home health, 568 clinical concerns, 318 airway clearance, ineffective, 239 psychiatric health, 566–567 definition of, 318 energy field disturbance, 21 target dates, 563 differential diagnosis, 318 nutrition, imbalanced, less than body women’s health, 564–566 perioperative-positioning injury, risk requirements, 157 related factors, 562 for, 71 Copyright © 2002 F.A. Davis Company INDEX 745 NANDA taxonomy, Nursing Interventions target dates, 322 expected outcome, 501, 507 Classification, Nursing Outcomes women’s health, 324 flowchart evaluation, 507 Classification, 318 related factors, 322 gerontic health, 505 nursing actions/interventions Physiology, toddlers and preschoolers, home health, 505–506 adult health, 318 228 psychiatric health, 504–505 child health, 319 Pickwickian syndrome, 368 target dates, 501 expected outcome, 318, 321 Plan of care, 7 women’s health, 503–504 flowchart evaluation, 321 Planning, 2–3 related factors, 501 gerontic health, 320 establishing target dates, 5–6 risk for, 501 home health, 320 expected outcomes, 5 Pregnancy psychiatric health, 320 setting priorities, 5 breastfeeding. See Breastfeeding target dates, 318 valuation of, 13–14 postpartum period. See Postpartum period women’s health, 319 Play activity unwanted, nursing actions/interventions, related factors, 318 infants, 227 401 Peristalsis, 192 toddlers and preschoolers, 523 weight gain in, 161, 170 “A person’s authority within himself,” 682 Poisoning, 42. See also Injury, risk for Pregnancy-induced hypertension (PIH), 131, Personal identity, disturbed Post-trauma syndrome 234 clinical concerns, 497 actual, 670 Preload, definition of, 262 definition of, 497 characteristics of, 670 Premature rupture of membranes, 233 differential diagnosis, 497 clinical concerns, 670 Preschoolers anxiety, 457 definition of, 670 activity-exercise pattern, 227–228 body image, disturbed, 465 differential diagnosis, 671 cognitive-perceptual pattern, 383 self-esteem disturbance, 508 NANDA taxonomy, Nursing Interventions coping–stress tolerance pattern, 635 NANDA taxonomy, Nursing Interventions Classification, Nursing Outcomes elimination pattern, 194 Classification, Nursing Outcomes Classification, 670 health perception–health management Classification, 497 nursing actions/interventions pattern, 19 nursing actions/interventions adult health, 671 nutritional-metabolic pattern, 90 adult health, 497 child health, 672 role-relationship pattern, 523–524 child health, 497–498 expected outcome, 671, 675 self-perception/self-concept pattern, expected outcome, 497, 500 flowchart evaluation, 675 454–455 flowchart evaluation, 500 gerontic health, 674 sexuality-reproductive pattern, 612–613 gerontic health, 499 home health, 674 sleep-rest pattern, 368–369 home health, 499 psychiatric health, 672–674 smell sense development, 383 psychiatric health, 498–499 target dates, 671 taste sense development, 383 target dates, 497 women’s health, 672 touch sense development, 383 women’s health, 498 related factors, 670 value-belief pattern, 683 Physical mobility, impaired risk for, 670 visual development, 383 characteristics of, 322 Postpartum period Preterm labor, 233–234 clinical concerns, 322 activity-exercise pattern, 235 Primary prevention, 18 definition of, 322 maternal nutritional needs, 88 Problem, in diagnostic statement, 4 differential diagnosis, 322 nursing actions/interventions Problem list, 7–8 activity intolerance, 231 affective disorders, 639–640 Problem Oriented Record (POR), 7–8 bed mobility, impaired, 251 anxiety, 460–461 Problem, Intervention, and Evaluation (PIE) constipation, 200 depression, 485 documentation system, 8 delayed development, risk for, 302 loneliness, risk for, 492 Progress note, 7 disproportionate growth, risk for, 302 pain, 425–426 Proprioception, developmental disuse syndrome, risk for, 270 parental role conflict, 565–566 considerations diversional activity, deficient, 275 parenting, impaired, 565–566 adolescents, 384 falls, risk for, 285 self-esteem disturbance, 510–511 adults and older adults, 385 fluid volume, excess, 129 Power metaphor, 502 infants, 383 growth and development, delayed, 302 Powerlessness Proprioceptor, 382 infection, risk for, 37 actual, 501 Prostate gland, enlarged, 195 injury, risk for, 43 characteristics of, 501 Protection, ineffective physical mobility, impaired, 322 clinical concerns, 501 characteristics of, 75 self-care deficit, 331 definition of, 501 clinical concerns, 75 surgical recovery, delayed, 81 developmental considerations definition of, 75 transfer ability, impaired, 350 adults, 456 differential diagnosis, 75 urinary incontinence, 212 infants, 454 adaptive capacity, intracranial, walking, impaired, 356 differential diagnosis, 501 decreased, 386 wheelchair mobility, impaired, 364 adjustment, impaired, 637 latex allergy response, 51 NANDA taxonomy, Nursing Interventions health maintenance, ineffective, 27 NANDA taxonomy, Nursing Interventions Classification, Nursing Outcomes health-seeking behaviors, 33 Classification, Nursing Outcomes Classification, 322 hopelessness, 484 Classification, 75 nursing actions/interventions individual coping, ineffective, 662 nursing actions/interventions adult health, 323 knowledge, deficient, 410 adult health, 75–76 child health, 323–324 NANDA taxonomy, Nursing Interventions child health, 77 expected outcome, 322, 329 Classification, Nursing Outcomes expected outcome, 75, 80 flowchart evaluation, 329 Classification, 501 flowchart evaluation, 80 gerontic health, 326–327 nursing actions/interventions gerontic health, 78 home health, 327–328 adult health, 502 home health, 79 psychiatric health, 324–326 child health, 502–503 psychiatric health, 78 Copyright © 2002 F.A. Davis Company 746 INDEX Protection, ineffective—Continued injury, risk for, 47 of toddler/preschooler, 613 target dates, 75 knowledge, deficient, 413 of young adult, 613 women’s health, 77–78 latex allergy response, 55 Rape-trauma syndrome related factors, 75 loneliness, risk for, 493–495 characteristics of, 614 Prototaxic mode, 452 memory, impaired, 417–418 compound reaction, 614 Psychiatric health, nursing nausea, 154 definition of, 614 actions/interventions nutrition, imbalanced differential diagnosis, 614 activity intolerance, 235–236 less than body requirements, 163–164 post-trauma syndrome, 671 adaptive capacity, intracranial, decreased, more than body requirements, 170 sexuality patterns, ineffective, 628 389 pain, 426–427 male victim, 616 adjustment, impaired, 640–643 parental role conflict, 566–567 NANDA taxonomy, Nursing Interventions adult failure to thrive, 93–94 parenting, impaired, 566–567 Classification, Nursing Outcomes airway clearance, ineffective, 243 perioperative-positioning injury, risk for, 73 Classification, 614 anxiety, 461–463 peripheral neurovascular dysfunction, risk nursing actions/interventions aspiration, risk for, 99 for, 320 adult health, 615–616 autonomic dysreflexia, 248 personal identity, disturbed, 498–499 child health, 616 bed mobility, impaired, 253 physical mobility, impaired, 324–326 expected outcome, 614, 620 body image, disturbed, 468–469 post-trauma syndrome, 672–674 flowchart evaluation, 620 body temperature, imbalanced, risk for, powerlessness, 504–505 gerontic health, 619 104–105 protection, ineffective, 78 home health, 619 bowel incontinence, 197 rape-trauma syndrome, 617–618 psychiatric health, 617–618 breastfeeding relocation stress syndrome, 571–572 target dates, 614 ineffective, 112 role performance, ineffective, 576–577 women’s health, 617 interrupted, 117 self-care deficit, 333–334 related factors, 614 breathing pattern, ineffective, 259 self-esteem disturbance, 511–512 silent reaction, 614 cardiac output, decreased, 266–267 self-mutilation behavior, 516–517 Rapid eye movement (REM) sleep, 367, 369 caregiver role strain, 530–531 sensory perception, disturbed, 436–437 Rationality, definition of, 381 community coping, 647 sexual dysfunction, 623–625 Recommended dietary allowances (RDA), confusion, 393–395 sexuality patterns, ineffective, 630–631 87 constipation, 204 sleep deprivation, 372 Reflex urinary incontinence, 211 death anxiety, 473 sleep pattern, disturbed, 378 “Related to,” 4 decisional conflict, 402–403 social interaction, impaired, 582–583 Relating, definition of, 11t delayed development, risk for, 303–304 social isolation, 587–588 Religion, 681–682. See also Value-belief dentition, impaired, 120 sorrow, chronic, 593–594 pattern diarrhea, 208 spiritual distress, 686 Relocation stress syndrome disproportionate growth, risk for, spiritual well-being, readiness for actual, 570 303–304 enhanced, 691 characteristics of, 570 disuse syndrome, risk for, 271–272 spontaneous ventilation, impaired, 339 clinical concerns, 570 diversional activity, deficient, 277–278 suicide, risk for, 677–678 definition of, 570 energy field disturbance, 23–24 surgical recovery, delayed, 83 differential diagnosis, 570 environmental interpretation syndrome, swallowing, impaired, 175–176 NANDA taxonomy, Nursing Interventions impaired, 407–408 therapeutic regimen Classification, Nursing Outcomes falls, risk for, 287 effective management of, 58–59 Classification, 570 family coping ineffective management of, 65–67 nursing actions/interventions compromised, 652–654 thermoregulation, ineffective, 179 adult health, 571 disabled, 652–654 thought process, disturbed, 442–443 child health, 571 readiness for enhanced, 658–659 tissue integrity, impaired, 188 expected outcome, 570, 573 family processes tissue perfusion, ineffective, 346–347 flowchart evaluation, 573 dysfunctional: alcoholism, 538–541 transfer ability, impaired, 353 gerontic health, 572 interrupted, 538–541 unilateral neglect, 448 home health, 572 fatigue, 291–292 urinary incontinence, 215–216 psychiatric health, 571–572 fear, 479–481 urinary retention, 221 target dates, 570 fluid volume verbal communication, impaired, 598–600 women’s health, 571 deficient, 127 violence, risk for, 605–608 related factors, 570 excess, 132–133 walking, impaired, 358 risk for, 570 imbalanced, risk for, 138 wandering, 361 Reproductive pattern. See Sexuality- gas exchange, impaired, 297–298 wheelchair mobility, impaired, 365 reproductive pattern grieving Psychosocial-cultural stress, 634 Reproductive system, developmental anticipatory, 547–548 Puberty. See Adolescents considerations, adolescents, 229 dysfunctional, 553–554 Put Prevention into Practice, 18 Residual volume, definition of, 240t growth and development, delayed, Resolved, definition of, 9 303–304 Respiratory system health maintenance, ineffective, 30 “Quicker, sicker” phenomenon, 2 developmental considerations health-seeking behaviors, 34–35 adolescents, 229 home maintenance, impaired, 310–311 adults, 230 hopelessness, 486–488 Radiation, loss of body heat, 89 infants, 227 hyperthermia, 142–143 Rape older adults, 230 hypothermia, 147 of adolescent, 613 school-age children, 228–229 individual coping, ineffective, 664–668 incidence of, 612 toddlers and preschoolers, 228 infant behavior, disorganized, 316 of older woman, 613 young adults, 229–230 infection, risk for, 39 of school-age child, 613 effects of prolonged bedrest, 226 Copyright © 2002 F.A. Davis Company INDEX 747 tissue perfusion. See Tissue perfusion, activity-exercise pattern, 228–229 NANDA taxonomy, Nursing Interventions ineffective cognitive-perceptual pattern, 384 Classification, Nursing Outcomes Rest, definition of, 367 coping–stress tolerance pattern, 635 Classification, 508 Rest pattern. See Sleep-rest pattern elimination pattern, 194 nursing actions/interventions Restless leg syndrome, 369 health perception–health management adult health, 509 Restraints, 271 pattern, 19–20 child health, 509–510 Reticular activating system, 367 nursing actions/interventions. See specific expected outcome, 509, 514 Revise, definition of, 9 nursing diagnosis flowchart evaluation, 514 “Risk for,” 5 nutritional-metabolic pattern, 90 gerontic health, 512 Role role-relationship pattern, 524 home health, 513 definition of, 521–522 self-perception/self-concept pattern, 455 psychiatric health, 511–512 factors that effect, 521–522 sexuality-reproductive pattern, 613 target dates, 509 Role achievement, 521 sleep-rest pattern, 369 women’s health, 510–511 Role performance, ineffective value-belief pattern, 683 related factors, 508 characteristics of, 574 Seclusion, 271 situational low self-esteem, 508 clinical concerns, 574 Secondary prevention, 18 risk for, 508 definition of, 574 “Secondary to,” 4 Self-mutilation behavior differential diagnosis, 574 Self, definition of, 452–453 actual, 515 NANDA taxonomy, Nursing Interventions Self-care deficit characteristics of, 515 Classification, Nursing Outcomes bathing-hygiene, 330 clinical concerns, 515–516 Classification, 574 characteristics of, 330 definition of, 515 nursing actions/interventions clinical concerns, 330 differential diagnosis, 516 adult health, 575

definition of, 330 suicide, risk for, 676 child health, 575–576 differential diagnosis, 331 NANDA taxonomy, Nursing Interventions expected outcome, 575, 579 activity intolerance, 231 Classification, Nursing Outcomes flowchart evaluation, 579 fluid volume, deficient, 123 Classification, 515 gerontic health, 578 infection, risk for, 37 nursing actions/interventions home health, 578 nutrition, imbalanced, less than body adult health, 516 psychiatric health, 576–577 requirements, 157 child health, 516 target dates, 575 sensory perception, disturbed, 431 expected outcome, 516, 519 women’s health, 576 therapeutic regimen, ineffective flowchart evaluation, 519 related factors, 574 management of, 62 gerontic health, 517 Role-play, 384 dressing-grooming, 330 home health, 517–518 Role-relationship pattern feeding, 330 psychiatric health, 516–517 assessment of, 530–531 NANDA taxonomy, Nursing Interventions target dates, 516 caregiver role strain, 526–533 Classification, Nursing Outcomes women’s health, 516 conceptual information, 521–522 Classification, 330 related factors, 515 description of, 10, 11t, 520 nursing actions/interventions risk for, 515 developmental considerations adult health, 331–332 Self-perception, development of, 453 adolescents, 524–525 child health, 332 Self-perception/self-concept pattern middle-age adults, 525 expected outcome, 331, 336 anxiety, 456–464 neonates and infants, 522–523 flowchart evaluation, 336 assessment of, 451–452 older adults, 525 gerontic health, 334 body image, disturbed, 465–470 preschoolers, 523–524 home health, 335 conceptual information, 452–453 school-age children, 524 psychiatric health, 333–334 death anxiety, 471–475 toddlers, 523–524 target dates, 331 description of, 10, 11t, 451 young adults, 525 women’s health, 332–333 developmental considerations family processes related factors, 330 adolescents, 455–456 dysfunctional: alcoholism, 534–543 toileting, 330 adults, 456 interrupted, 534–543 differential diagnosis infants, 453–454 grieving bowel incontinence, 195 older adults, 456 anticipatory, 544–551 constipation, 200 preschoolers, 454–455 dysfunctional, 551–556 urinary retention, 219 school-age children, 455 parent, infant, and child attachment, Self-concept toddlers, 454–455 impaired, risk for, 557–560 definition of, 452–453 fear, 476–483 parental role conflict, 561–569 development of, 452 hopelessness, 484–490 parenting, impaired, 561–569 Self-concept pattern. See Self-perception/self- loneliness, risk for, 491–496 relocation stress syndrome, 570–573 concept pattern personal identity, disturbed, 497–500 role performance, ineffective, 574–579 Self-control, development of, 455 powerlessness, 501–507 social interaction, impaired, 580–584 Self-disclosure, 453 self-esteem disturbance, 508–514 social isolation, 585–590 Self-esteem disturbance self-mutilation behavior, 515–519 sorrow, chronic, 591–595 characteristics of, 508 Sensory organs, health perception and, 15 verbal communication, impaired, chronic low self-esteem, 508 Sensory perception, disturbed 596–601 clinical concerns, 508 characteristics of, 431 violence, risk for, 602–610 definition of, 508 clinical concerns, 431 Role strain, caregiver. See Caregiver role differential diagnosis, 508 definition of, 431 strain body image, disturbed, 465 differential diagnosis, 431 diarrhea, 206 adjustment, impaired, 637 nutrition, imbalanced, less than body confusion, 391 Salivation, 89 requirements, 157 delayed development, risk for, 302 School-age children personal identity, disturbed, 497 disproportionate growth, risk for, 302 Copyright © 2002 F.A. Davis Company 748 INDEX Sensory perception, disturbed—Continued Sexuality-reproductive pattern expected outcome, 376, 380 diversional activity, deficient, 275 assessment of, 611 flowchart evaluation, 380 energy field disturbance, 21 conceptual information, 611–612 gerontic health, 378 grieving description of, 10, 11t, 611 home health, 379 anticipatory, 544 developmental considerations psychiatric health, 378 dysfunctional, 551 adolescents, 613 target dates, 376 growth and development, delayed, 302 adults, 613 women’s health, 377–378 individual coping, ineffective, 662 infants, 612 related factors, 375 nutrition, imbalanced, less than body older adults, 613 Sleep-rest pattern requirements, 157 preschoolers, 612–613 assessment of, 367 thought process, disturbed, 440 school-age children, 613 conceptual information, 367–368 unilateral neglect, 447 toddlers, 612–613 description of, 10, 11t, 367 verbal communication, impaired, young adults, 613 developmental considerations 596 rape-trauma syndrome, 614–620 adolescents, 369 NANDA taxonomy, Nursing Interventions sexual dysfunction, 621–627 adults, 369 Classification, Nursing Outcomes sexuality patterns, ineffective, infants, 368 Classification, 431 628–632 older adults, 369 nursing actions/interventions Single adult alone, 522 preschoolers, 368–369 adult health, 431–434 Single-parent family school-age children, 369 child health, 434–435 definition of, 522 toddlers, 368–369 expected outcome, 431, 439 nursing actions/interventions, 492–493 sleep deprivation, 369–374 flowchart evaluation, 439 Skin sleep pattern, disturbed, 375–380 gerontic health, 438 effects of prolonged bedrest, 226 Smell sense home health, 438 as thermoregulatory organ, 89 deficit, nursing actions/interventions, psychiatric health, 436–437 Skin integrity, 88–89 434–435 target dates, 431 impaired, 181–190 developmental considerations women’s health, 435 differential diagnosis adolescents, 384 related factors, 431 autonomic dysreflexia, 247 adults and older adults, 385 Separation anxiety, 453–454 infection, risk for, 37 infants, 383 Setting priorities, 5 tissue integrity, impaired, 182 toddlers and preschoolers, 383 Sex-appropriate behavior, 612 risk for, 181 SOAPIER format, 7–8 Sexual dysfunction Sleep Social interaction, impaired characteristics of, 621 hypersomnia, 367–368 characteristics of, 580 clinical concerns, 621 narcolepsy, 367 clinical concerns, 580 definition of, 621 stages of, 367 definition of, 580 differential diagnosis, 621 Sleep apnea, 368–369 differential diagnosis, 580 rape-trauma syndrome, 614 Sleep deprivation loneliness, risk for, 492 sexuality patterns, ineffective, characteristics of, 369–370 social isolation, 585 628 clinical concerns, 370 NANDA taxonomy, Nursing Interventions NANDA taxonomy, Nursing Interventions definition of, 369 Classification, Nursing Outcomes Classification, Nursing Outcomes differential diagnosis, 370 Classification, 580 Classification, 621 NANDA taxonomy, Nursing Interventions nursing actions/interventions nursing actions/interventions Classification, Nursing Outcomes adult health, 580–581 adult health, 621–622 Classification, 369 child health, 581 expected outcome, 621, 627 nursing actions/interventions expected outcome, 580, 584 flowchart evaluation, 627 adult health, 370–371 flowchart evaluation, 584 gerontic health, 625 child health, 371 gerontic health, 583 home health, 625–626 expected outcome, 370, 374 home health, 583 psychiatric health, 623–625 flowchart evaluation, 374 psychiatric health, 582–583 target dates, 621 gerontic health, 372–373 target dates, 580 women’s health, 622–623 home health, 373 women’s health, 581 related factors, 621 psychiatric health, 372 related factors, 580 Sexuality patterns, ineffective target dates, 370 Social isolation characteristics of, 628 women’s health, 372 characteristics of, 585 clinical concerns, 628 related factors, 370 clinical concerns, 585 definition of, 628 Sleep paralysis, 367 definition of, 585–590 differential diagnosis, 628 Sleep pattern, disturbed differential diagnosis, 585 NANDA taxonomy, Nursing Interventions characteristics of, 375 diversional activity, deficient, 275 Classification, Nursing Outcomes clinical concerns, 375 loneliness, risk for, 492 Classification, 628 definition of, 375 nutrition, imbalanced, less than body nursing actions/interventions differential diagnosis, 376 requirements, 157 adult health, 628–629 diarrhea, 206 role performance, ineffective, 574 child health, 629 energy field disturbance, 21 social interaction, impaired, 580 expected outcome, 628, 632 fatigue, 289 verbal communication, impaired, flowchart evaluation, 632 sleep deprivation, 370 596 gerontic health, 631 NANDA taxonomy, Nursing Interventions NANDA taxonomy, Nursing Interventions home health, 631 Classification, Nursing Outcomes Classification, Nursing Outcomes psychiatric health, 630–631 Classification, 375 Classification, 585 target dates, 628 nursing actions/interventions nursing actions/interventions women’s health, 629–630 adult health, 376 adult health, 586 related factors, 628 child health, 377 child health, 586 Copyright © 2002 F.A. Davis Company INDEX 749 expected outcome, 585, 590 gerontic health, 691 NANDA taxonomy, Nursing Interventions flowchart evaluation, 590 home health, 691 Classification, Nursing Outcomes gerontic health, 589 psychiatric health, 691 Classification, 81 home health, 589 target dates, 689 nursing actions/interventions psychiatric health, 587–588 women’s health, 690–691 adult health, 81–82 target dates, 585 Spirituality, 681–682. See also Value-belief child health, 82 women’s health, 586–587 pattern expected outcome, 81, 85 related factors, 585 Spontaneous ventilation, impaired flowchart evaluation, 85 Sodium excess, 129 characteristics of, 337 gerontic health, 83 Sorrow, chronic clinical concerns, 337 home health, 84 characteristics of, 591 definition of, 337 psychiatric health, 83 clinical concerns, 591 differential diagnosis, 337 target dates, 81 definition of, 591–595 NANDA taxonomy, Nursing Interventions women’s health, 82–83 differential diagnosis, 591 Classification, Nursing Outcomes Swallowing NANDA taxonomy, Nursing Interventions Classification, 337 impaired Classification, Nursing Outcomes nursing actions/interventions characteristics of, 173 Classification, 591 adult health, 337–338 clinical concerns, 173 nursing actions/interventions child health, 338–339 definition of, 173 adult health, 591–592 expected outcome, 337, 340 differential diagnosis, 174 child health, 592 flowchart evaluation, 340 adult failure to thrive, 92 expected outcome, 591, 595 gerontic health, 339 aspiration, risk for, 97 flowchart evaluation, 595 home health, 339 NANDA taxonomy, Nursing gerontic health, 594 psychiatric health, 339 Interventions Classification, home health, 594 target dates, 337 Nursing Outcomes Classification, psychiatric health, 593–594 women’s health, 339 173 target dates, 591 related factors, 337 nursing actions/interventions women’s health, 592–593 Stable health, 33 adult health, 174–175 related factors, 591 Standards of care, 2t child health, 175 Spiritual distress Startle response, 383 expected outcome, 174, 177 actual, 683 Stillborn, nursing actions/interventions flowchart evaluation, 177 characteristics of, 683 decisional conflict, 402 gerontic health, 176 clinical concerns, 683–685 sorrow, chronic, 592–593 home health, 176 definition of, 683 spiritual distress, 685 psychiatric health, 175–176 differential diagnosis, 684 Stranger anxiety, 453–454 target dates, 174 anxiety, 457 Stress women’s health, 175 grieving definition of, 634 related factors, 173 anticipatory, 544 psychosocial-cultural, 634 by infants, 89 dysfunctional, 551 Stress response, levels of, 634 phases of health maintenance, ineffective, 27 Stress tolerance pattern. See also Coping- esophageal phase, 87 nutrition, imbalanced, less than body stress tolerance pattern oral phase, 87 requirements, 157 definition of, 633 oral preparatory phase, 87 spiritual well-being, readiness for Stress urinary incontinence, 211 pharyngeal phase, 87 enhanced, 689 Stroke volume, cardiac output and, 262 Symbolic interaction, 452, 522 NANDA taxonomy, Nursing Interventions Subjective data, 3 Symbolic mode, in Piaget’s theory of Classification, Nursing Outcomes Sudden infant death syndrome (SIDS), 368, cognitive development, 382 Classification, 683 553 Symptoms, in diagnostic statement, 4 nursing actions/interventions Suffocation, 42 Syntaxic mode, 452 adult health, 684 Suicide, risk for System persistence, 65 child health, 684–685 characteristics of, 676 Systems theory, 502 expected outcome, 684, 688 clinical concerns, 676 flowchart evaluation, 688 definition of, 676 gerontic health, 687 differential diagnosis, 676 Target date, 5–6 home health, 687 NANDA taxonomy, Nursing Interventions Taste, developmental considerations psychiatric health, 686 Classification, Nursing Outcomes adults and older adults, 385 target dates, 684 Classification, 676 infants, 383 women’s health, 685–686 nursing actions/interventions toddlers and preschoolers, 383 related factors, 683 adult health, 676 Taxonomy II (NANDA), 11–13, 12–13t risk for, 683 child health, 677 domains and classes, 12–13t Spiritual well-being, readiness for enhanced expected outcome, 676, 680 taxonomic axes, 13, 13t characteristics of, 689 flowchart evaluation, 680 Teen parenting, nursing clinical concerns, 689 gerontic health, 679 actions/interventions, 529 definition of, 689 home health, 679 Teen pregnancy, 613 differential diagnosis, 689 psychiatric health, 677–678 Teenagers. See Adolescents NANDA taxonomy, Nursing Interventions target dates, 676 Temperature. See Body temperature, Classification, Nursing Outcomes women’s health, 677 imbalanced, risk for; Classification, 689 related factors, 676 Thermoregulation nursing actions/interventions Surgical recovery, delayed Tertiary prevention, 18 adult health, 689–690 characteristics of, 81 Therapeutic regimen child health, 690 clinical concerns, 81 effective management of expected outcome, 689, 692 definition of, 81 characteristics of, 57 flowchart evaluation, 692 differential diagnosis, 81 clinical concerns, 57 Copyright © 2002 F.A. Davis Company 750 INDEX Therapeutic regimen—Continued clinical concerns, 440 gastrointestinal, 341 definition of, 57 definition of, 440 NANDA taxonomy, Nursing Interventions differential diagnosis, 57 differential diagnosis, 440 Classification, Nursing Outcomes NANDA taxonomy, Nursing Interven - adjustment, impaired, 637 Classification, 341 tions Classification, Nursing confusion, 391 nursing actions/interventions Outcomes Classification, 57 environmental interpretation syndrome, adult health, 342–343 nursing actions/interventions impaired, 406 child health, 343–344 adult health, 57–58 home maintenance, impaired, 308 expected outcome, 341, 349 child health, 58 hopelessness, 484 flowchart evaluation, 349 expected outcome, 57, 60 individual coping, ineffective, 662 gerontic health, 347–348 flowchart evaluation, 60 injury, risk for, 43 home health, 348 gerontic health, 59 knowledge, deficient, 410 psychiatric health, 346–347 home health, 59 memory, impaired, 416 target dates, 341 psychiatric health, 58–59 post-trauma syndrome, 671 women’s health, 344–345 target dates, 57 powerlessness, 501 peripheral, 341 women’s health, 58 self-care deficit, 331 related factors, 341 ineffective management of sensory perception, disturbed, 431 renal, 341 characteristics of, 61 therapeutic regimen, ineffective Today’s Caregiver, 530 clinical concerns, 62 management of, 62 Toddlers. See also Infants for communities, 61 wandering, 360 activity-exercise pattern, 227–228 definition of, 61 NANDA taxonomy, Nursing Interventions cognitive-perceptual pattern, 383 differential diagnosis, 62 Classification, Nursing Outcomes coping–stress tolerance pattern, 635 community coping, 645 Classification, 440 elimination pattern, 194 infection, risk for, 37 nursing actions/interventions health perception–health management transfer ability, impaired, 350 adult health, 440–441 pattern, 18–19 for families, 61–62 child health, 441–442 nutritional-metabolic pattern, 90 for individuals, 61 expected outcome, 440, 446 role-relationship pattern, 523–524 NANDA taxonomy, Nursing Interven - flowchart evaluation, 446 self-perception/self-concept pattern, tions Classification, Nursing gerontic health, 443–444 454–455 Outcomes Classification, 61 home health, 444–445 sexuality-reproductive pattern, noncompliance, 61 psychiatric health, 442–443 612–613 nursing actions/interventions target dates, 440 sleep-rest pattern, 368–369 adult health, 63–64 women’s health, 442 smell sense development, 383 child health, 64–65 Three-generation family, 522 taste sense development, 383 expected outcome, 62, 70 Tidal volume, definition of, 240t touch sense development, 383 flowchart evaluation, 70 Tissue integrity value-belief pattern, 683 gerontic health, 68 definition of, 88–89 visual development,

383 home health, 68–69 impaired Toilet training, 194, 455, 524 psychiatric health, 65–67 characteristics of, 181 Toileting, by toddlers and preschoolers, target dates, 62 clinical concerns, 182 228 women’s health, 65 definition of, 181 Toileting self-care deficit, 330 related factors, 61–62 differential diagnosis, 182 TORCH infections, 19 Thermoregulation infection, risk for, 37 Total lung capacity, definition of, 240t definition of, 88–89 latex allergy response, 51 Total parenteral nutrition, 159–160 ineffective nursing actions/interventions Total urinary incontinence, 211 characteristics of, 178 adult health, 182–184 Touch sense clinical concerns, 178 child health, 184–185 deficit, nursing actions/interventions, definition of, 178 expected outcome, 182, 190 433–434 differential diagnosis, 178 flowchart evaluation, 190 developmental considerations body temperature, imbalanced, risk gerontic health, 189 adolescents, 384 for, 102 home health, 189 adults and older adults, 385 energy field disturbance, 21 psychiatric health, 188 infants, 383 hyperthermia, 140 target dates, 182 toddlers and preschoolers, 383 hypothermia, 145 women’s health, 185–187 during pregnancy, 435 NANDA taxonomy, Nursing Interven - related factors, 181–182 Transfer ability, impaired tions Classification, Nursing Tissue perfusion, ineffective characteristics of, 350 Outcomes Classification, 178 cardiopulmonary, 341 clinical concerns, 350 nursing actions/interventions cerebral, 341 definition of, 350 adult health, 178–179 characteristics of, 341 differential diagnosis, 350 child health, 179 clinical concerns, 341 NANDA taxonomy, Nursing Interventions expected outcome, 178, 180 definition of, 341 Classification, Nursing Outcomes flowchart evaluation, 180 differential diagnosis, 341 Classification, 350 gerontic health, 179 adaptive capacity, intracranial, nursing actions/interventions home health, 179 decreased, 386 adult health, 350–353 psychiatric health, 179 cardiac output, decreased, 262 child health, 353 target dates, 178 nutrition, imbalanced, less than body expected outcome, 350, 355 women’s health, 179 requirements, 157 flowchart evaluation, 355 related factors, 178 peripheral neurovascular dysfunction, gerontic health, 353 Thought process, disturbed risk for, 318 home health, 354 characteristics of, 440 surgical recovery, delayed, 81 psychiatric health, 353 Copyright © 2002 F.A. Davis Company INDEX 751 target dates, 350 functional, 193 characteristics of, 602 women’s health, 353 mechanical, 193 clinical concerns, 602 Trauma, 42–43. See also Injury, risk for; NANDA taxonomy, Nursing Interventions definition of, 602–610 Post-trauma syndrome; Rape- Classification, Nursing Outcomes differential diagnosis, 602 trauma syndrome Classification, 219 individual coping, ineffective, Tube feedings, 159 nursing actions/interventions 662 continuous, 159–160 adult health, 219–220 injury, risk for, 43 child health, 220 self-mutilation behavior, 516 expected outcome, 219, 223 suicide, risk for, 676 Underweight, 88 flowchart evaluation, 223 NANDA taxonomy, Nursing Interven - Unilateral neglect gerontic health, 221 tions Classification, Nursing characteristics of, 447 home health, 222 Outcomes Classification, 602 clinical concerns, 447 psychiatric health, 221 nursing actions/interventions definition of, 447 target dates, 219 adult health, 603 differential diagnosis, 447 women’s health, 221 child health, 603–604 NANDA taxonomy, Nursing Interventions related factors, 219 expected outcome, 603, 610 Classification, Nursing Outcomes Urinary tract, description of, 193 flowchart evaluation, 610 Classification, 447 Urination, process of, 193 gerontic health, 608 nursing actions/interventions Urine volume, 193 home health, 608–609 adult health, 447 Uterine prolapse, 196 psychiatric health, 605–608 child health, 448 target dates, 603 expected outcome, 447, 450 women’s health, 604–605 flowchart evaluation, 450 Valsalva maneuver, 193 other-directed, 602 gerontic health, 448 Value-belief pattern self-directed, 602 home health, 448–449 assessment of, 681 Vision psychiatric health, 448 conceptual information, 681–682 deficit, nursing actions/interventions, target dates, 447 description of, 10, 11t, 681 432–433, 435, 437 women’s health, 448 developmental considerations developmental considerations related factors, 447 adolescents, 683 adolescents, 384 Unwanted pregnancy, nursing adults, 683 adults and older adults, 384–385 actions/interventions, 401 infants, 682–683 infants, 382–383 Urge urinary incontinence, 211 older adults, 683 toddlers and preschoolers, 383 risk for, 211–212 preschoolers, 683 Vital capacity, definition of, 240t Urinary control, 193 school-age children, 683 Voiding. See Urination Urinary elimination, process of, 193 toddlers, 683 Urinary incontinence young adults, 683 characteristics of, 211 spiritual distress, 683–688 Walking, impaired clinical concerns, 212 spiritual well-being, readiness for characteristics of, 356 definition of, 211 enhanced, 689–692 clinical concerns, 356 differential diagnosis, 212 Valuing, definition of, 11t definition of, 356 fluid volume, deficient, 123 Ventilation, impaired. See Spontaneous differential diagnosis, 356 urinary retention, 219 ventilation, impaired bed mobility, impaired, 251 functional, 211 Ventilatory weaning response. See NANDA taxonomy, Nursing Interventions NANDA taxonomy, Nursing Interventions Dysfunctional ventilatory weaning Classification, Nursing Outcomes Classification, Nursing Outcomes response Classification, 356 Classification, 211 Verbal communication, impaired nursing actions/interventions nursing actions/interventions characteristics of, 596 adult health, 356–357 adult health, 213–214 clinical concerns, 596 child health, 357–358 child health, 215 definition of, 596 expected outcome, 356, 359 expected outcome, 212, 218 differential diagnosis, 596 flowchart evaluation, 359 flowchart evaluation, 218 social interaction, impaired, 580 gerontic health, 358 gerontic health, 216 social isolation, 585 home health, 358 home health, 216–217 urinary incontinence, 212 psychiatric health, 358 psychiatric health, 215–216 NANDA taxonomy, Nursing Interventions target dates, 356 target dates, 212 Classification, Nursing Outcomes women’s health, 358 women’s health, 215 Classification, 596 Wandering reflex, 211 nursing actions/interventions characteristics of, 360 related factors, 211–212 adult health, 596–597 clinical concerns, 360 stress, 211 child health, 597–598 definition of, 360 total, 211 expected outcome, 596, 601 differential diagnosis, 360 urge, 211 flowchart evaluation, 601 NANDA taxonomy, Nursing Interventions risk for, 211–212 gerontic health, 600 Classification, Nursing Outcomes Urinary output, 193 home health, 600 Classification, 360 Urinary retention psychiatric health, 598–600 nursing actions/interventions characteristics of, 219 target dates, 596 adult health, 360–361 clinical concerns, 219 women’s health, 598 child health, 361 definition of, 219 related factors, 596 expected outcome, 360, 363 differential diagnosis, 219 Violence flowchart evaluation, 363 autonomic dysreflexia, 247 domestic. See Domestic violence gerontic health, 361–362 fluid volume, excess, 129 risk for home health, 362 Copyright © 2002 F.A. Davis Company 752 INDEX Wandering—Continued nursing actions/interventions Women, nursing actions/interventions for. psychiatric health, 361 adult health, 364 See specific nursing diagnosis target dates, 360 child health, 364–365 women’s health, 361 expected outcome, 364, 366 related factors, 360 flowchart evaluation, 366 Young adults. See also Adults Wheelchair mobility, impaired gerontic health, 365 activity-exercise pattern, 229–230 characteristics of, 364 home health, 365 coping–stress tolerance pattern, clinical concerns, 364 psychiatric health, 365 636 definition of, 364 target dates, 364 elimination pattern, 194 differential diagnosis, 364 women’s health, 365 nutritional-metabolic pattern, 91 NANDA taxonomy, Nursing Interventions Widowhood, nursing actions/interventions, sexuality-reproductive pattern, Classification, Nursing Outcomes 493 613 Classification, 364 Wisdom teeth, 91 value-belief pattern, 683

RENAL Tumors Dr. Abd El-hamed Youssef Prof. Of Urology Ain Shams University Glenn(1980) Glenn(1980) Renal Cortical Adenoma Small, evidently benign, solid renal cortical lesions have been found at autopsy with an incidence 7-23% Renal Cortical Adenoma ØThe majority of such lesions are solitary; 25% are multicentric ØIncidence increases with patient age Ømore common in patients with von Hippel–Lindau disease (VHL) and acquired renal cystic disease associated with end- stage renal failure ØThe male-to-female ratio is 3 to 1 Renal Cortical Adenoma ØThe diagnosis of renal adenoma remains controversial, with many believing that all solid renal epithelial-derived masses are potentially malignant and should be treated as such. ØRenal exploration and wedge resection or other ablative therapies should be strongly considered, with appropriate consideration of patient age, comorbidities, and other relevant factors. Oncocytoma Ø3% to 7% of all solid renal masses ØGrossly, these tumors are light brown or tan, homogeneous, and well circumscribed but, like most renal tumors, not truly encapsulated ØA central scar is commonly found, but prominent necrosis or hypervascularity is lacking. ØSite or origin is distal renal tubules Oncocytoma Ø Microscopically, uniform round or polygonal eosinophilic cells with granular cytoplasm, most commonly arranged in an organoid, tubulocystic, solid, or mixed growth pattern ØUltrastructurally, oncocytomas are packed with numerous large mitochondria, which contributes to their distinctive staining characteristics Oncocytoma Oncocytoma qClinical picture ØUsually discovered accidentally ØPain ,hematuria ,mass are found less frequently qInvestigation ØCT, US and MR solid mass with central scar ØAngiography typical spoke-wheal appearance Oncocytoma qManagement If pre operatively reliable diagnosis NSS If the diagnosis is not sure and the size beyond 5cm Radical Nephrectomy Angiomyolipoma qIncidence ØIsolated or as a part of syndrome associated with tuberous sclerosis ØTuberous sclerosis is familial syndrome characterized by mental retardation ,epilepsy and adenoma sebaceum ØIn all patients hamartoma may be found in the brain ,eye, lung , heart and bone Angiomyolipoma qPathology –Macroscopic ØYellow and gray in color ,may attain a huge size and have propensity of profuse hemorrhage and multiplicity –Microscopic Three main component ØUnusual blood vessels ØSheets of smooth muscle ØClusters of adipocytes Angiomyolipoma qInvestigation § U/S Hyperchoec lesion due to fat content §CT The high fat content of the tumor let CT accurately defined the presence of the tumor Angiomyolipoma qPresentation – Three main types ØIncidentally in patients undergoing CT for other abdominal problems ØLarge tumors may cause discomfort and GI manifestation due to compression ØSudden pain or sever hemorrhage to the retro peritoneum (Wunderlich's syndrome ) or to the tumor it self Angiomyolipoma qManagement It was found that the size of the tumor is related to the symptoms Less than 4 cm Follow up Persistent symptomatic tumors of any Selective size embolization NSS Angiomyolipoma Most patients with acute or potentially life-threatening hemorrhage require total nephrectomy if explored RENAL CELL CARCINOMA qIncidence Ø3% of all adult malignancies ØMore than 40% of patients with RCC have died from their cancer ØApproximately 30,000 new diagnoses of RCC are made each year in the united states, and 12,000 patients die of disease Ø8.7 new cases are diagnosed per 100,000 population per year ØMale-to-female predominance of 3 to 2 RENAL CELL CARCINOMA qIncidence ØDisease of the elderly patient, with typical presentation in the sixth and seventh decades of life. Ø Incidence rates are 10% to 20% higher in African than Americans for unknown reasons RCC……Etiology ØAlthough a number of potential etiologic factors have been identified in animal models, no specific agent has been definitively established as causative in human RCC ØThe only generally accepted environmental risk factor for RCC is tobacco use, ranging from 1.4 to 2.3 when compared with controls. RCC…….Pathology qGross ØUnilateral or bilateral ( 2%) ØRounded ,varying in size from few cm to tumors which fills the abdomen ØIt has no true histologic capsule but pseudo capsule of compressed fibrous tissue and renal parenchyma ØVarying degree of hemorrhage and necrosis RCC…….Pathology qGross ØAreas of yellowish or brownish soft tissue are alternating with areas of hge and necrosis. ØCalcification may be stibbled or palque like ØPelvicalyseal system always displaced but may be involved. ØGerota’s fascia represent a barrier against local spread but may be compressed and invaded . ØRenal vein may be invaded and may be propagated to IVC. RCC…….Pathology qMicroscopic – Site of origin ØProximal convoluted tubules – 5 histologic types ØClear cell type ØGranular cell type ØSarcomatoid cell type ØTubulo papillary cell type ØChromophobe cell type RCC….Clinical presentation qClassic triad (10%) ØPain ØMass ØHematuria qPain 41% qMass 24% qHematuria 38% qWeight loss ,fever , night sweeting qLeft varicocoele RCC….Clinical presentation qParaneoplastic syndrome – Staufer syndrome 14.4% ØIt is non metastatic liver dysfunction ØIncrease serum enzymes ØDecrease WBC’S ØIncrease prothrombin time ØFever ØAreas of liver necrosis After nephrectomy Normal lever values RCC….Clinical presentation qParaneoplastic syndrome • Hypercalcemia 10% ØParathormone like substance ØSkeletal metastasis ØIncrease 1,25 cholecalciferol • hypertension37% ØIncrease rennin ØAV fistula ØPolycythemia ØUretral obstruction ØCerebral metastasis RCC….Clinical presentation qParaneoplastic syndrome – Polycythemia 3.5% ØIncrease erythropoitien by malignant cells ØHypoxia by the tumor – Hypoglycemia – Cushing syndrome – Galactorrhea – Protien enterapathy – Females hirsutism and ammenotthea – Males loss of libido and gynecomastia RCC……Investigation ØRadiological ØLab. ØFine needle aspiration and biopsy RCC……Investigation qRadiology…KUB ØEnlarged renal shadow with distorted contour ØCalcification ØAbsent psoas boarder RCC……Investigation qRadiology….IVP ØNephrogram phase Enlarged shadow ØCalyces are distorted ,stretched, elongated or amputated ØFailure to visualize part due to compression of a part ØCompression of the ureter hydronephrosis ØNon visualization due to renal vein thrombosis or total infiltration RCC……Investigation qU/S ØSolid echogenic mass ØVenous extension ØRPLN ØLiver metastasis ØP.C aspiration and biopsy RCC……Investigation qC.T ØThe single coast effective ØAccurate diagnosis ØDensity of the solid lesion ØStaging ( liver ,L.N,R.V,IVC) qDrawback ØFalse positive invasion ØWill not detect limited LN RCC……Investigation qMR vBetter than CT in ØRenal vein and IVC ØMultidimensional RCC……Investigation qSelective renal angiography ØVery limited indication ØBilateral tumors or in solitary kidney ØWhen CT in unclear ØBefore angioinfarction oNeovascularity oAV fistula oPooling of contrast material oAccentuation of capsular vessels RCC……Investigation ØX ray chest ØBone scan ØTumors markers ……non specific o CEA and urinary polyamines may be increase o Erythropoitin RCC….Staging qRobson ØStage I o Tumors within the capsule ØStage II o invasion of the perinephric fat but within gerota’s fascia ØStage III Main renal vein or IVC o Regional LN o Local vessels and LN ØStage VI o Adjacent organ rather than adrenal o Distant metastasis RCC….TNM Staging RCC….TNM Staging Management of RCC ØOpen surgery Radical nephrectomy ØNephron sparing surgery (NSS) ØLaparoscopic surgery SURGICAL APPROACHES TO THE KIDNEY ØExtra-peritoneal flank approach ØAnterior trans-peritoneal approach ØThoraco-abdominal approach Flank Approach qThe principal disadvantage of the flank incision is that : the exposure in the area of the renal pedicle is not as good as with anterior trans-peritoneal approaches. qThe flank incision may prove unsuitable for the patient with scoliosis or cardio- respiratory problems. Flank Approach Flank Approach Flank Approach Thoracoabdominal Incision Thoracoabdominal approach A) Patients with large tumors involving the upper portion of the kidney B) Patients with caval thrombus extend above the level of portal vein •Incision •Rib •Muscle •Diaphragm Standard technique The most important aspect of radical nephrectomy Removal of the kidney outside Gerota's fascia as It has been shown that removal of the ipsilateral adrenal gland is not routinely necessary unless the malignancy either extensively involves the kidney or is located in the upper portion of the kidney Anterior Transperitoneal Approach • disadvantage Ølonger period of postoperative ileus is possible Ølong-term complication of intra- abdominal adhesions leading to bowel obstruction. Standard technique Standard technique The colon is reflected medially to expose the great vessels. This is facilitated by division of the spleno- colic ligaments, which also helps to avoid excessive traction and injury to the spleen Radical Nephrectomy With Renal Vein And Vena Caval Involvement Radical Nephrectomy With Renal Vein And Vena Caval Involvement Radical Nephrectomy with renal vein and vena caval involvement Radical Nephrectomy with renal vein and vena caval involvement Radical Nephrectomy with renal vein and vena caval involvement Local Recurrence After Radical Nephrectomy TREATMENT OF METASTATIC RENAL CELL CARCINOMA 1) Nephrectomy Approximately one third of patients with RCC exhibit metastatic disease at the time of initial presentation : • severe hemorrhage • severe pain • paraneoplastic syndromes • compression of adjacent viscera. TREATMENT OF METASTATIC RENAL CELL CARCINOMA 2) Hormonal Therapy TREATMENT OF METASTATIC RENAL CELL CARCINOMA vinblastine appeared to The combination of be the most promising, vinblastine and other the overall response chemotherapeutics gives rate was approximately no improvement but 25%. more side effect TREATMENT OF METASTATIC RENAL CELL CARCINOMA 4) Radiation Therapy TREATMENT OF METASTATIC RENAL CELL CARCINOMA 5) Immuno-biologic Therapy ØGood performance status. ØNephrectomy for the primary lesion. ØExhibit non-bulky pulmonary and/or soft- tissue metastases. ØAsymptomatic or have minimal symptoms. TREATMENT OF METASTATIC RENAL CELL CARCINOMA unfavorable response to immunotherapy TREATMENT OF METASTATIC RENAL CELL CARCINOMA Immunobiologic Therapy protocoles : ØInterferon-α ØIL-2 ØInterferon-α and IL-2 ØIL-2, interferon-α, and 5-FU Ølymphokine-activated killer (LAK) ØTILs ØMore recent approaches to adoptive therapy involve the use of autologous vaccines to generate sensitized T cells in vivo TREATMENT OF METASTATIC RENAL CELL CARCINOMA 6) Multimodality Therapy initial adjuvant initial immunotherapy nephrectomy followed by followed by Nephrectomy immunotherapy For responders nephrectomy and immunotherapy followed by resection of residual or recurrent metastatic lesions Urothelial Tumors Of The Kidney qRisk factors ØOccupational ØSmoking ØCoffee ØAnalgesic ØCyclophosphamide ØHereditary Urothelial Tumors Of The Kidney qDistribution ØBilateral in 2-5% either synchronous or asynchronous Ø2-4% associated with bladder cancer but in occupational cancer the incidence may reach 13% Urothelial Tumors Of The Kidney qPathology ØTransitional cell cancer ØSquamous cell cancer ØAdenocarcinoma ØInverted papilloma Urothelial tumors of the kidney qClinical picture ØHematuria in 75% ØFlank pain ØAcute flank pain due to passage of clots ØAsymptomatic in 10-15% ØSymptoms of advanced disease ØAnorexia ,wt loss ,bone pain Urothelial tumors of the kidney qInvestigation Radiology § Excretory urography §Retrograde urography ,selective cytology and brush biopsy § C.T §MR – Flexible uretoroscopy and biopsy Urothelial tumors of the kidney qStaging Grabstald Cumming system I Confined to mucosa II Invade lamina propria and confined to submucosa III Tumor invade to muscles of the pelvis or renal parenchyma VI Extended to the muscles, renal capsule or distant metastasis TNM system Urothelial tumors of the kidney qTreatment vRadical nephrouretrectomy Distal Ureterectomy ØAn anterior cystotomy may be made and intravesical and extravesical dissection ØOne centimeter of bladder mucosa is included circumferentially around the ureteral orifice. ØThe defect in the bladder wall at the ureteral hiatus is closed in two layers from within the bladder using interrupted 2–0 or 3–0 absorbable suture on the muscle and 4–0 suture on the mucosa. ØThe anterior cystotomy is closed carefully in two layers with running 3–0 absorbable suture. Distal Ureterectomy The same dissection may be performed entirely by extravesical dissection of the distal ureter and the intramural portion within the bladder wall all the way to the ureteral orifice Distal Ureterectomy qComplete endoscopic, transvesical, distal ureterectomy may also be performed and the dissected ureter intussuscepted into the bladder. q This approach has obvious benefit when it is combined with laparoscopic removal of the kidney, but it is of much less value for open nephroureterectomy Urothelial tumors of the kidney Indication of conservative treatment o Solitary or functioning dominant kidney o Bilateral tumors o Small polypoidal low grade tumor Urothelial tumors of the kidney qConservative Treatment ØUretrorenoscope and resection or laser fulguration ØPC resection ØInstillation therapy ØRadiation therapy o Post operative to decrease recurrence o For painful osseous metastasis ØChemotherapy o M-VAC

Neoplastic Gastrointestinal Pathology Neoplastic Gastrointestinal Pathology An Illustrated Guide Laura W. Lamps, MD Professor and Vice-Chair for Academic Affairs Department of Pathology University of Arkansas for Medical Sciences Little Rock, Arkansas Andrew M. Bellizzi, MD Clinical Associate Professor Director of Gastrointestinal Pathology Co-Director of Immunopathology Laboratory Department of Pathology University of Iowa Hospitals and Clinics University of Iowa Carver College of Medicine Holden Comprehensive Cancer Center Iowa City, Iowa Wendy L. Frankel, MD The Kurtz Chair and Distinguished Professor Chair and Director of Gastrointestinal Pathology Department of Pathology The Ohio State University Wexner Medical Center Columbus, Ohio Scott R. Owens, MD Associate Professor of Pathology Director, Division of Quality and Health Improvement Department of Pathology University of Michigan Health System Ann Arbor, Michigan Rhonda K. Yantiss, MD Professor of Pathology and Laboratory Medicine Chief, Gastrointestinal Pathology Department of Pathology and Laboratory Medicine Weill Cornell Medical College New York, New York NEW YORK Visit our website at www.demosmedical.com ISBN: 9781936287727 e-book: 9781617051210 Acquisitions Editor: Rich Winters Compositor: Exeter Premedia Services Private Ltd © 2016 Demos Medical Publishing, LLC. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Medicine is an ever-changing science. Research and clinical experience are continually expanding our knowledge, in particular our under- standing of proper treatment and drug therapy. The authors, editors, and publisher have made every effort to ensure that all information in this book is in accordance with the state of knowledge at the time of production of the book. Nevertheless, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the contents of the publication. Every reader should examine carefully the package inserts accompanying each drug and should carefully check whether the dosage schedules mentioned therein or the contraindications stated by the manufacturer differ from the statements made in this book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Library of Congress Cataloging-in-Publication Data Lamps, Laura W. (Laura Webb), author. Neoplastic gastrointestinal pathology : an illustrated guide / Laura W. Lamps, Andrew M. Bellizzi, Wendy L. Frankel, Scott R. Owens, and Rhonda K. Yantiss p. ; cm. Includes bibliographical references and index. ISBN 978-1-936287-72-7 — ISBN 978-1-61705-121-0 (e-book) I. Bellizzi, Andrew M., author. II. Frankel, Wendy L., author. III. Yantiss, Rhonda K., author. IV. Owens, Scott R., author. V. Title. [DNLM: 1. Gastrointestinal Neoplasms—diagnosis. 2. Gastrointestinal Neoplasms—pathology. WI 149] RC280.D5 616.99'433—dc23 2015008140 Special discounts on bulk quantities of Demos Medical Publishing books are available to corporations, professional associations, pharmaceutical companies, health care organizations, and other qualifying groups. For details, please contact: Special Sales Department Demos Medical Publishing, LLC 11 West 42nd Street, 15th Floor New York, NY 10036 Phone: 800-532-8663 or 212-683-0072 Fax: 212-941-7842 E-mail: specialsales@demosmedical.com Printed in the United States of America by Bradford & Bigelow. 14 15 16 17 / 5 4 3 2 1 To Dr. Aubrey J. Hough, Jr. Chairman, UAMS Dept. of Pathology, 1981–2002 Thank you for giving me the best job ever—LWL To Sara May and Aidan, for standing by me through thick and thin; to Ed, Wendy, and Jason, for showing me how to be an academic surgical pathologist; to my students, especially Michael, Marty, Bryan, Tom, and Emily, for encouraging me to do great things—AMB To my husband Brian Rubin for his endless patience—WLF To Brendan, whose curiosity astounds me and whose precocious wisdom humbles me—SRO For Madeleine and Zachary, my little loves—RKY Contents Contributors ix 8. Neoplasms of the Stomach 173 Preface xi Laura W. Lamps and Scott R. Owens Share Neoplastic Gastrointestinal Pathology: An 9. Neoplasms of the Small Intestine 217 Illustrated Guide Wei Chen, Scott R. Owens, and Wendy L. Frankel 1. Introduction to Diagnosis and Reporting of 10. Neoplasms of the Appendix 249 Gastrointestinal Tract Neoplasia 1 Rhonda K. Yantiss Andrew M. Bellizzi 11. Neoplasms of the Colon 265 2. Approach to Epithelial Neoplasms of the Benjamin J. Swanson, Scott R. Owens, and Gastrointestinal Tract 19 Wendy L. Frankel Wei Chen and Wendy L. Frankel 12. Neoplasms of the Anus 315 3. Approach to Neuroendocrine Neoplasms 39 Scott R. Owens Andrew M. Bellizzi 13. Applications of Diagnostic 4. General Approach to Lymphomas of the Immunohistochemistry 331 Gastrointestinal Tract 75 Andrew M. Bellizzi Scott R. Owens 14. Applications of Molecular Pathology 379 5. Approach to Mesenchymal Neoplasms of the Rhonda K. Yantiss Gastrointestinal Tract 87 Laura W. Lamps and Matthew R. Lindberg Index 391 6. Approach to Hereditary Cancer Syndromes 121 Rhonda K. Yantiss 7. Neoplasms of the Esophagus 141 Rhonda K. Yantiss v i i Contributors Wei Chen, MD, PhD Benjamin J. Swanson, MD, PhD Department of Pathology Department of Pathology The Ohio State University Wexner Medical Center The Ohio State University Wexner Medical Center Columbus, Ohio Columbus, Ohio Matthew R. Lindberg, MD Department of Pathology University of Arkansas for Medical Sciences Little Rock, Arkansas i x Preface “Omnis cellula e cellula (All cells come from cells).” diagnostic abilities and their passion for education. It is my —Rudolph Virchow hope that the organization of the book, combined with the extensive number and variety of illustrations, will prove to be a valuable reference companion for all aspects of Cancer remains one of the leading causes of mortality neoplastic gastrointestinal pathology. We would also like worldwide, and gastrointestinal malignancies (particu- to specifically acknowledge certain colleagues who pro- larly colorectal, gastric, and esophageal) are responsible vided invaluable help and support on this project. Rhonda for a significant number of cancer deaths around the Yantiss would like to acknowledge Dr. Wade Samowitz globe. In addition to the histologic criteria required for for sharing his seemingly endless funds of knowledge and the diagnosis of gastrointestinal tumors, knowledge of patience. Wendy Frankel would like to thank Shawn Scully ever-evolving staging parameters, immunohistochemical in the Department of Pathology at OSU for help with the markers, and molecular testing for both prognosis and figures. Personally, I would like to extend a special thanks therapeutics is necessary. Neoplastic Gastrointestinal to all of my residents, fellows, and colleagues who have Pathology: An Illustrated Guide is intended to serve as contributed cases and photographs over the years. an approachable and practical reference for pathologists that includes all of the information needed to evaluate and Laura W. Lamps report these specimens in daily practice. Andrew M. Bellizzi I am fortunate to have had the opportunity to cre- Wendy L. Frankel ate this book with a uniquely talented and dedicated Scott R. Owens group of co-authors; their contributions reflect both their Rhonda K. Yantiss x i Share Neoplastic Gastrointestinal Pathology: An Illustrated Guide 1 Introduction to Diagnosis and Reporting of Gastrointestinal Tract Neoplasia ANDREW M. BELLIZZI INTRODUCTION For example, the precursor lesions of inflammation- associated adenocarcinomas are typically flat, and tubular This chapter introduces key terminology used through- adenomas initially arise in a single crypt. out this book, including neoplasia, dysplasia, and the benign–malignant dichotomy. General criteria for grad- Clonality and the Benign/Malignant Dichotomy ing non-neuroendocrine carcinomas, neuroendocrine neoplasms, lymphomas, gastrointestinal stromal tumors The idea that all the neoplastic cells in a tumor are the (GISTs), and sarcomas are discussed, as are broad issues progeny of a single mutated cell is referred to as clonality. pertaining to staging. The importance of synoptic Although clonality implies neoplasia, it does not equate reporting of cancer resection specimens is emphasized. with malignancy, as benign neoplasms are also clonal. Prognostic and predictive markers are distinguished, Recent investigations have further emphasized that neo- and several key examples are presented. The concepts of plasms, particularly malignant ones, typically have unsta- screening and surveillance are reviewed, again with sev- ble genomes in addition to being clonal. eral key examples. The chapter concludes with a general Malignancy is characterized by invasive growth and approach to the diagnosis and reporting of biopsy and the capacity for metastasis. For epithelial tumors in the resection specimens. tubal gut, the relationship between the anatomic extent of invasion and metastatic risk varies with anatomic site. For example, invasion into the lamina propria in the KEY TERMINOLOGY esophagus, stomach, and small intestine denotes meta- static risk (albeit low). In the colon, invasive neoplasms Neoplasia confined to the mucosa (sometimes termed intramuco- sal carcinoma) do not metastasize. Conversely, benign The term neoplasia is derived from Greek and literally tumors typically do not recur after complete excision and means new growth, creation, or formation. Mid-twentieth do not metastasize. century Australian pathologist Rupert Allan Willis’s defi- As suggested by the example of intramucosal carci- nition of neoplasia is often cited, stating that, “A neoplasm noma of the colon above, the benign–malignant dichotomy is an abnormal mass of tissue, the growth of which exceeds and the terms associated with this concept are insufficient and is uncoordinated with that of the normal tissues and to describe the spectrum of all tumor behavior. Some persists in the same excessive manner after cessation of the neoplasms are locally destructive, yet nonmetastasizing; stimuli which evoked the change.” This definition empha- this phenotype has been described as “intermediate.” sizes the proliferative and autonomous nature of tumors. Examples include verrucous carcinoma of the esophagus Neoplasms need not form “masses of tissue,” however. or anus and desmoid fibromatosis. For other tumors, the 1 2 Neoplastic Gastrointestinal Pathology: An Illustrated Guide assessment of risk of metastasis, and thus the assessment gastric carcinoma with lymphoid stroma (also known of whether or not a tumor can be expected to behave in as lymphoepithelioma-like carcinoma or medullary car- a benign or a malignant fashion, cannot be predicted on cinoma), many types of lymphoma, and smooth muscle histologic appearance alone and attention to other clinico- tumors in immunosuppressed individuals; and human pathologic parameters is needed. For example, parameters herpesvirus 8 (HHV8; also known as Kaposi-sarcoma- of risk stratification for GIST include anatomic location, associated herpesvirus), which drives primary effusion tumor size, and mitotic rate, with the risk of metastasis lymphoma, multicentric Castleman disease, and Kaposi or tumor-related death for various combinations of these sarcoma. Patients with a primary or secondary immu- three parameters ranging from 0% (essentially benign) to nodeficiency, the latter including stem cell or solid organ 90% (a high expectation of malignant behavior). transplantation, HIV infection, and in some instances, merely advanced age, are at increased risk for this class Risk Factors for Neoplasia of tumors. Immunohistochemistry, in situ hybridization, or molecular methods for detection of virus, or surrogate There are four basic contexts in which neoplasms arise. markers (eg, p16 in HPV-driven tumors), may be useful Many neoplasms arise in a background of inflamma- diagnostic adjuncts in this group of tumors. tion. Carcinomas of the esophagus and stomach are Neoplasms may also arise in the setting of a genetic particularly apt to arise in inflammatory backgrounds. predisposition to cancer. Hereditary cancer predisposition Barrett-esophagus-associated adenocarcinomas and syndromes are due to highly penetrant germline mutations chronic-gastritis-associated intestinal-type adenocarci- and share the following features: nomas are believed to arise through an inflammationÆ metaplasiaÆdysplasiaÆcarcinoma sequence, and gastric 1. They are generally autosomal dominant. adenocarcinomas are etiologically linked to Helicobacter 2. The tumors occur in relatively young persons (com- pylori gastritis. A large subset (~65%) of gastric neuro- pared to sporadic tumors). endocrine tumors (NETs) arise in a background of auto- 3. The tumors occur at a defined set of anatomic sites. immune atrophic gastritis, and extranodal marginal 4. The tumors are often multiple (synchronous or zone lymphomas of the stomach and small intestine metachronous). (mucosa-associated lymphoid tissue [MALT] lymphomas) In addition, these tumors, their associated precursors, are also etiologically linked to Helicobacter pylori and or other syndromic “marker lesions” often have char- Campylobacter jejuni infection, respectively. In the small acteristic clinical and/or histologic features, such as the intestine, patients with celiac disease are at increased risk morphologic features that are seen in Lynch-syndrome- for adenocarcinoma and lymphoma, including enteropa- associated colorectal adenocarcinoma. thy-associated T-cell lymphoma. Patients with idiopathic Most of the tumors that arise in hereditary cancer syn- inflammatory bowel disease (IBD) are at increased risk dromes are carcinomas, but NETs, GISTs, other mesenchy-

for developing colorectal cancer, and this risk is modu- mal tumors, and lymphomas occur in select settings. For lated by factors including disease duration, anatomic example, multiple duodenal gastrinomas and enterochro- extent of disease, histologic inflammatory activity, fam- maffin-like (ECL)-cell gastric NETs may be seen in patients ily colon cancer history, and the presence of concomitant with multiple endocrine neoplasia type I (MEN1), and primary sclerosing cholangitis. Across the spectrum of rarely, patients with neurofibromatosis type I (NF1) mani- inflammation-associated neoplasms, effective treatment fest periampullary somatostatin-producing NETs. GISTs of the underlying inflammatory disease is typically associ- are seen in patients with NF1, Carney–Stratakis syndrome ated with improved outcomes and decreased risk of neo- (due to germline succinate dehydrogenase subunit muta- plasia. For example, Helicobacter pylori eradication has tions), and in rare patients with germline mutations in KIT been shown to decrease disease recurrence in early gastric or PDGFRA. Among other mesenchymal tumors, desmoid cancer and, in many gastric MALT lymphomas, leads to fibromatosis is seen in 10% to 30% of patients with famil- disease regression. Furthermore, a declining risk of IBD- ial adenomatous polyposis (FAP), and diffuse-type ganglio- associated colon cancer in contemporary series has been neuromatosis is essentially an NF1 or MEN2B-defining also attributed, at least in part, to improved medical man- lesion. Lymphomas often develop in the very rare patients agement of colitis. who inherit two defective copies of a given DNA mismatch Epithelial, lymphoid, and even mesenchymal neo- repair gene (ie, constitutional Lynch syndrome). plasms may also arise in association with oncogenic The recognition of a hereditary cancer syndrome viruses. The most common implicated viruses include may affect the management of a presenting tumor, trig- human papillomavirus (HPV), the major cause of anal ger syndrome-specific surveillance, inform the decision to intraepithelial neoplasia (AIN) and anal squamous cell undergo various prophylactic resections, and, perhaps most carcinoma; Epstein–Barr virus (EBV), which is associ- importantly, permit the identification of other at-risk fam- ated with numerous neoplasms including most cases of ily members. The approach to the recognition, diagnosis, 1 Introduction to Diagnosis and Reporting of Gastrointestinal Tract Neoplasia 3 and reporting of HCPSs involving the gastrointestinal (GI) powerful concept. The histologic correlate of clonality is tract will be presented in more detail in Chapter 6. the abrupt transition from a non-neoplastic background While hereditary cancer syndromes account for a small to dysplasia (Figure 1.1A). Stated another way, dysplasia percentage of GI malignancies, more commonly, cancers “stops and starts;” in contrast, reactive atypia usually aggregate in families without an obvious Mendelian inher- blends imperceptibly into adjacent areas that are non- itance pattern. For example, 20% to 30% of colon cancers neoplastic (Figure 1.1B). Immunohistochemical stains are arise in this setting. These tumors have been referred to sometimes useful to highlight an area of abrupt transition as “familial” (rather than hereditary). This phenomenon when one is concerned about dysplasia/clonality. Examples is believed to reflect shared environment and/or inheri- include p53 in Barrett esophagus (Figures 1.2A–B), tance of (possibly multiple) low-penetrant susceptibility chronic gastritis, and IBD; MLH1 in serrated polyps alleles. Patients with a non-Mendelian family history are (Figure 1.2C); and SMAD4 in the pancreatobiliary tree at increased cancer risk, a fact that is taken into account in (Figure 1.2D). These immunohistochemical applications screening guidelines. will be discussed in greater detail in Chapter 13. The majority of neoplasms, including carcinomas, neu- Some pathologists use the terms “atypia” and “dys- roendocrine neoplasms, lymphomas, and mesenchymal plasia” interchangeably. Epithelial atypia simply refers to tumors appear to arise sporadically, that is, outside of any cytologic and/or architectural features that deviate from of the predisposing contexts described in the preceding normal. Because dysplasia is, by definition, neoplastic, paragraphs. while the meaning of atypia is less specific, the two terms are not synonymous. Use of the term “atypia” on the Dysplasia diagnostic line, even if qualified as reactive, is therefore discouraged. Dysplasia is defined as an unequivocal neoplastic altera- tion of the epithelium, frequently within the confines of a basement membrane in the tubal gut. Dysplastic epi- Grading of Dysplasia thelium is often a precursor to the development of malig- From an historical standpoint, the Inflammatory Bowel nancy. The distinction of reactive atypia from dysplasia, Disease-Dysplasia Morphology Study Group (IBD-DMSG) especially in the context of an inflammatory background, undertook the key early effort of developing a standard- is perhaps one of the most difficult exercises in neoplastic ized nomenclature and classification for dysplasia in IBD. GI pathology. “Dysplasia in inflammatory bowel disease: a standard- Applying the concept of clonality in the distinction ized classification with provisional clinical applications,” between dysplastic and reactive changes is a useful and published by Riddell and colleagues in Human Pathology (A) (B) FIGURE 1.1 Adenomatous crypts with nuclear elongation and slight stratification as well as striking epithelial apoptosis are sharply demarcated from background, non-neoplastic crypts with small, basally located nuclei and preservation of goblet cells. An abrupt transition is characteristic of a dysplastic process (A). In this biopsy of Barrett mucosa, the greatest degree of atypia is seen in the crypt bases (*), with gradual diminution of nuclear size and progressive accumulation of cytoplasm as cells approach the surface, in keeping with a reactive process (B). Note also the lack of an abrupt transition between the reactive epithelium and the adjacent mucosa. 4 Neoplastic Gastrointestinal Pathology: An Illustrated Guide (A) (B) (C) (D) FIGURE 1.2 A p53 immunostain in an esophageal biopsy demonstrates abrupt transitions between foci of diffuse, strong staining in the nuclei of Barrett mucosa with high-grade dysplasia (likely due to TP53 missense mutation) and focal weak or negative staining in the background Barrett epithelium without dysplasia (A). A p53 immunostain demonstrates the abrupt transition between foci of completely absent staining in dysplastic Barrett epithelium (likely due to TP53 deletion or truncating mutation) and moderately intense (wild-type pattern) staining in non-dysplastic Barrett mucosa and adjacent squamous epithelium (B). Clonal loss of MLH1 expression corresponding to the acquisition of cytologic dysplasia in a background of sessile serrated polyp (C). Clonal loss of SMAD4 expression in a pancreatic ductal adenocarcinoma, compared to intact expression in stroma and adjacent non-neoplastic islets and ductules (D). in 1983, remains a seminal reference work in GI pathol- recognition of the limits of interobserver reproducibility, ogy. This classification forms the foundation of dysplasia the “mild, moderate, severe” classification scheme has assessment in Western GI pathology, and has been adopted been largely discarded and is no longer appropriate for for columnar lesions throughout the tubal gut. grading dysplasia in the tubal gut. Grading of dysplasia Whereas previously dysplasia was graded as mild, will be discussed in more detail in the organ-specific chap- moderate, or severe, the IBD-DMSG introduced the cate- ters that follow. gories “negative for dysplasia,” “indefinite for dysplasia,” By including “indefinite for dysplasia,” the group for- and “positive for dysplasia.” The “positive for dysplasia” mally recognized diagnostic uncertainty in the form of group is subdivided into “low-grade dysplasia (LGD)” and lesions that could not be readily classified as negative or “high-grade dysplasia (HGD)”. Due to their work and the positive. In clinical practice, when a lesion is worrisome 1 Introduction to Diagnosis and Reporting of Gastrointestinal Tract Neoplasia 5 TABLE 1.1 Key Features of the Inflammatory Bowel Carcinoma In Situ and Disease-Dysplasia Morphology Study Group Classification Intramucosal Carcinoma of Dysplasia Historically, carcinoma in situ (CIS) generally refers to Defined dysplasia as “unequivocally neoplastic epithelium” a tumor that is “cytologically malignant” but has yet to As a consequence, the term “atypia” could no longer be used breach the basement membrane. As such, it has no meta- synonymously with dysplasia static potential, and is essentially equivalent to dysplasia. Established the category of indefinite for dysplasia Established the categories of low-grade dysplasia and high-grade Theoretically, CIS is considered “more advanced” than dysplasia and made provisional clinical recommendations based HGD, but the distinction between these entities is not on these diagnoses reproducible. Some authors have also used CIS to refer to Recommended seeking a second opinion in diagnostically tumors without metastatic potential, regardless of whether challenging cases Contained an interobserver variability study or not they are confined to the basement membrane (this Provided an atlas of 84 images broader definition encompasses colonic tumors that have Stated that low-grade dysplasia could directly give rise to invaded into but not beyond the mucosa). Again, given the adenocarcinoma lack of reproducibility in distinguishing HGD and CIS, compounded by the ambiguity of meaning, use of the term “carcinoma in situ” in reporting specimens from the tubal for dysplasia but is very focal, there is significant back- gut is strongly discouraged. ground inflammation, or the transition between the lesion In intramucosal carcinoma (IMC), tumor cells have and adjacent non-neoplastic mucosa is not well-visualized, breached the basement membrane to invade into, but the term “indefinite for dysplasia” is appropriate. not beyond, the mucosa. This includes tumors that have Another key goal of the group was to create a classi- invaded into the lamina propria and those that have fication scheme that was clinically actionable. The group invaded into, but not through, the muscularis mucosae. made provisional clinical recommendations based on In the esophagus and stomach, IMC is associated with a their classification that, for dysplasia in IBD, have largely small but definite risk of lymph node metastasis (4% or stood the test of time. Recommendations included short less) and is staged as T1a (as are small intestinal adenocar- interval follow-up for diagnoses of LGD or indefinite for cinomas). In contrast, in the colon, IMC is not associated dysplasia, and consideration of colectomy for HGD. The with lymph node metastasis and, thus, is staged as Tis (as results of the interobserver variability component of the are appendiceal tumors). Because the distinction of IMC group’s work highlighted the importance of seeking a sec- from HGD in the colon is not as biologically meaningful ond opinion in diagnostically challenging cases, which is as it is in the upper GI tract, some pathologists avoid this emphasized today in multidisciplinary medical position term and do not diagnose IMC in the colon. statements/practice guidelines regarding the management Similar to the grading of dysplasia, the diagnosis of of Barrett esophagus and IBD. The contributions of the IMC is subject to significant interobserver variability. IBD-DMSG are summarized in Table 1.1. Cases in which single cells or small groups of cells are pres- Dysplasia detected at an index examination (or within ent in the lamina propria are readily recognized as IMC 1 year) is referred to as “prevalent,” while that detected in (Figure 1.3A), as are those characterized by large expanses the context of surveillance is “incident.” The natural his- of anastomosing glands (Figure 1.3B) or sheets of cells. tory of prevalent dysplasia appears more aggressive than Since IMC is defined by tumor cells having breached the incident dysplasia. basement membrane, and pathologists do not directly visu- alize that breach, the degree of architectural perturbation that is required to distinguish a small focus of IMC from Alternative Classifi cations HGD is not well defined (Figure 1.4). Two groups have Western pathologists generally use a modified IBD- published criteria for a category intermediate between DMSG definition of dysplasia that defines it as a “pre- HGD and IMC, referred to as “high-grade dysplasia with invasive unequivocal neoplastic epithelial proliferation.” marked glandular architectural distortion, cannot exclude When used as such, dysplasia is a carcinoma precursor. intramucosal carcinoma” and “high-grade dysplasia The third edition of the WHO Classification of Tumours with features ‘suspicious’ for invasive carcinoma.” These of the Digestive System (WHO GI Blue Book) introduced concepts will be discussed further in Chapter 7. the generally synonymous term “intraepithelial neopla- As with the distinction of dysplasia from reactive sia,” and an alternative international consensus classifica- changes, the concept of clonality is again applicable to grad- tion known as the Vienna system refers to “non-invasive ing dysplasia and distinguishing HGD from early carci- neoplasia.” For practical purposes, this textbook will noma; the notion of “neoplastic progression” is additionally refer to “dysplasia” throughout, except in the anus, where useful. As one considers the diagnosis of HGD, it is useful intraepithelial neoplasia (anal intraepithelial neoplasia if one can identify a specific area that is cytologically and/ [AIN]) has gained more widespread usage. or architecturally distinct from the background LGD (ie, a 6 Neoplastic Gastrointestinal Pathology: An Illustrated Guide (A) (B) FIGURE

1.3 Intramucosal carcinoma is readily diagnosed when single cells or small groups of cells (arrows) are visualized in the lamina propria (A) or in the setting of an expansive anastomosing gland pattern (the so-called never- ending gland pattern) (B). These examples are from Barrett esophagus-associated neoplasms. clonal area that has progressed) (Figure 1.5). This assumes, of course, confidence in the underlying diagnosis of dys- plasia, and one may not always have the luxury of a back- ground of LGD (although it is nearly always present in an adenomatous colon polyp with HGD). A similar approach may be used when one is considering a diagnosis of IMC in a background of HGD in the setting of Barrett esophagus. FIGURE 1.5 The right half of this mucosal biopsy specimen shows low-grade dysplasia. The discrete foci of more complex, cribriformed architecture (*) on the left are characteristic of a higher-grade lesion. Discrepancies Between Western and Eastern Neoplasia Assessment FIGURE 1.4 This focus of dysplastic Barrett epithelium The histologic features of LGD and HGD presented here shows at least high-grade dysplasia, and some would and in subsequent chapters, and the concept that invasion consider the degree of gland branching and budding (*) defines carcinoma, represent distinctly Western view- compatible with intramucosal carcinoma. The dilated points. It has long been recognized that many lesions glands with intraluminal debris also suggest a more classified as LGD or HGD by Western pathologists are advanced lesion. diagnosed as early carcinomas by Japanese pathologists. 1 Introduction to Diagnosis and Reporting of Gastrointestinal Tract Neoplasia 7 While Western pathologists seek “objective” evidence of lesions (Figure 1.7B). A desmin immunostain can also help invasion to secure a diagnosis of carcinoma, Japanese define the boundaries of the muscularis mucosae (as well pathologists place greater weight on nuclear and architec- as the muscularis propria), which is especially useful in tural features, and, actually arrive at a diagnosis of carci- cases where the microanatomy is obscured by fibrosis or noma independent of the presence of invasion. These very inflammation (Figure 1.8A–B). This is less helpful in cases different approaches to diagnosis profoundly affect the that are tangentially embedded. comparability of the incidence and survival rates for early carcinoma in Western and Japanese series (this applies mainly to gastric cancer, since Barrett-associated neopla- GRADING AND STAGING OF sia is rare in Japan and colonic IMC lacks the capacity to GASTROINTESTINAL MALIGNANCIES metastasize). This textbook will reflect the Western view- point throughout because it is the one we have learned, Tumor Grading the one we apply in our practices, and the one upon which Western clinical guidelines are based. Tumor grading has traditionally represented an assess- ment of how well (or poorly) a given tumor resembles the normal tissue type it recapitulates (ie, differentiation). Submucosally Invasive Carcinoma This assessment is inherently qualitative. For some tumor Once tumors invade beyond the muscularis mucosae, they types, grading has incorporated more objective, repro- initially encounter the submucosa, and are thus submu- ducible features (eg, mitotic rate). Grade is prognostically cosally invasive. As the submucosa is frequently not well- significant and in many instances influences clinical man- represented in endoscopic mucosal biopsy material, this agement. For example, in pT3 N0 colon cancer, patients diagnosis can be challenging. In cases where the bound- with poorly differentiated/high-grade tumors may be ary between the mucosa and submucosa is not readily offered adjuvant chemotherapy, and patients with resected apparent, there are two histologic clues that suggest a high-risk GISTs generally receive adjuvant tyrosine kinase diagnosis of submucosal invasion. First, the presence of inhibitor therapy. In addition, chemotherapy regimens are desmoplastic (ie, cellular, fibroblastic, often blue-tinged) entirely different for low-grade versus high-grade lympho- stroma strongly correlates with the presence of submu- mas and well-differentiated NETs versus neuroendocrine cosal invasion (Figures 1.6A–B). Second, one can search carcinomas (NECs). Table 1.2 compares the grading of the for the close approximation of neoplastic epithelium to major categories of tumor in the tubal gut. thick-walled, muscular submucosal blood vessels. These For non-neuroendocrine carcinomas of the tubal gut, vessels are readily apparent in endoscopic mucosal resec- mainly adenocarcinomas and squamous cell carcinomas, tions (Figure 1.7A) and can usually be identified in well- there is no uniformly agreed upon, extensively clinically oriented polypectomy specimens of larger, pedunculated validated grading system as there is in breast (Nottingham (A) (B) FIGURE 1.6 Stromal desmoplasia is an indicator of submucosal invasion. These are two examples of desmoplastic stroma, one more cellular (A) and the other more fibrotic (B). 8 Neoplastic Gastrointestinal Pathology: An Illustrated Guide (A) (B) FIGURE 1.7 Barrett esophagus-associated adenocarcinoma (A) and adenocarcinoma arising in an adenomatous polyp (B) each infiltrate up to and around thick-walled muscular blood vessels, suggesting a diagnosis of submucosal invasion. Stromal desmoplasia is also seen in (B). grade), kidney (Fuhrman grade), or prostate (Gleason Tumor grading will be discussed in greater detail in the grade). For adenocarcinomas of the colon and rectum, organ-specific chapters. the WHO suggests that tumors may be graded based on The grading system for neuroendocrine neoplasms is the extent of gland formation, although this only applies entirely different from that used for non-neuroendocrine to “adenocarcinoma, NOS” (ie, adenocarcinoma with no tumors. In the World Health Organization (WHO) 2010 special morphologic features). Throughout the tubal gut, Classification, gastroenteropancreatic neuroendocrine grading may be two-, three-, or four-tiered, with two-tiered epithelial neoplasms are graded based on mitotic rate and grading (high-grade versus low-grade) increasingly advo- Ki-67 proliferation index. In this system, morphologically cated based on greater reproducibility and clinical utility. well-differentiated neuroendocrine neoplasms are referred (A) (B) FIGURE 1.8 While this Barrett esophagus-associated adenocarcinoma was suspicious for invasion into the superficial submucosa (A), a desmin immunostain clarified that, at its deepest point, the tumor is confined by strands of muscularis mucosae (B). 1 Introduction to Diagnosis and Reporting of Gastrointestinal Tract Neoplasia 9 TABLE 1.2 Tumor Grading in the Tubal Gut Epithelial Neoplasms, Non-Neuroendocrine Grade Grade % Gland Formation: Qualitative Features: (Four-Tiered) (Two-Tiered) Adenocarcinomas Squamous Cell Carcinoma Well-differentiated Low-grade >95% Prominent keratinization with squamous pearl formation Moderately differentiated Low-grade 50%–95% Less frequent keratinization; squamous pearls generally absent Poorly differentiated High-grade >0%–49% Predominance of basal-like cells; few, if any, keratinized cells Undifferentiated High-grade Not applicable Not applicable Neuroendocrine Epithelial Neoplasms Qualitative Grade WHO 2010 Grade Mitotic Rate Proliferation Index (Two-Tiered) (Three-Tiered) (Ki-67 Labeling) Well-differentiated G1 <2 per 10 HPF and/or ≤2% G2 2–20 per 10 HPF 3%–20% Poorly differentiated G3 >20 per 10 HPF >20% Lymphomas: Grade is Based on Tumor Type Grade (Two-Tiered) Representative Tumor Types Low-grade Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma), mantle cell lymphoma, follicular lymphoma High-grade Diffuse large B-cell lymphoma, Burkitt lymphoma Gastrointestinal Stromal Tumor Grade (Two-Tiered) Mitotic Rate Low-grade (G1) ≤5 per 5 mm2 High-grade (G2) >5 per 5 mm2 Sarcoma: Fédération Nationale des Centre de Lutte Contre le Cancer (FNCLCC) System Grade (Three-Tiered) Total Score Tumor Differentiation Mitotic Count Tumor Necrosis Grade 1 2 or 3 1: Closely resembles normal 1: 0–9 per 10 HPF 0: None tissue Grade 2 4 or 5 2: Histologic typing certain 2: 10–19 per 10 HPF 1: <50% Grade 3 6, 7, or 8 3: Embryonal and 3: >19 per 10 HPF 2: ≥50% undifferentiated sarcomas, synovial sarcoma, sarcomas of uncertain type to as “neuroendocrine tumors (NETs),” while poorly dif- with the former category further stratified based on the ferentiated examples (small cell and large cell) are termed following parameters: size, angioinvasion, perineural inva- “neuroendocrine carcinomas (NECs).” NETs with a low sion (PNI), mitotic count, and Ki-67 proliferation index. mitotic rate (less than 2 per 10 high-power fields [HPFs]) Of note, the current mitotic threshold for G3/NEC (greater and proliferation index (2% or less) are considered G1, than 20 per 10 HPF) is greater than in the 2000 system while those with a mitotic rate between 2 and 20 per 10 (greater than 10 per 10 HPF). Rarely, morphologically HPF and/or a proliferation index of 3% to 20% are G2. well-differentiated tumors demonstrate a mitotic rate and/ NECs (G3 in this classification) demonstrate more than or proliferation index in the G3 range; these behave some- 20 mitotic figures per 10 HPF and/or a proliferation index what better than typical, poorly differentiated G3 tumors. greater than 20%. This classification supplants the WHO Tumor type largely defines the grade (low vs. high 2000 Classification, in which well-differentiated tumors grade) in lymphoma. Follicular lymphoma (FL) can be fur- were “graded” based on the absence (well-differentiated ther graded based on the number of centroblasts in neo- endocrine tumor) or presence (well-differentiated endo- plastic follicles per HPF, based on an assessment of at least crine carcinoma) of metastases and/or gross local invasion, 10 HPFs. In the 2008 WHO Classification of Tumours 10 Neoplastic Gastrointestinal Pathology: An Illustrated Guide of Haematopoietic and Lymphoid Tissues, the separation The UICC/AJCC Classification is periodically revised of grade 1 from grade 2 FL is discouraged, as this is not a (most recently at 6–8-year intervals), increasingly based clinically meaningful distinction. The presence of diffuse on large, population-based clinical datasets. The AJCC architecture distinguishes diffuse large B-cell lymphoma first published a staging manual in 1977; the AJCC (DLBCL) from FL, grade 3. Grading of GI lymphomas Cancer Staging Manual is now in its seventh edition will be further discussed in Chapter 4. (AJCC 7). This classification went into effect on January GISTs are graded based on mitotic rate. Low-grade/G1 1, 2010. It includes, for the first time, TNM staging for tumors demonstrate 5 or fewer mitotic figures per 5 mm2, GISTs and NETs. Appendiceal carcinomas, classified while high-grade/G2 tumors contain 5 or more mitotic with colorectal tumors in the sixth edition, are now sep- figures per 5 mm2. Grade, tumor size, and anatomic loca- arately classified. For every site in the tubal gut (except tion are combined to determine the overall “risk assess- the anal canal), various T, N, and M categories were ment” in GIST (none, very low risk, low risk, intermediate redefined or subclassified and various stage groupings risk, high risk, overtly malignant/metastatic), which cor- were reassigned. For pathologists, the most significant relates with the likelihood of metastasis or tumor-related change to their routine practices was perhaps the cre- death. Of special note, mitotic rates in GIST were his- ation of the N1c category in colon cancer, defined as the torically described in relation to 50 HPFs. It was recently presence of “tumor deposit(s) in the subserosa, mesen- discovered that the microscopes used to count mitotic fig- tery, or nonperitonealized pericolic or perirectal tissues ures in the initial clinical studies that form the evidence without regional nodal metastasis” (discussed further in basis of the risk assessment had much smaller field areas Chapter 11). than most modern microscopes. For many modern micro- In the past, stage groupings at a given site in the tubal scopes, 5 mm2 is equal to approximately 20 high-power gut were determined exclusively by TNM. In AJCC 7 this (40×) fields. Grading of mesenchymal tumors will be dis- is no longer the case. The so-called nonanatomic factors, cussed in more detail in Chapter 5. including tumor type, location within an organ, grade, For sarcomas, the American Joint Committee on and mitotic rate, affect staging at some sites (summarized Cancer (AJCC), the College of American Pathologists in Table 1.3). Additional nonanatomic factors, includ- (CAP), and the WHO each advocate use of the Fédération ing molecular-based ones, will have increasing influence Nationale de Centre de Lutte Contre le Cancer (FNCLCC) on stage groupings going forward. For the foreseeable grading system. Tumors are assessed for differentia- future, however, anatomic factors will continue to form tion, mitotic rate, and tumor necrosis. Each of these the core of tumor staging, as they permit comparisons of three parameters is given a score, and the overall grade stage data over time and because they are applicable to the is assigned based on the sum of the scores. FNCLCC majority of patients worldwide who may not have access grade correlates with metastatic risk and overall survival, to advanced medical technologies. while adequacy of excision is a better predictor of local recurrence. Clinical Versus Pathologic Staging Clinical staging is performed at disease presentation, Tumor Staging before definitive treatment, and takes into account data Historically, tumor stage has represented the anatomic obtained by any combination of history and physical extent of disease. It is typically

expressed in the form of examination, diagnostic imaging, endoscopy, biopsy (of the tumor, node, metastasis (TNM) classification. Aside the primary tumor and/or a regional lymph node), and from tumor type, stage is the single most important deter- surgical exploration without resection. If a biopsy is minant of an individual patient’s therapy and prognosis. performed, the pathologist’s role in clinical staging is to Accurate staging is also critical to the conduct of clinical confirm the presence of tumor, rather than to define its trials and facilitates the comparison of cancer outcomes anatomic extent, the latter of which is based on nonpatho- on large scales (eg, regionally, nationally, and internation- logic information (eg, imaging results). Clinical staging ally). The TNM Committee of the Union for International provides an estimate of prognosis and, most importantly, Cancer Control (UICC) and the AJCC work together to determines the initial treatment course. define T, N, and M stage categories and stage groups The pathologic stage is based mainly on histologic (also known as anatomic stage/prognostic groups) for examination of a surgically resected specimen. This pro- each anatomic site. For a given site, any combination of vides more precise prognostic information and informs the T, N, and M can be expressed as an overall stage group need for additional treatment (eg, adjuvant chemotherapy (I through IV), with combinations of similar prognosis or radiation). The value of synoptic reporting as a tool to assigned to the same stage group (eg, T4a N1 M0 and ensure completeness of reporting of pathologic stage and T1 N2b M0 colon cancers are each considered stage IIIB other clinically significant parameters will be discussed in disease). the section on synoptic reporting. 1 Introduction to Diagnosis and Reporting of Gastrointestinal Tract Neoplasia 11 TABLE 1.3 “Nonanatomic Factors” Influencing AJCC/UICC Tubal Gut Stage Groupings Anatomic Site (or Tumor Type) Factor Notes Esophagus Tumor type Separate stage groupings for squamous cell carci- noma (SCC) and adenocarcinoma (AdCa) Tumor location Applies to SCC (ie, upper, middle, lower) Grade (ie, 1, 2, 3) Applies to SCC and AdCa Appendix Grade (ie, 1, 2, 3) Low-grade appendiceal mucinous neoplasm with extra-appendiceal spread is considered G1; separate stage groupings for G1 vs. G2/3 tumors with intraperitoneal metastasis beyond the right lower quadrant Gastrointestinal stromal tumor (GIST) Mitotic rate (ie, ≤5 per 5 mm2 vs. >5 per 5 mm2 Tumor location Separate stage groupings for gastric/omental (ie, stomach/omentum vs. GISTs vs. nongastric/nonomental GISTs based small intestine/esophagus/colorectum/ on increased aggressiveness of the latter mesentery/peritoneum) Neuroendocrine tumor (NET) Tumor location Separate stage groupings for appendiceal NETs vs. all other tubal gut NETs Stomach, small intestine, colon, and None Stage groupings based purely on TNM rectum Staging After Neoadjuvant Therapy symbol is a vital component of accurate staging. For exam- ple, the prognosis of a patient with pT2 N0 disease may be Neoadjuvant therapy refers to the use of chemotherapy very different than that of a patient with ypT2 N0 disease, and radiation, either singly or in combination, prior to sur- who may have had clinically positive lymph nodes at pre- gical resection. Adjuvant therapy refers to chemotherapy sentation. Furthermore, for the purpose of research, these and/or radiation administered after the definitive surgical stages are not comparable. The ypTNM stage is based on procedure. In the adjuvant setting, radiation is generally the extent of viable tumor. Evidence of regressed tumor applied to improve local control, while chemotherapy is in the form of fibrosis, calcifications, and acellular mucin used to achieve a systemic effect. Chemotherapy may also pools does not affect stage. Significant tumor regression sensitize the tumor to the effects of radiation. In the neo- in the face of neoadjuvant therapy may be associated with adjuvant setting, combined chemoradiotherapy aims to improved prognosis. Assessment of treatment effect after downstage tumors and treats occult metastatic disease. In neoadjuvant therapy is a CAP required data element for some patients it converts locally advanced, unresectable carcinomas of the esophagus, stomach, pancreas, col- tumors to resectable ones, and it may improve the resect- orectum, and anal canal; assessment in GIST is optional, ability of “borderline-resectable” tumors. In patients who with a recommendation to report the percentage of viable are marginal surgical candidates (eg, due to comorbid con- tumor. There are several published regression grading sys- ditions), a period of neoadjuvant therapy may provide the tems, including three-, four-, and five-tiered examples. The opportunity for metastasis to declare itself, sparing these CAP Cancer Protocols include a four-tiered example (see patients surgery from which they would not derive benefit. Table 1.4). This is discussed in more detail in Chapter 11. Neoadjuvant chemoradiotherapy is the standard of care for clinical stage T3/4 rectal cancer, in which it has been proven in clinical trials to significantly decrease the risk of local recurrence (compared to adjuvant therapy). TABLE 1.4 Tumor Regression Grading in Neoadjuvant It is also generally applied in patients with clinical nodal Treated Tumors (Four-Tiered) disease. Neoadjuvant chemoradiotherapy is also the evolv- ing standard of care for patients with clinical stage T2 or Grade Histologic Description greater esophageal/gastroesophageal junction/proximal 0 (complete response) No residual viable tumor gastric cancers. Its application in distal gastric cancers is 1 (moderate response) Single cells or small groups of tumor more variable. In addition, neoadjuvant imatinib therapy cells may be used in locally advanced and/or high-risk GISTs. 2 (minimal response) Residual tumor outgrown by fibrosis Pathologic staging after neoadjuvant therapy is des- 3 (poor response) Little or no tumor kill; extensive residual tumor ignated by the prefix “y” (ie, ypTNM). The use of this 12 Neoplastic Gastrointestinal Pathology: An Illustrated Guide SYNOPTIC VERSUS NARRATIVE REPORTING advent of synoptic reporting, presumably because pathol- ogists prompted by checklist items performed more dili- For cancer resections, synoptic reporting (also known as gent searches for these features. checklist-based, template-driven, and pro forma report- Synoptic reporting also increases the clarity of report- ing) has largely supplanted traditional narrative (ie, free- ing, and thus the effectiveness of communication, between text) reporting. Multiple published studies have shown the pathologist and the treating clinicians. Sheldon that synoptic reporting improves the completeness (and Markel and Samuel Hirsch, credited with coining the thus the prognostic and therapeutic relevance) of cancer term “synoptic reporting,” expressed frustration over the reporting. A 1991 CAP Q-Probes Quality Improvement disconnect between their perception of carefully crafted Study, based on data from 15,940 reports of resected pri- “conventional paragraphic” reports and occasional dis- mary colorectal cancers from 532 laboratories, related the satisfaction with these reports by their clinicians, stating, completeness of reporting for 11 gross and microscopic “To our chagrin, surgeons and other clinicians frequently parameters to: (a) use of a cancer checklist; (b) use of a questioned why certain information, which was actually microscopic description; (c) teaching institution status; in the body or our reports, was not.” Synoptic reports also (d) whether the institution had a pathology residency; and facilitate data mining and reporting to cancer registries. (e) bed size. The use of a cancer checklist was the single Not surprisingly, the quality of oncology reporting most important predictor of completeness of reporting, sta- is of interest to laboratory accrediting bodies. The CAP tistically significant for 8 of 11 parameters. Interestingly, Laboratory Accreditation Program Anatomic Pathology at that time, only 12.5% of the 532 laboratories surveyed Checklist includes the Phase II requirement that “All data employed synoptic reporting. elements required in applicable CAP Cancer Protocols are More contemporary data demonstrating the signifi- included in the surgical pathology report.” (Phase II defi- cance of the adoption of synoptic reporting in an indi- ciencies on inspection require a written response and doc- vidual laboratory are presented in Table 1.5. Messenger umentation demonstrating compliance.) Furthermore, the and colleagues found synoptic reporting to significantly required data elements must relate to the current edition of increase the completeness of reporting for 7 of 10 data ele- the protocols, with an 8-month grace period. The American ments in a series of 498 rectal cancer resections. Several of College of Surgeons Commission on Cancer (CoC), which these increases are quite dramatic and affect parameters accredits cancer programs, similarly mandates the inclu- that are highly clinically actionable, such as lymphovas- sion of CAP Cancer Protocol required data elements in cular invasion, perineural invasion, and tumor deposits. surgical pathology reports. While neither the CAP nor the They also showed that while narrative reports from GI CoC dictates the specific use of the CAP Cancer Protocols, pathologists were more complete for the data elements but rather that reports contain the required data elements lymphovascular invasion and extramural venous inva- from those protocols, AJCC 7 specifically recommends the sion, after the adoption of synoptic reporting, reports use of CAP Cancer Protocols for pathology reporting. from non-GI and GI pathologists were equally complete. The CAP Cancer Protocols were originally developed Furthermore, detection rates for lymphovascular inva- in 1989 and are frequently updated by the CAP Cancer sion, perineural invasion, and extramural venous invasion Committee and CAP Cancer Protocol Review Panels. At the dramatically increased (tripled to quadrupled) with the time of writing this chapter, all the protocols relevant to the TABLE 1.5 Effect of Report Format on Reporting of Data Elements Report Format P Value Narrative (n = 183), Synoptic (n = 315), Parameter % Complete % Complete Tumor size 99 99 NS TNM stage 24 96 <0.001 Tumor type 99 99 NS Tumor grade 92 98 0.004 Circumferential/radial margin (CRM) status 100 100 NS Distance to CRM 86 97 <0.001 Lymphovascular invasion 39 98 <0.001 Extramural venous invasion 41 97 <0.001 Perineural invasion 14 94 <0.001 Regional deposits 13 83 <0.001 Source: Messenger DE, McLeod RS, Kirsch R. What impact has the introduction of a synoptic report for rectal cancer had on report- ing outcomes for specialist gastrointestinal and nongastrointestinal pathologists? Arch Pathol Lab Med. 2011 Nov;135(11):1471–1475. 1 Introduction to Diagnosis and Reporting of Gastrointestinal Tract Neoplasia 13 TABLE 1.6 College of American Pathologists Required actionable (eg, influence decision to place a patient into Data Elements for Carcinomas and Neuroendocrine Tumors surveillance and determine surveillance intensity; inform of the Tubal Gut, Regardless of Anatomic Site decision to give adjuvant chemotherapy), emphasizing the importance of accuracy of assessment and completeness of Specimen (ie, organs received) reporting. This textbook will specifically highlight issues Procedure Tumor site related to the pathologic assessment of the most clinically Tumor size significant prognostic markers. Histologic type Histologic grade Predictive Markers Microscopic tumor extension Margin status Predictive markers provide information about whether a Distance to closest margin, if uninvolved Treatment effect* given patient will (or will not) respond to a specific ther- Lymphovascular invasion** apy. Estrogen receptor and HER2 status in breast cancer Number of regional lymph nodes examined and involved*** represent the most well-known examples. At present, there Pathologic staging (pTNM) are four main clinical applications of predictive markers in the GI tract: *not mentioned in appendix checklist **not required for anal canal 1. HER2 testing to select patients for anti-HER2 therapy ***applies to resections in advanced esophageal, gastroesophageal, and gastric adenocarcinoma; tubal gut had been updated within the prior 4 months. The 2. KRAS mutation testing (and in some instances, assess- protocols contain both “required” and “not required” data ment of related molecular markers) to determine the elements, the latter denoted by a “+.” The required data ele- appropriateness of anti-EGFR (epidermal growth fac- ments are considered essential for cancer care and have a tor receptor) therapy in metastatic colorectal cancer; strong evidence base. A summary of required data elements 3. DNA mismatch repair function testing (ie, mismatch common to all the checklists germane to this textbook is repair protein immunohistochemistry and/or MSI presented in Table 1.6. At each anatomic site, there may be testing) in colorectal cancer to inform the decision additionally required data elements (eg, perineural invasion regarding adjuvant chemotherapy in stage II disease; in colon cancer, mitotic rate per 10 HPF in NETs, risk assess- 4. KIT and PDGFRA mutation analysis in GIST to pre- ment in GIST), which will be further discussed in subsequent dict response to specific tyrosine kinase inhibitors. chapters. Nonrequired elements have less data to support Predictive marker assays are generally held to a “higher them or are less routinely used in patient care (eg, histologic standard,” in terms of clinical validation and reporting features suggestive of microsatellite instability [MSI] in colon than are purely diagnostic markers. These

four sets of cancer, tumor necrosis in NET, treatment effect in GIST). markers will be discussed further in the relevant organ- Further information about synoptic reporting is avail- specific chapters, as well as Chapters 13 and 14. able in the following document: www.cap.org/apps/docs/committees/cancer/cancer_ protocols/synoptic_report_definition_and_examples.pdf. SCREENING AND SURVEILLANCE Finally, the CAP Cancer Protocols are accessible online in PDF and Word format at the CAP website through the Screening “Reference Resources and Publications” tab. Screening refers to an effort to identify early, treatable disease in asymptomatic individuals. In the setting of neo- plasia, the goal is to identify lesions at risk for neoplastic PROGNOSTIC AND PREDICTIVE MARKERS progression or early, treatable cancers. Screening may be undertaken in “average-risk” individuals or targeted to Prognostic Markers specific at-risk groups, based on factors such as the disease A prognostic marker provides information that allows burden in the population and a precursor lesion’s risk for one to make a probabilistic statement about a patient’s neoplastic progression. These data, along with the avail- anticipated disease course. Although we typically think of ability of good screening tests and the cost of a screening these in the setting of overt malignancies (eg, tumor grade, program to the population, are considered in the construc- microscopic tumor extension, presence or absence of lym- tion of clinical guidelines. phovascular invasion), the presence of Barrett esophagus, As an example, the lifetime risk of developing colon the extent of a patient’s chronic colitis, the absence or pres- cancer is 5% to 6%, with more than 90% of new diagno- ence and grade of flat dysplasia, and the number and size ses and cancer deaths occurring in patients over age 50. of neoplastic colon polyps can all be considered prognostic Cancer arises in neoplastic polyps, with a fairly long inter- markers. Many prognostic markers are directly clinically val between a polyp becoming macroscopically evident and 14 Neoplastic Gastrointestinal Pathology: An Illustrated Guide progression to cancer. Several reasonably sensitive tests exist or less per year. Barrett esophagus is not as amenable to to identify polyps or early cancers (eg, flexible sigmoidos- eradication as are neoplastic colon polyps, and endoscopic copy, colonoscopy, and/or fecal occult blood test), and polyp- ablative techniques are associated with a significant risk of ectomy or treatment of early cancers has been proven to lead stricture. Up to half of the patients presenting with esoph- to decreased mortality from colon cancer. In this setting, the ageal adenocarcinoma do not report a history of GERD United States Preventative Services Task Force, the American symptoms. Fifty to sixty percent of patients present with Cancer Society (ACS), the American College of Radiology locally advanced or metastatic disease, and even in patients (ACR), and the United States Multi-Society Task Force with localized disease, the 5-year survival is less than 40% (USMSTF; a collaboration between the American College of (though substantially better in patients with T1 and espe- Gastroenterology, the American Society for Gastrointestinal cially T1a disease). Thus, in the general population, the Endoscopy [ASGE], and the American Gastroenterological costs associated with screening for esophageal adenocar- Association [AGA]) each recommend colorectal cancer cinoma clearly outweigh the benefits. In a 2011 medical screening in average-risk individuals beginning at age 50. position statement, the AGA recommended screening for Screening recommendations are modifiable based on the Barrett esophagus specifically in patients with multiple presence of additional risk factors. In patients with colon risk factors associated with esophageal adenocarcinoma cancer or adenomatous polyps diagnosed in a first-degree (age 50 years and above, male, Caucasian, chronic GERD, relative 60 years or older or with colorectal cancer diag- hiatal hernia, elevated body mass index, and intra-abdom- nosed in two second-degree relatives, an ACS/USMSTF/ACR inal distribution of body fat), in whom the benefits of guideline recommends that screening commence at age 40. screening would appear to outweigh the costs. Table 1.7 In contrast, the lifetime risk of developing esophageal summarizes GI conditions in which screening may be con- adenocarcinoma is only 0.5%. Cancer arises in Barrett sidered, the means of screening, the lesion the screening esophagus, which is found in 1% to 2% of the general test aims to detect, and relevant expert guidelines. population and up to 10% of patients with chronic gastro- esophageal reflux disease (GERD) (by comparison, 30% Surveillance of average-risk patients 50 years or older will have polyps at an index colonoscopy). The risk of progression from Surveillance refers to testing in patients with “at-risk” Barrett esophagus to adenocarcinoma is reportedly 0.25% lesions with the goal of identifying more advanced lesions or TABLE 1.7 Screening for Neoplasia in the Tubal Gut Underlying Condition Procedure Target Lesion Comment(s) Reference* Gastroesophageal reflux Barrett esophagus, In patients with multiple risk disease (GERD) prevalent dysplasia factors for esophageal adenocarcinoma (ie, age ≥ 50, male, White, chronic GERD, hiatal hernia, elevated body AGA 2011 mass index, intra-abdominal Upper endoscopy distribution of body fat) Screening not recommended in general population with GERD Pernicious anemia (autoimmune Intestinal metaplasia, Insufficient data to support ASGE 2006 atrophic gastritis) prevalent dysplasia, routine surveillance after neuroendocrine single endoscopy proliferations Long-standing idiopathic inflammatory bowel disease Colitis, prevalent To determine if disease extent Colonoscopy AGA 2010 dysplasia warrants surveillance Primary sclerosing cholangitis Age ≥ 50 years in patients with Multiple options including average colon cancer risk flexible sigmoidoscopy, Age 40 years in patients with a colonoscopy, double family history of colon cancer/ contrast barium enema, Adenoma and sessile ACS/ Positive screening tests are polyps (defined here as colon computed tomography serrated polyp, USMSTF/ followed up with colonoscopy cancer or adenomas in a first- colonography, fecal early colon cancer ACR 2008 degree relative ≥ age 60 or occult blood test, fecal two second-degree relatives immunochemical test, or with colon cancer) stool DNA test *references available in the Screening and Surveillance section of the references 1 Introduction to Diagnosis and Reporting of Gastrointestinal Tract Neoplasia 15 early, treatable cancers. It is the presence of a baseline “at- the non-neoplastic background. Epithelial lesions wor- risk” lesion that distinguishes surveillance from screening. risome for dysplasia but for which the diagnosis cannot The “at-risk” lesion may represent an inflammatory condi- be made with certainty may be interpreted as “indefi- tion, neoplasm, known germline mutation, or even a fam- nite for dysplasia.” The distinction of lymphoma from ily history highly suspicious for a family cancer syndrome. a reactive inflammatory process may require the dem- Patients with a positive screening test are typically entered onstration of immunoglobulin heavy chain or T-cell into surveillance. (A positive fecal occult blood test is an receptor gene rearrangements or evidence of an aberrant exception; it is followed up with colonoscopy, and patients immunophenotype. may be entered into surveillance based on the results of this If neoplastic, what is the tumor type? Primary con- second test.) For example, if a patient with chronic GERD siderations include epithelial (generally columnar or squa- and the multiple risk factors for esophageal adenocarcinoma mous), neuroendocrine, hematolymphoid, mesenchymal, discussed previously undergoes screening endoscopy, the melanocytic, mesothelial, and germ cell. detection of Barrett esophagus (the “at-risk” lesion) would If the histogenesis is uncertain, could immunohisto- dictate patient placement into endoscopic surveillance. chemistry be helpful? For especially poorly differentiated Patients in whom the “at-risk” lesion is genetic are generally tumors, broad spectrum keratins, LCA/CD45, and S100 placed directly into surveillance, without first undergoing are a useful start. Even if the broad tumor type is fairly screening. For example, in a patient with a known germline certain (eg, lymphoma), immunohistochemistry may be mutation in a DNA mismatch repair gene (ie, Lynch syn- useful to secure a more specific diagnosis (eg, demonstra- drome), surveillance colonoscopy, at an interval of 1 to 2 tion of CD20 and cyclin D1 expression to support a diag- years, should commence at age 20 to 25, or 10 years ear- nosis of mantle cell lymphoma). lier than the youngest colon cancer in the immediate family. If epithelial, is the lesion pre-invasive or invasive? Another characteristic of surveillance is that the intensity Pre-invasive neoplasms are confined to the basement (ie, the surveillance interval and, in some instances, the membrane. Single cells or small groups of cells, a never- number of biopsies) is adjusted based on biopsy results. For ending gland pattern, and sheets of cells suggest invasion. example, for the patient with chronic GERD and Barrett If pre-invasive, what is the grade of dysplasia? Two- esophagus discussed previously, the finding of no dysplasia tiered grading is recommended (low-grade or high-grade). on biopsy might dictate a surveillance interval of 3 to 5 years If invasive, what is the microscopic tumor extension? with four-quadrant biopsies taken every 2 cm of metaplasia For columnar lesions, stromal desmoplasia and the juxta- (as recommended in a recent AGA guideline), while follow- position of glands and thick-walled muscular blood ves- up in 6 to 12 months with biopsies every 1 cm would be sels suggest a tumor is at least submucosally invasive. recommended, given a biopsy finding of LGD. Are there any other potentially clinically actionable Major indications for GI surveillance are listed in histologic parameters that should be sought out? Tumor Table 1.8. The ones most frequently encountered include type and microscopic tumor extension are the key param- Barrett esophagus, extensive IBD, and precancerous colon eters. Additional features are important in select settings. polyps. For example, in polypectomy specimens of pedunculated adenomas in which an associated adenocarcinoma invades the stalk submucosa, tumor grade, LVI status, and margin GENERAL APPROACH TO status determine the adequacy of polypectomy versus the THE BIOPSY SPECIMEN need for segmental colectomy. Could the reporting of any additional histologic When faced with a biopsy specimen, the pathologist should information be helpful to the clinician or to a pathologist seek the answers to a series of questions. Patient age, gen- interpreting a subsequent resection specimen from this der, and the clinical indication for the biopsy inform the patient? This is especially applicable to resections seen further evaluation of the specimen. as intraoperative consultations. For example, a diagnosis First, is the tissue normal or abnormal? If the tis- of “invasive adenocarcinoma,” though perhaps sufficient sue is apparently normal, does that make clinical sense, to drive neoadjuvant chemoradiotherapy and resection in and if not, would step sections be helpful? Step sections esophageal carcinoma, is not as useful as one of “invasive should be considered in many situations, particularly if adenocarcinoma, poorly differentiated, intestinal-type/ the endoscopist saw a lesion or abnormality, yet the initial tubular (or diffuse-type/poorly cohesive or mixed),” as biopsy sections are normal. signet ring cells, especially in small numbers, are notori- If the tissue is abnormal, is the lesion inflammatory ously difficult to interpret at a frozen section. or neoplastic? The answer to this question is not always Finally, are any additional studies indicated on the obvious. As discussed previously, neoplasms are clonal. As biopsy material? For example, HER2 testing should be a consequence of this, pre-invasive epithelial neoplasms considered for esophageal/gastroesophageal/gastric ade- (dysplasias) are characterized by abrupt transitions from nocarcinomas; Ki-67 immunohistochemistry is necessary 16 Neoplastic Gastrointestinal Pathology: An Illustrated Guide TABLE 1.8 Surveillance for Neoplasms in the Tubal Gut Condition Qualifier Surveillance Method Surveillance Interval Reference* No dysplasia Upper endoscopy with 3–5 years random four-quadrant biopsies every 2 cm of Barrett length** Indefinite for dysplasia Not defined Not defined Barrett esophagus AGA 2011 Low-grade dysplasia Four-quadrant biopsies 6–12 months every 1 cm** High-grade dysplasia Four-quadrant biopsies 3 months (strongly every 1 cm** consider endoscopic eradication) History of caustic Begin surveillance 15–20 years after Upper endoscopy 1–3 years ASGE 2006 ingestion ingestion Extensive No dysplasia Colonoscopy with 1–3 years**** inflammatory four-quadrant bowel disease (ie, Indefinite for dysplasia biopsy specimens 3–12 months left-sided, subtotal, Polypoid low-grade dysplasia, approximately every If entirely removed and or pan-ulcerative adenoma-like 10 cm of colitic no other flat dysplasia, colitis; or Crohn’s segment; 33 and 64 regular or increased colitis involving at biopsy specimens surveillance least one third of detect dysplasia the colon)*** **** Unifocal flat low-grade dysplasia with 90% and 3–6 months (consider 95% confidence, colectomy) AGA 2010 Multifocal flat low-grade dysplasia respectively; consider 3–6 months (consider increased sampling colectomy) (eg, every 5 cm) in rectosigmoid Polypoid dysplasia, Indication for colectomy non-adenoma-like Flat high-grade dysplasia Indication for colectomy Findings at baseline colonoscopy: No polyps 10 years Small (ie, <1 cm) rectosigmoid 10 years hyperplastic polyps 1–2 small tubular adenomas 5–10 years 3–10 tubular adenomas 3 years

OR any adenoma ≥ 1 cm OR Colon polyps at any adenoma with villous features prior examination, OR Colonoscopy with USMSTF otherwise average any adenoma with high-grade polypectomy 2012 risk dysplasia >10 adenomas <3 years Sessile serrated polyp(s) <1 cm 5 years without cytologic dysplasia Sessile serrated polyp(s) ≥1 cm 3 years OR with cytologic dysplasia OR Traditional serrated adenoma Serrated polyposis syndrome 1 year (continued) 1 Introduction to Diagnosis and Reporting of Gastrointestinal Tract Neoplasia 17 TABLE 1.8 Surveillance for Neoplasms in the Tubal Gut (continued) Condition Qualifier Surveillance Method Surveillance Interval Reference* Personal history of Patients should undergo removal of 1 year from surgery or colon cancer all polyps (perioperative clearing) perioperative clearing; within 6 months of surgery with if negative, next curative intent examination at 3 years; if again negative, next at 5 years ACS/ Colonoscopy with USMSTF/ Strong family Colonoscopy beginning at 40 years or polypectomy 5 years (or more frequent ACR 2008 history***** 10 years before the youngest case based on findings) in the immediate family Lynch syndrome Colonoscopy beginning at 20–25 years 1–2 years or 10 years before the youngest case in the immediate family *references available in the Screening and Surveillance section of the references **any mucosal abnormalities should be separately biopsied ***extent of disease is clarified at a screening endoscopy performed 8 years after onset of symptoms; patients with pancolitis and left-sided colitis are entered into surveillance within 1 to 2 years; patients with ulcerative proctitis, ulcerative proctosigmoiditis, and limited Crohn’s colitis are not at increased risk of developing colon cancer and are managed as average risk (see table entry “Colon polyps”) ****patients with primary sclerosing cholangitis should undergo screening colonoscopy at the time of that diagnosis, as patients may have long-standing subclinical IBD; for these patients entering surveillance, yearly colonoscopy (for no dysplasia) is recommended *****defined here as colon cancer or adenomas in a first-degree relative [FDR] before age 60 or in 2 or more FDRs at any age to accurately grade NETs; and mismatch repair protein as up to 5% of Lynch syndrome mutations abrogate immunohistochemistry should be considered for colorec- protein function (resulting in MSI), while maintaining tal adenocarcinomas. antigenicity (resulting in falsely normal immunohisto- chemistry results). GENERAL APPROACH TO THE RESECTION SPECIMEN SELECTED REFERENCES Analogous to the approach to biopsy specimens described Key Terminology previously, evaluation should begin with patient age, gen- Hanahan D, Weinberg RA. The hallmarks of cancer. Cell. 2000;100(1): der, and the clinical indication for the procedure. Often, 57–70. Epub 2000/01/27. however, pathologists evaluating a resection specimen have Hanahan D, Weinberg RA. Hallmarks of cancer: the next generation. access to the results of a diagnostic biopsy and all of the Cell. 2011;144(5):646–674. Epub 2011/03/08. information that is included in that evaluation, which may Riddell RH, Goldman H, Ransohoff DF, et al. Dysplasia in inflam- matory bowel disease: standardized classification with provisional make the evaluation of the resection specimen easier. clinical applications. Hum Pathol. 1983;14(11):931–968. Given an established diagnosis, the first step in inter- Schlemper RJ, Itabashi M, Kato Y, et al. Differences in diagnostic cri- preting a resection specimen is to confirm that diagno- teria for gastric carcinoma between Japanese and western patholo- sis. If available, review of prior diagnostic material is gists. Lancet. 1997;349(9067):1725–1729. Schlemper RJ, Kato Y, Stolte M. Review of histological classifications sometimes helpful. Once the diagnosis is confirmed, a of gastrointestinal epithelial neoplasia: differences in diagnosis systematic assessment of key histologic parameters, as of early carcinomas between Japanese and Western pathologists. represented by the required data elements of the appro- J Gastroenterol. 2001;36(7):445–456. priate synoptic reporting form, should be undertaken. Willis RA. The Spread of Tumours in the Human Body. 2nd ed. London: Butterworth & Co; 1952. As with biopsy specimens, additional immunohisto- chemical or molecular studies may be appropriate. For example, repeat HER2 testing may be considered on Grading and Staging of gastroesophageal adenocarcinomas as overexpression Gastrointestinal Malignancies may be heterogeneous and, thus, not identified on a Brierley JD, Greene FL, Sobin LH, Wittekind C. The “y” symbol: an biopsy specimen. If a Ki-67 immunostain has been per- important classification tool for neoadjuvant cancer treatment. formed on the biopsy of a NET, repeat testing may again Cancer. 2006;106(11):2526–2527. be useful, as the proliferation index may also be hetero- Chang F, Deere H, Mahadeva U, George S. Histopathologic examina- tion and reporting of esophageal carcinomas following preopera- geneous. MSI testing may be useful to confirm normal tive neoadjuvant therapy: practical guidelines and current issues. mismatch repair protein immunohistochemistry results, Am J Clin Pathol. 2008;129(2):252–262. 18 Neoplastic Gastrointestinal Pathology: An Illustrated Guide College of American Pathologists. Cancer Protocols and Checklists. Prognostic and Predictive Markers www.cap.org/cancerprotocols Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, eds. AJCC Bellizzi AM. Contributions of molecular analysis to the diagnosis and Cancer Staging Manual. 7th ed. New York, NY: Springer; 2010. treatment of gastrointestinal neoplasms. Semin Diagn Pathol. Fletcher CDM, Bridge JA, Hogendoorn PCW, Mertens F, eds. WHO 2013;30(4):329–361. Classification of Tumours of Soft Tissue and Bone. 4th ed. Lyon: IARC; 2013. Markel SF, Hirsch SD. Synoptic surgical pathology reporting. Hum Screening and Surveillance Pathol. 1991;22(8):807–810. Messenger DE, McLeod RS, Kirsch R. What impact has the introduction Farraye FA, Odze RD, Eaden J, et al. AGA medical position state- of a synoptic report for rectal cancer had on reporting outcomes ment on the diagnosis and management of colorectal neo- for specialist gastrointestinal and nongastrointestinal pathologists? plasia in inflammatory bowel disease. Gastroenterology. Arch Pathol Lab Med. 2011;135(11):1471–1475. 2010;138(2):738–745. Miettinen M, Lasota J. Gastrointestinal stromal tumors: pathology and Farraye FA, Odze RD, Eaden J, Itzkowitz SH. AGA technical review on prognosis at different sites. Semin Diagn Pathol. 2006;23(2):70–83. the diagnosis and management of colorectal neoplasia in inflam- Rindi G, Kloppel G, Alhman H, et al. TNM staging of foregut (neuro) matory bowel disease. Gastroenterology. 2010;138(2):746–774, endocrine tumors: a consensus proposal including a grading sys- 74 e1–e4; quiz e12–e13. tem. Virchows Archiv. 2006;449(4):395–401. Hirota WK, Zuckerman MJ, Adler DG, et al. ASGE guideline: the role Ryan R, Gibbons D, Hyland JM, et al. Pathological response following of endoscopy in the surveillance of premalignant conditions of the long-course neoadjuvant chemoradiotherapy for locally advanced upper GI tract. Gastrointest Endosc. 2006;63(4):570–580. rectal cancer. Histopathology. 2005;47(2):141–146. Levin B, Lieberman DA, McFarland B, et al. Screening and surveil- Swerdlow SH, Campo E, Harris NL, et al, eds. WHO Classification of lance for the early detection of colorectal cancer and adenoma- Tumours of Haematopoietic and Lymphoid Tissues. 4th ed. Lyon: tous polyps, 2008: a joint guideline from the American Cancer IARC; 2008. Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology. Synoptic Versus Narrative Reporting 2008;134(5):1570–1595. Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin World Health Organization Classification of Tumours. WHO TR. Guidelines for colonoscopy surveillance after screening and pol- Classification of Tumours of the Digestive System. 4th ed. Bosman ypectomy: a consensus update by the US Multi-Society Task Force FT, Carneiro F, Hruban RH, Theise ND, eds. Lyon: IARC; 2010. on Colorectal Cancer. Gastroenterology. 2012;143(3):844–857. Zarbo RJ. Interinstitutional assessment of colorectal carcinoma surgi- Spechler SJ, Sharma P, Souza RF, Inadomi JM, Shaheen NJ. American cal pathology report adequacy. A College of American Pathologists Gastroenterological Association medical position statement Q-Probes study of practice patterns from 532 laboratories and on the management of Barrett’s esophagus. Gastroenterology. 15,940 reports. Arch Pathol Lab Med. 1992;116(11):1113–1119. 2011;140(3):1084–1091. 2 Approach to Epithelial Neoplasms of the Gastrointestinal Tract W EI CHEN AND W ENDY L . FR ANKEL INTRODUCTION neuroendocrine tumors (NETs), and mixtures of those cell types. Adenocarcinomas arise from the columnar epi- The epithelial lining of the gastrointestinal (GI) tract thelia of the GI tract, and this type of carcinoma is the provides an extremely large interface between the out- most common epithelial neoplasm in the stomach and side environment and the luminal surfaces of the GI tract colon. There is well-documented evidence of a dysplasia/ (approximately 2,000,000 cm2). Given the amount of epi- adenoma–c arcinoma development sequence in both the thelium required to create this interface, it is not surprising colon and stomach as well. Histologic variants include that the majority of gastrointestinal neoplasms are epithe- tubular, papillary, mucinous, cribriform comedo-type, lial in origin. medullary, micropapillary, hepatoid, serrated, and signet ring cell carcinoma. When compared to glandular adeno- carcinomas, signet ring cells are poorly cohesive, show a EPIDEMIOLOGY diffuse infiltrative growth pattern, and generally carry a worse prognosis. A more extensive discussion of specific According to 2013 cancer statistics from the American histologic variants can be found in Chapters 7–11. Cancer Society, the five most common digestive system Squamous cell carcinoma most commonly arises in the cancers in the United States, by decreasing incidence, parts of the GI tract lined by squamous mucosa, that is, are colorectal (49.2%), pancreatic (15.6%), liver/intrahe- the upper to middle esophagus and anus. Worldwide, squa- patic bile duct (13.9%), gastric (7.4%), and esophageal mous cell carcinoma is still the predominant carcinoma in (6.2%). These account for 35.2%, 26.6%, 15.0%, 7.6%, the esophagus, whereas adenocarcinoma has surpassed and 10.5% of GI cancer-related deaths, respectively. The squamous cell carcinoma in the esophagus in Western male to female ratios for these cancers are 1.1:1 (colorec- countries in recent years. Anal squamous cell carcinoma tal), 1:1 (pancreatic), 2.9:1 (liver/intrahepatic bile duct), is associated with human papillomavirus (HPV) infection 1.6:1 (gastric), and 4.1:1 (esophageal). Overall, colorec- and immunosuppression; in contrast, HPV is detected in tal c ancer is the third most common malignant neoplasm only a small number of esophageal squamous cell carcino- worldwide, and the second leading cause of cancer deaths mas, and its role in esophageal carcinogenesis is unclear. in the United States. Neuroendocrine cells are present throughout the GI tract, which is considered to be the largest endocrine organ of the human body. Given the distribution of neuro- SUBTYPES OF EPITHELIAL NEOPLASMS endocrine cells in the gut, it is not surprising that neuroen- docrine tumors (NETs) occur throughout the tubular GI Epithelial neoplasms of the GI tract are broadly clas- tract. An estimated 8,000 people in the United States are sified as adenocarcinomas, squamous cell carcinomas, diagnosed with an NET arising in the GI tract each year. 19 2 0 Neoplastic Gastrointestinal Pathology: An Illustrated Guide Appendiceal NETs are the most common neoplasms of the appendix, and NETs also surpassed adenocarcinomas as the most common small bowel tumor reported to the National Cancer Data Base in the year 2000. In contrast, adenocarcinoma and squamous cell carcinomas are still the dominant primary malignant neoplasms in other parts of the GI tract, as discussed previously. Malignant mixed epithelial neoplasms are those that are composed of more than one distinct histologic type. They are less common overall than pure adenocarcino- mas in the GI tract. There are several different types of mixed neoplasms, and some types are more common in certain locations within the GI tract than others. Some of the most common examples of mixed tumors of the luminal GI tract are discussed briefly in the following paragraphs. (A) Mixed Carcinoma of the Stomach This tumor is a mixture of discrete cohesive glandular (tubular and/or papillary) elements, as well as signet ring cell or poorly cohesive cellular components (Figure 2.1). The presence of any percentage of the latter is associated with a poor prognosis. Adenosquamous Carcinoma Adenosquamous carcinoma is a mixture of neoplastic glan- dular and neoplastic squamous elements (Figure 2.2A–B). The presence of benign metaplastic squamoid foci within an adenocarcinoma does not fulfill the criteria for adeno- squamous carcinoma. In contrast to the ampulla and pan- creas, no specific percentages of squamous differentiation are required in the tubular GI tract for this diagnosis to be (B) made (WHO 2010 classification). Adenosquamous carci- FIGURE 2.2 This adenosquamous carcinoma of the small nomas are rare, but can be found throughout the GI tract, bowel contains both a neoplastic glandular component with esophagus and colorectum the most common sites. and a neoplastic squamous component (A–B). Mixed Adenoneuroendocrine Carcinoma (MANEC) These tumors are a mixture of neoplastic glandular (exo- crine) and neuroendocrine components (Figure 2.3A–C), and diagnosis requires at least 30% of each component present in the tumor. Common sites in the GI tract include stomach, ampullary/periampullary region, and appendix (see also Chapter 3). DETERMINATION OF MALIGNANCY FIGURE 2.1 This mixed adenocarcinoma of the stomach contains

a cohesive well-developed glandular component Making a definite diagnosis of malignancy (versus one of a admixed with dyscohesive signet ring cells. benign lesion or dysplasia) can be challenging, particularly 2 Approach to Epithelial Neoplasms of the Gastrointestinal Tract 21 TABLE 2.1 Histologic Features Useful in Distinguishing Benign and Malignant Epithelial Lesions in the GI Tract Benign Malignant Architecture Preserved + − Regular borders + − Fused/cribriform glands − +/− Cytology Nuclear atypia −/+ ++ Loss of polarity − + Mitotic figures −/+ + Stroma Desmoplasia − + Hemorrhage −/+ − Glands associated with lamina + − propria (A) Immunohistochemistry Ki-67 −/+ ++ P53 −/+ ++ on small biopsies. Numerous pitfalls and differential diag- noses are encountered, many of which vary with the exact location of the lesion within the GI tract. Table 2.1 summa- rizes some histologic features that can be useful in differen- tiating benign from malignant lesions. In general, benign lesions are circumscribed with regular borders, and show preserved architecture without desmoplastic stromal reac- tions. Malignant lesions, in contrast, often have irregular, poorly circumscribed borders with an associated desmo- plastic reaction. Cytologically, benign lesions retain cellu- lar polarity and lack prominent cytologic atypia, whereas malignant lesions demonstrate more significant atypia (B) and often loss of nuclear polarity. Mitotic figures are typically more frequent in malignant neoplasms, although some inflammatory conditions may contain significantly increased mitoses and significant cytologic atypia. A back- ground of inflammation may be very helpful in diagnosing a reactive lesion, although an inflammatory background can certainly be seen in malignant conditions as well. Potential pitfalls exist when a small biopsy sample contains atypical reactive cells at the edge of an ulcer, but the ulcer or ischemic area is not clearly present in the biopsy. In difficult cases, immunohistochemical stains for Ki-67 and p53 may be helpful in distinguishing benign from malignant. Malignant lesions usually show a high Ki-67 proliferative labeling index and strong p53 staining, whereas benign lesions generally show negative to weak staining (Figure 2.4A–D). (C) PRIMARY VERSUS METASTATIC FIGURE 2.3 Mixed adenoneuroendocrine carcinoma EPITHELIAL MALIGNANCY (MANEC) of the colon showing a mixture of neoplastic glandular (A, left) and neuroendocrine components One of the most important issues when evaluating epi- (A, right). High power views of the glandular (B) and thelial malignancies of the GI tract is whether or not a neuroendocrine (C) components. tumor is primary or metastatic. Secondary tumors of the 2 2 Neoplastic Gastrointestinal Pathology: An Illustrated Guide (A) (B) (C) (D) FIGURE 2.4 Ki-67 and p53 immunostains can be helpful in distinguishing between benign reactive epithelium and a malignancy. Reactive gastric epithelium is negative for p53 (A), and shows only focal positivity for Ki-67 (B) at the base of proliferating gastric pits. Malignant epithelial cells from a gastric adenocarcinoma are diffusely positive for both p53 (C) and Ki-67 (D). GI tract are not uncommon, particularly in the small TABLE 2.2 Most Common Metastatic Malignancies to the bowel, where metastatic disease occurs more frequently GI Tract by Site than primary malignancies. The most common metastatic Most Common Most Common Metastatic tumors to the GI tract overall are malignant melanoma, Site of GI Tract Subsite Tumors lung adenocarcinoma, and breast cancer. The most com- mon metastatic malignancies to the GI tract by site are Esophagus Middle third Breast, lung, melanoma listed in Table 2.2, and features useful in distinguishing Stomach Upper two Breast (two thirds are lobular primary from metastatic tumors in the GI tract are listed thirds carcinoma), melanoma, lung, esophagus, in Table 2.3. Knowledge of the clinical, radiographic, and pancreas endoscopic findings is crucial, as are morphologic fea- Small intestine Any site Melanoma, breast, ovary, tures of the tumor, and the presence of multiple lesions lung, pancreas favors a metastasis rather than a primary tumor. When Colon and Any site Breast, lung, ovary, kidney, rectum pancreas the primary tumor is available for review, comparing it 2 Approach to Epithelial Neoplasms of the Gastrointestinal Tract 2 3 TABLE 2.3 Clinical and Pathologic Features Useful in with the metastatic lesion may be all that is required to Distinguishing Primary From Metastatic Epithelial Tumors make a diagnosis, but immunohistochemistry may also be helpful in some cases to make the distinction between Features Primary Metastatic primary and metastatic carcinomas. In metastatic lesions, tumors often undermine, rather than arise from, the Age Younger Older History No previous Previous malignancy mucosa (Figure 2.5A), or the tumor may be present only malignancy in the serosa or within the muscular wall. However, in Radiology Single tumor Multiple tumors some cases the metastatic tumor cells are intimately Endoscopy Mucosal lesion Submucosal lesion or lesion admixed with benign mucosal glands (Figure 2.5B). The pushing into lumen Gross Mucosa-based Serosa-based rather than identification of an in situ lesion is generally helpful in rather than mucosa-based determining that a neoplasm is primary, but there are pit- serosa-based falls. Metastatic tumors to the GI tract can involve the Microscopic In situ precursor No in situ precursor or mucosal surface and superficial glands (Figure 2.5C), (dysplasia) undermines mucosa in adjacent mucosa and thus mimic carcinoma in situ or a dysplastic muco- sal lesion. In the small bowel, tumor growth along the (A) (B) (C) FIGURE 2.5 This metastatic colonic adenocarcinoma undermines the small bowel mucosa. This is a typical growth pattern for a metastasis to the GI tract (A). Metastatic poorly differentiated gastric adenocarcinoma infiltrates between benign rectal glands (B). Metastatic adenocarcinoma involving the mucosa and surface epithelium of the small bowel mimics carcinoma in situ (C). 2 4 Neoplastic Gastrointestinal Pathology: An Illustrated Guide basement membrane and the presence of an apparent underlying the glands, and the endometrial glands may adenoma cannot be assumed to be definite evidence of a have cilia (tubal metaplasia). When endometriosis involves primary neoplasm for similar reasons. the colonic wall, the irregularly shaped glands lined by hyperchromatic cells may mimic an invasive colonic ade- nocarcinoma. The recognition of endometrial stroma is DIAGNOSTIC PITFALLS important, in contrast to the desmoplastic stroma typi- cally seen in adenocarcinoma. Endometrial stroma is There are many benign and/or non-neoplastic epithelial usually composed of densely packed small cells (Figure lesions in the GI tract that mimic malignant tumors both 2.6C) but can also contain large pink decidualized cells. radiographically, endoscopically, and histologically. Some Occasionally, the endometrial stroma may be inconspicu- can be seen throughout the GI tract, while others are more ous. Endometriosis tends to be circumscribed, often shows common in certain anatomic locations. Some common mural concentric smooth muscle hyperplasia and hypertro- diagnostic pitfalls in the differential diagnosis of GI epi- phy, and frequently contains hemorrhage and hemosiderin thelial neoplasms and their diagnostic clues are listed in deposition (Figure 2.6D). Rarely, the ectopic endometrial Table 2.4 and discussed here. glands may give rise to endometrioid adenocarcinoma or Müllerian adenosarcoma. Immunohistochemically, these Endometriosis/Endosalpingiosis tumors stain similarly to endometriosis. Endometriosis and endosalpingiosis frequently involve the GI tract, and these diagnoses should always be consid- Ectopic Pancreas ered in the differential diagnosis of a glandular lesion in Ectopic pancreatic tissue may present as a mucosal polyp a woman of reproductive age. The rectum (73%), sigmoid or a submucosal mass lesion on endoscopy, and is most colon (20%), and ileum (7%) are the three most commonly frequently located in the stomach or duodenum, especially involved sites. Endometriosis may present clinically as a within a few centimeters of either side of the gastroduode- mass, stricture, or perforation, and thus suggest malig- nal junction. Less often, ectopic pancreatic tissue is seen nancy. The glands of endometriosis and endosalpingiosis in the jejunum, ileum, or colon. Ectopic pancreas is com- may also mimic malignancy histologically, as they may posed of variable proportions of pancreatic acinar tissue, infiltrate anywhere from serosa to mucosa. ducts, and islets, arranged in a rounded or lobular con- The detection of endometrial or tubal-type glands, figuration. Histologically, it can mimic adenocarcinoma stroma, and hemosiderin on routine slide preparations is in the submucosa (particularly on the frozen section), usually sufficient for diagnosis, but immunostains may especially if only ducts are present (Figure 2.7A–B). The be helpful in differentiating the glands of endometriosis lobulated architecture and lack of cytologic atypia are from those of gastrointestinal origin. Typically, glands aris- very useful findings in supporting a diagnosis of ectopic ing from the GI tract are cytokeratin (CK)20 and CDX2 pancreas. Knowing the location of the endoscopic biopsy positive, and in general PAX8 and CK7 will mark glands is also helpful for the correct diagnosis. The minor papilla of Müllerian origin. When endometriosis involves the in the duodenum can show the same histologic appearance intestinal mucosal surface, the diagnosis may be particu- as heterotopic pancreas, with surface intestinal epithelium larly challenging, as the endometrial glands may contain undermined by submucosal pancreatic tissue. Most dis- mucin-depleted cells with enlarged nuclei on or near the eases of the pancreas, including pancreatic intraepithelial luminal surface, mimicking dysplasia (Figure 2.6A–B). neoplasia and carcinoma, have been rarely reported aris- However, there is usually hypercellular endometrial stroma ing from ectopic pancreas. TABLE 2.4 Common Diagnostic Pitfalls in the Diagnosis of GI Epithelial Neoplasms Pitfall Mimic Clue Site Endometriosis/endosalpingiosis Adenocarcinoma Endometrial or tubal- Anywhere (most common in type glands, stroma, rectum and sigmoid colon) hemorrhage Ectopic pancreas Adenocarcinoma Lobular arrangement, no Anywhere (most common in atypia, islets stomach and duodenum) Prolapse change/misplaced epithelium Adenocarcinoma in a Fibromuscular stroma, Rectum, sigmoid colon, stomach polyp hemorrhage, lack cytologic atypia Pseudo-signet ring cells (xanthoma, Signet ring cell Lack atypia, background Stomach, colon crushed gastric glands, ischemia) carcinoma 2 Approach to Epithelial Neoplasms of the Gastrointestinal Tract 2 5 (A) (B) (C) (D) FIGURE 2.6 Endometriosis can be a major pitfall in the diagnosis of epithelial neoplasia. This example of endometriosis near the mucosal surface shows mucin-depleted cells with enlarged nuclei that mimic dysplastic crypts (A–B), but there is surrounding endometrial-type stroma. Endometrial stroma is composed of densely packed small cells, and should be distinguished from true desmoplasia (C). Endometrial stroma may be inconspicuous in some cases, but hemosiderin deposition can also be a clue to the diagnosis (D). Prolapse Change or Misplaced Epithelium similar condition found in the stomach, in which cystic gastric glands are misplaced into the submucosa due to The solitary rectal ulcer syndrome, colitis cystica pro- chronic inflammation, ischemia, or surgery. Other sce- funda, and other forms of mucosal prolapse are a related narios in which mucosal entrapment can mimic invasive spectrum of disorders in which benign, often dilated adenocarcinoma include misplaced epithelium in small glands may herniate into the submucosa, often due to intestinal Peutz–Jeghers polyps, adenomatous polyps excessive straining during defecation. These misplaced of the left colon, and hyperplastic polyps of the sigmoid benign glands in the submucosa may mimic adenocar- colon and rectum. Misplaced glands in adenomas can be cinoma, although the misplaced epithelium typically particularly problematic due to the dysplasia inherently shows no dysplasia and is associated with a surround- present in adenomatous epithelium (Figure 2.8C–D). Key ing rim of lamina propria. There are often neighboring findings that can help distinguish these glands from inva- diamond-shaped, focally dilated, distorted crypts located sive adenocarcinoma include similar degrees of atypia in between hypertrophic disorganized fibromuscular fibers the misplaced and surface adenomatous glands, lack of that extend upwards, perpendicular to the muscularis desmoplastic stroma, and surrounding hemorrhage and mucosae (Figure 2.8A–B). Gastritis cystica profunda is a hemosiderin deposition. 2 6 Neoplastic Gastrointestinal Pathology: An Illustrated Guide (A) (B) FIGURE 2.7 Ectopic pancreas composed primarily of dilated pancreatic ducts in the submucosa can closely mimic invasive adenocarcinoma (A). Note the lobular configuration of the glands. This high power image shows small islets associated with the pancreatic ducts (B, arrows). (A) (B) (C) (D) FIGURE 2.8 In this rectal biopsy showing prolapsed glands in the submucosa, there is no cytologic atypia and the crypts are surrounded by hypertrophic and disorganized fibromuscular fibers (A–B). In this tubulovillous adenoma with submucosal epithelial displacement, the downwardly displaced epithelium shows continuity with the surface epithelium (C). At higher power, the misplaced glands show the same degree of atypia as the surface adenomatous glands (D). Note also the lack of desmoplastic stroma. 2 Approach to Epithelial Neoplasms of the Gastrointestinal Tract 27 Approximately 10% of Peutz–Jeghers polyps contain epithelioid features are not, in fact, epithelial in origin. misplaced epithelium, which may herniate into the sub- For example, 20% to 25% of gastric

gastrointestinal stro- mucosa, muscularis propria, or subserosa with frequent mal tumors (GIST) are epithelioid (Figure 2.10A), with associated mucin-containing cysts. Demonstration of many cases showing a mixed spindle and epithelioid his- continuity of the misplaced epithelium with the overlying tology. Many sarcomas also contain focal areas of epi- mucosa, surrounding associated lamina propria, associ- thelioid morphology that mimic carcinomas. Conversely, ated chronic inflammation and hemorrhage, lack of cyto- sarcomatoid carcinomas can be confused with sarcomas, logic atypia, and lack of desmoplastic response are helpful and may lack CK positivity. Metastatic melanoma (Figure in correctly diagnosing such cases as misplaced epithe- 2.10B) frequently has well developed epithelioid features lium rather than true invasive adenocarcinoma (see also as well. In such cases, a previous history of a cutaneous Chapter 6). pigmented lesion, less cohesive tumor cells with cytoplas- mic pigment and prominent nucleoli, and positive mela- Signet Ring Cells and Pseudo-Signet Ring Cells noma markers are all helpful. Malignant mesotheliomas (Figure 2.10C) can be composed of large epithelioid cells Signet ring cells are malignant epithelial cells found in ade- arranged in nests or pseudoglands, and are well-known nocarcinoma, and are the hallmark of signet ring cell ade- mimics of adenocarcinomas. Lymphomas of the GI tract nocarcinomas. However, several types of benign reactive (Figure 2.10D), in particular large B cell lymphomas, can cells can mimic neoplastic signet ring cells (pseudo- signet appear epithelioid but are usually dyscohesive, and a pre- ring cells), most commonly of epithelial or histiocytic vious history of lymphoma may be an important clue. origin. Table 2.5 summarizes the initial, “first-line” immuno- Malignant signet ring cells contain a large cytoplas- chemical markers that aid in distinguishing between the mic vacuole that displaces the crescent-shaped nucleus to major categories of tumors, including epithelial tumors the periphery of the cell (Figure 2.9A). In reactive pro- (carcinomas and NETs), sarcoma, melanoma, and lym- cesses such as mucosal ulceration or ischemia, degener- phoma. Table 2.6 summarizes immunohistochemical ated or sloughed mucin-containing epithelial cells may markers that are commonly used in the diagnosis of epi- mimic malignant s ignet ring cells (pseudo-signet ring cells). thelial neoplasms, as well as their most frequent uses. The Pseudo-signet ring cells are usually limited to the mucosa or utility of immunohistochemistry in the diagnosis of neo- luminal fibrinopurulent debris, although they are occasion- plasms of the GI tract will be discussed in more detail in ally seen in the lamina propria. They should lack cytologic Chapter 13. atypia and an associated desmoplastic stromal response. Common diseases associated with benign epithelial signet ring cells are pseudomembranous colitis (Figure 2.9B–C), ischemia, ulcerative colitis, gastritis, and cystic fibrosis, GENERAL APPROACH TO THE DIAGNOSIS OF among others. Pseudo-signet ring cells can also be seen in EPITHELIAL NEOPLASMS ulcerated adenomas and Peutz–Jeghers polyps. In difficult cases, immunostains for E-cadherin, p53, and Ki-67 may The general approach to the diagnosis of any epithelial neo- be used; benign epithelial pseudo- signet ring cells are usu- plasm in the GI tract begins with a review of the patient’s ally positive for E-cadherin, and negative for the latter two history, including age, gender, and previous malignancies stains (Figure 2.9D–I). However, reactive processes may or lesions such as adenomas or hamartomatous polyps. occasionally stain with proliferation markers. Radiologic and endoscopic findings can be very important Benign histiocytic cells residing in the GI tract may as well. engulf mucin, lipid, or other materials and also simulate Figure 2.11 illustrates a basic algorithmic approach to malignant signet ring cells. Examples include normal epithelial lesions of the GI tract. Initially, neoplastic lesions muciphages in the rectum (Figure 2.9J), xanthoma cells should be differentiated from a reactive or inflammatory anywhere in the GI tract (Figure 2.9K), and other foamy process, an ectopic lesion (eg, ectopic pancreas), or a ham- histiocytes. Immunostains for histiocyte markers such artomatous lesion (such as Peutz–Jeghers or juvenile pol- as CD68 and CK are positive and negative in histiocytes yps). The morphologic features, together with history, site, respectively, with malignant signet ring cells showing the and background histologic findings are very helpful in this opposite staining pattern. initial determination. Once an epithelial neoplasm is con- firmed, attention should be focused on whether it is benign or malignant. Malignant neoplasms in the GI tract can be DIFFERENTIAL DIAGNOSIS OF primary, but the possibility of metastatic disease should be EPITHELIAL NEOPLASMS always considered (see section on primary versus meta- static epithelial malignancy). If a primary tumor is diag- Most epithelial neoplasms have an epithelioid morphol- nosed in a resection specimen, it must then be graded and ogy; however, many neoplasms in the GI tract with staged (see Chapters 7–12 for more details). If the tumor 2 8 Neoplastic Gastrointestinal Pathology: An Illustrated Guide (A) (B) (C) (D) (E) (F) FIGURE 2.9 (continued) 2 Approach to Epithelial Neoplasms of the Gastrointestinal Tract 2 9 (G) (H) (I) (J) (K) FIGURE 2.9 Signet ring cells within a colonic adenocarcinoma, showing infiltrative atypical cells with signet- shaped nuclei that are displaced by cytoplasmic vacuoles (A). Degenerating mucin-containing epithelial cells in pseudomembranous colitis mimicking signet ring cells (B–C). Epithelial pseudo-signet ring cells in a case of ischemic colitis are positive for E-cadherin (D), but negative for Ki-67 (E) and p53 (F). In contrast, neoplastic signet ring cells are negative for E-cadherin (G), and positive for Ki-67 (H) and p53 (I). Benign foamy macrophages including muciphages (J) and xanthoma cells (K) resemble signet ring cells, but have round, bland-appearing nuclei. 3 0 Neoplastic Gastrointestinal Pathology: An Illustrated Guide (A) (B) (C) (D) FIGURE 2.10 Common epithelioid neoplasms that involve the GI tract, but are not epithelial in origin, include epithelioid gastrointestinal stromal tumor (GIST) (A), metastatic melanoma (B), malignant mesothelioma (C), and diffuse large B cell lymphoma (D). TABLE 2.5 Basic Panel of Immunohistochemical Stains Useful in the Differential Diagnosis of Epithelioid Neoplasms Carcinoma NET Sarcoma Melanoma Lymphoma CKAE1/3* + + − − − CK5/6 + (SCCA) − − − − Chromogranin − + − − − Synaptophysin − + − − − S100 − −/+ + (Neural) + − Vimentin −/+ −/+ + + +/− HMB-45 − − − + − Melan A − − −/+ + − KIT/DOG1 − − + (GIST) − − CD31 − − + (Vascular) − − SMA − − + (Muscle) − − CD45 − − − − + Abbreviations: CK, cytokeratin; GIST, gastrointestinal s tromal tumor; NET, neuroendocrine tumor; SCCA, squamous cell carcinoma. *Other useful cytokeratins include high and low molecular weight cytokeratin cocktails, CAM 5.2, CK7, CK19, and CK20 depending on the site of origin. 2 Approach to Epithelial Neoplasms of the Gastrointestinal Tract 31 TABLE 2.6 Immunohistochemical Markers Useful in the Diagnosis of Gastrointestinal Epithelial Neoplasms Epithelial Marker Common Uses Most Common GI Site CK AE1/3 First-line marker Broad spectrum (squamous and nonsquamous) CK CAM 5.2/Low Molecular Weight First-line marker Broad spectrum (nonsquamous), complementary to CKAE1/3 CK (LMWK) for detecting CK18+ carcinomas, such as hepatocellular carcinoma EMA Second-line marker Broad spectrum (glandular epithelia) High Molecular Weight CK (HMWK; Second-line marker Broad spectrum, predominantly in squamous epithelia and in K903, 34βE12) basal cells CK7 Site of origin Stomach, biliary CK19 Site of origin Bile duct CK20 Site of origin Colorectal CDX2 Site of origin Intestinal SATB2 Site of origin Intestinal CK5/6 Squamous cell, mesothelium Esophagus, anorectal, mesothelium p63 Squamous cell Esophagus, anorectal Abbreviation: CK, cytokeratin; Epithelial Lesion Ectopia/Hamartoma Inflammatory/ Neoplastic Reactive - Ectopic Pancreas - Inflammation Benign/Premalignant Malignant - Peutz-Jeghers Polyps - Ulcer - Juvenile Polyps - Prolapse Primary Metastatic Grade and stage Site of Origin FIGURE 2.11 General algorithmic approach to evaluating epithelial neoplasms of the GI tract. is metastatic, the site of origin should be addressed to the investigated with immunohistochemistry and other extent that it is possible, using clinical findings, morphol- ancillary testing as necessary. For each pattern, there are ogy, and immunohistochemical panels. specific epithelial tumors that are most likely to fall into More detailed diagnostic descriptions of individual that category, as well as nonepithelial tumors that must epithelial tumors are in the organ-specific chapters that be considered in the differential diagnosis. The final diag- follow, but the following paragraphs summarize a basic nosis should, of course, correlate the results of immuno- approach to the initial evaluation of hematoxylin and histochemical panels with the clinical and morphologic eosin (H&E) stained sections of epithelial neoplasms. An findings, and basing a diagnosis on the interpretation of important initial step in tumor diagnosis is the assign- a single immunostain should be avoided. The ability to ment of a general morphologic pattern (Figure 2.12) make a diagnosis may be further limited, in many cases, to the lesion. Once the pattern is identified, a differen- by the size of the tissue sample, crush or cautery artifact, tial diagnosis is generated, which can then be further and necrosis. 3 2 Neoplastic Gastrointestinal Pathology: An Illustrated Guide Neoplasm Dyscohesive Cohesive - Melanoma - PAd* - Lymphoma - SRCC - SRBC - Undif Spindle Epithelioid - Benign mesenchymal - Sarcomatoid* - Sarcoma carcinoma - Melanoma - Mesothelioma - Undif Nested Glandular - Sarcoma - SCCA* - Melanoma - PAd - Undif - HCC - NET - Mesothelioma Pseudoglands/Acini True Glands - Acinar cell* - Adenocarcinoma* carcinoma - NET - HCC - Mesothelioma FIGURE 2.12 Algorithmic approach to general morphologic patterns in epithelioid neoplasms. *Indicates epithelial tumors Abbreviations: HCC, hepatocellular carcinoma; NET, neuroendocrine tumor; PAd, poorly differentiated adenocarcinoma; SCCA, squamous cell carcinoma; SRBC, small round blue cell tumor; SRCC, signet ring cell carcinoma; Undif, undifferentiated tumor. Many epithelial neoplasms may be divided as to their and desmoplastic small round cell tumor), and undifferen- cohesiveness, whether they have predominantly epitheli- tiated neoplasms. Tumors that are actually cohesive may oid or spindled patterns, and whether they are composed appear to be dyscohesive due to artifacts (such as that of nests, glands, signet ring cells, etc. introduced during needle biopsy or fine needle aspira- tion) or necrosis. Prior to ordering immunohistochemical stains, useful morphologic features include brown pig- Dyscohesive Tumors ment and cherry red nucleoli in melanomas, keratiniza- The most classic dyscohesive epithelial tumor is signet tion in squamous cell carcinomas, and mucin production ring cell adenocarcinoma. However, many poorly differ- in adenocarcinomas. Mucicarmine or periodic acid–Schiff entiated carcinomas can be dyscohesive as well. The dif- (PAS) with diastase histochemical stains may be useful for ferential diagnosis for dyscohesive tumors is broad, and detecting mucin, but are frequently negative or only show includes epithelial as well as nonepithelial neoplasms such very focal positivity in poorly differentiated adenocarcino- as melanoma, lymphoma, small round blue cell tumors mas. Immunohistochemical stains that are most useful for (such as Ewing sarcoma/primitive neuroectodermal tumor dyscohesive tumors include a broad spectrum CK such as 2 Approach to Epithelial Neoplasms of the Gastrointestinal Tract 3 3 AE1/3 for carcinomas, leukocyte common antigen (CD45) staining in angiosarcomas and some other epithelioid for lymphomas, and S100 for melanoma. Other markers sarcomas. Depending on the site, mesothelioma may also may be useful if a sarcoma is in the differential diagnosis, be worthy of consideration when there are positive epi- and these are discussed later in Chapters 5 and 13 as well thelial markers. CK5/6, WT-1, and calretinin positivity as in the organ-specific chapters. Additional stains may favors mesothelioma, while MOC31, BerEp4, and pCEA be necessary depending on the findings from this initial favor adenocarcinoma. One pitfall of using CK AE1/3 panel, and in the case of limited material, cutting several alone to screen for carcinomas is that some carcinomas unstained slides on the front end may avoid wasting tissue (eg, hepatocellular carcinoma) may be weak or nega- in the block if it has to be refaced. tive. However, adding CAM5.2 to a panel may comple- ment CK AE1/3 by detecting CK18, an additional low molecular weight keratin that is not present in the AE1/3 Cohesive Tumors cocktail. Cohesive tumors may be categorized further into a num- Cohesive glandular tumors can be divided into those ber of morphologic patterns, including spindle cell and composed of true glands and those that are pseudoglan- epithelioid patterns, and epithelioid lesions can be further dular or acinar. True glandular tumors are adenocarci- subdivided into nested, glandular, and pseudoglandular/ nomas, in which the glandular epithelium is lined by a acinar patterns. Some tumors show combinations of these basement membrane, forms a central lumen (true gland), patterns. and characteristically has

intracytoplasmic mucin. In Although spindled tumors are most often mesenchy- contrast, pseudoglandular/acinar tumors are composed mal in origin, carcinomas and malignant mesothelioma of nests of tumor cells that are arranged around a small can also have spindle cell features. One of the most com- lumen (acinus), central necrosis, or centrally dilated space mon spindled carcinomas of the GI tract is sarcomatoid that mimics a lumen; this pattern lacks intracytoplasmic carcinoma, which is most often seen in the esophagus and mucin. Examples of acinar/pseudoglandular epithelial pancreas. Immunohistochemical stains can be very useful neoplasms in the digestive tract include malignant meso- in distinguishing these tumors, and panels should consist thelioma, NETs, hepatocellular carcinoma, pancreatic of CK (both a broad spectrum keratin and a low molecu- solid pseudopapillary tumor, and acinar cell carcinoma. lar keratin such as CAM 5.2 may be useful), smooth mus- Immunohistochemical stains for CKs and neuroendo- cle actin, KIT, S100 (for neural and melanocytic lesions), crine markers are most helpful in this setting. If malignant and CD31 (for vascular lesions). It is important to note mesothelioma is in the differential diagnosis, the immu- that sarcomatoid carcinomas may not express CK at all nohistochemical stains discussed in the preceding para- in some cases. In addition, sarcomatoid malignant meso- graphs should be considered. thelioma and some sarcomas can express CKs, leading to possible confusion with carcinoma. Additional immu- nohistochemical stains useful in this differential will ILLUSTRATIVE EXAMPLES be further discussed in the next two paragraphs and in Chapter 13. The following three cases are presented to illustrate how Cohesive epithelial tumors that are nested and lack gland to integrate the above algorithms in the workup of an epi- formation include squamous cell carcinoma, NETs, poorly thelial lesion in the GI tract. differentiated adenocarcinoma, malignant mesothelioma, and hepatocellular carcinomas. Immunohistochemical Case 1 stains useful in differentiating between poorly differenti- ated adenocarcinoma and squamous cell carcinoma include A 32-year-old woman with a history of chronic abdomi- CK5/6, p63, and p40 for squamous cell carcinoma, and nal pain and no previous history of malignancy pre- MOC31, BerEp4, and mucicarmine for adenocarcinoma. sented with diarrhea and rectal bleeding. She was found Many benign and malignant nonepithelial lesions also can to have a submucosal rectal mass at colonoscopy. Biopsy feature a cohesive nested morphologic pattern, including of the rectal mass (Figure 2.13A) showed a few glands in granular cell tumors, paragangliomas, epithelioid sarcoma, the submucosa of colon, and thus corresponds to the cat- angiosarcoma, malignant peripheral nerve sheath tumor, egory of “epithelial lesion” in the Figure 2.11 algorithm. and GISTs. Melanomas frequently show a nested epitheli- The next step is to determine whether the lesion is inflam- oid pattern as well. matory/reactive, ectopic/hamartomatous (or another The initial immunohistochemical panel for the dif- benign lesion), or neoplastic (which, given the presence ferential diagnosis of a cohesive epithelioid tumor with of submucosal glands in this case, would be worrisome a nested pattern may include CK AE1/3, a neuroendo- for invasive adenocarcinoma). Histologic evaluation crine marker (synaptophysin, chromogranin, or CD56), using features previously described in the section deter- SMA, KIT, S100, and CD31. Beware of weak CK AE1/3 mination of malignancy and in Table 2.1 shows that the 3 4 Neoplastic Gastrointestinal Pathology: An Illustrated Guide (A) (B) (C) (D) FIGURE 2.13 A submucosal glandular proliferation with prominent eosinophilic stroma is seen on biopsy (A). The glands are composed of cuboidal epithelium with scant cytoplasm and small, regular nuclei. The surrounding stroma is composed of large eosinophilic cells (B). CK7 expression confirms that the glands are not colonic in origin (C). CD10 expression is seen in the decidualized stroma (D). lesion is somewhat circumscribed. A higher power view immunohistochemical markers may be employed. In endo- (Figure 2.13B) demonstrates benign appearing glands, metriosis, for example, glands express PAX8 and CK7 with intact cellular polarity. No nuclear atypia, mitoses, and are negative for CK20 and CDX2, whereas colonic or desmoplastic stromal reaction is noted. The lack of adenoma or adenocarcinoma typically shows the opposite prominent inflammatory cells, mucosal ulcers, or history staining pattern. In addition, estrogen receptor (ER) immu- of trauma or surgery makes an inflammatory/reactive nostain can also be helpful to highlight glands and stroma lesion less likely. In addition, large epithelioid cells with in endometriosis. abundant pink cytoplasm surround the glands, reminis- cent of decidualized endometrial stroma. Case 2 Immunostains revealed that the glandular cells are positive for CK7 (Figure 2.13C) and the stroma is posi- A 67-year-old man with no known past medical history tive for CD10, consistent with decidualized endometrial presented with nausea, vomiting, and constipation. He stroma (Figure 2.13D). The morphologic features on H&E, was found to have a complex pelvic mass with partial together with the immunohistochemical findings, are small bowel obstruction on CT scan. Small bowel biopsy diagnostic of endometriosis. In difficult cases, additional (Figure 2.14A) shows a neoplasm involving the mucosa 2 Approach to Epithelial Neoplasms of the Gastrointestinal Tract 3 5 and submucosa of the small bowel. The distinction between in the GI tract, depending on the clinical findings, mor- benign and malignant in this case is fairly straightforward, phologic features (eg, the presence of an in situ precursor since the tumor is poorly circumscribed with an invasive lesion), and site of the tumor. When necessary, the most growth pattern and a desmoplastic stromal reaction, and frequently employed immunohistochemical stain pan- thus one would begin with the “neoplastic” category in els to determine the site of origin include CK7, CK20, the Figure 2.11 algorithm. The definite site of origin is not CDX2, and SATB2 to confirm the GI tract origin. No discernible from this biopsy, however; thus the next step site of origin is characterized by an entirely distinct in the algorithm is to assess whether the malignant tumor immunophenotype, and there is significant immunophe- is a primary tumor of the small bowel or a metastasis. notypic overlap. Additional discussion on immunohisto- Morphologic features that favor a metastatic tumor in this chemical stains and the site of origin will be presented in case include the lack of an associated in situ lesion and the Chapters 7–13. fact that the majority of the tumor is present beneath the At this point, the Figure 2.12 algorithm is useful to mucosa (see also Table 2.3). elucidate the cell origin of the tumor. At the first branch As mentioned previously, the site of origin (primary point, the tumor is determined to be cohesive, and the vs. metastatic) is often an issue in glandular neoplasms cells are epithelioid and arranged in nests (Figure 2.14B). (A) (B) (C) (D) FIGURE 2.14 An epithelioid neoplasm in the small bowel, consisting of a predominantly submucosal proliferation of cells arranged in nests (A). Higher power view showing nests of epithelioid cells with small nucleoli (B). Synaptophysin expression is negative in the tumor (C). p63 immunostaining supports the diagnosis of metastatic urothelial carcinoma to the small bowel (D). 3 6 Neoplastic Gastrointestinal Pathology: An Illustrated Guide The primary differential diagnoses for a tumor with nests Case 3 of bland epithelioid cells without prominent nucleoli in the small bowel are a metastatic carcinoma or an NET. A 72-year-old man with weight loss and lethargy was Selected immunohistochemical stains show that the found to have a mass in his right colon at colonoscopy. tumor is positive for CKs AE1/3, CK7, and CK20 and Upon resection, the tumor consisted of plump spindle negative for synaptophysin (Figure 2.14C), chromogranin, cells with marked pleomorphism, arranged in a fascicu- and CDX2. Expression of both CK7 and CK20 is fre- lar pattern (Figure 2.15A). The degree of cellular pleo- quently seen in metastatic urothelial carcinoma, but is morphism and nuclear atypia in this tumor excludes also common in the peridiaphragmatic GI organs includ- benign lesions, and thus using the Figure 2.12 algorithm, ing pancreas, biliary tree, and stomach. As metastatic car- this tumor would be classified as cohesive and spindled. cinomas are far more common than primary ones in the The main entities under consideration include sarcoma, small bowel, and the immunophenotype suggested urothe- melanoma, sarcomatoid carcinoma, and sarcomatoid lial carcinoma as a diagnostic consideration, a p63 stain malignant mesothelioma. Immunohistochemical stains was performed and the positive staining (Figure 2.14D) showed that the tumor cells were positive for CK AE1/3 supported the diagnosis. Further clinical and radiographic (Figure 2.15B) and vimentin (Figure 2.15C), and negative workup revealed urothelial carcinoma of the bladder. for DOG1, KIT, CD31, SMA, and S100. The coexpression (A) (B) (C) FIGURE 2.15 Sections from the resection of a right colon mass show malignant spindle cells with marked nuclear pleomorphism (A). The tumor cells were positive with CK AE1/3 (B) and vimentin (C), supporting the diagnosis of a sarcomatoid carcinoma. 2 Approach to Epithelial Neoplasms of the Gastrointestinal Tract 37 of CK AE1/3 and vimentin suggests that the tumor is a Diagnostic Pitfalls carcinoma with sarcomatous differentiation (ie, sarco- De Petris G, Leung ST. Pseudoneoplasms of the gastrointestinal tract. matoid carcinoma). Further examination of the tumor Arch Pathol Lab Med. 2010;134:378–392. identified a small area of poorly formed glands, further Detlefsen S, Fagerberg CR, Ousager LB, et al. Histiocytic disorders of supporting the diagnosis. the gastrointestinal tract. Hum Pathol. 2013;44:683–696. Distler M, Rückert F, Aust D, et al. Pancreatic heterotopia of the duode- The preceding three cases illustrate that using an num: anatomic anomaly or clinical challenge? 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BELLIZZI INTRODUCTION HISTORICAL PERSPECTIVE The term “neuroendocrine epithelial neoplasms” (NENs) The term karzinoide (translated as carcinoid; literally encompasses both well-differentiated tumors, historically “carcinoma-like”) was introduced by the German pathol- referred to as carcinoid tumors, and poorly differentiated ogist Siegfried Oberndorfer in his 1907 seminal descrip- ones (small cell and large cell neuroendocrine carcinomas). tion of six patients with multifocal ileal tumors that These neoplasms have been variously referred to as endo- histologically resembled carcinoma, but were unique in crine (eg, in the 2000 WHO Classification) and neuroen- that they were unusually small, well-circumscribed, and docrine. The current World Health Organization (WHO) associated with a benign clinical course. Although their Classification refers to them as neuroendocrine, which function remained elusive, Rudolf Peter Heidenhain had emphasizes their dual nature. Many of these tumors’ prod- identified neuroendocrine cells in the stomach, based on ucts are distinctly neural. For example, the same serotonin their histochemical reaction with chromium salts (the produced by midgut neuroendocrine tumors (NETs) is also basis of the term enterochromaffin [EC] cell), 39 years a monoamine neurotransmitter, while the general neuroen- earlier. A year before that, Theodor Langhans had pro- docrine marker synaptophysin, a component of synaptic ves- vided the first histologic description of a carcinoid tumor. icles, is highly expressed by gray matter neuronal processes. Neuroendocrine cells in the pancreas and intestine were NENs can be characterized by three general features: subsequently described by Paul Langerhans (1869) and • Expression of the general neuroendocrine markers Nikolai Kulchitsky (1897), respectively. In 1914 Andre chromogranin A and/or synaptophysin. Gosset and Pierre Masson made the link between carci- • Production of peptide hormones and/or biogenic noid tumors and EC cells, demonstrating that each reacted amines. similarly with silver salts (the basis of the term argentaf- • Elaboration of the intermediate filament keratin. fin), and further speculating that these tumors and cells were neuroendocrine in nature. In 1929 Oberndorfer pub- Neuroendocrine neoplasms that do not make keratins lished a series of 36 additional carcinoid tumors of the (eg, pheochromocytoma/paraganglioma) and endocrine small intestine and appendix and acknowledged that some epithelial neoplasms lacking hybrid “neural” character- of these tumors were, in fact, malignant. istics (eg, thyroid follicular neoplasms, gonadal sex cord In 1931 A.J. Scholte coined the term carcinoid syn- stromal tumors) lie beyond this definition, though the drome to describe the edema, sweating, flushing, and thyroid (medullary thyroid carcinoma) and gonads (car- diarrhea in a patient found at autopsy to have a 1 cm ileal cinoid and small cell carcinoma-pulmonary type) can carcinoid tumor; the patient died of heart failure and was certainly harbor primary neoplasms showing dual neuro- also found to have a thickened tricuspid valve and right endocrine nature. Of these three overlapping tumor types atrial subendocardial fibrosis. Serotonin (5-hydroxy- (neuroendocrine/epithelial, neuroendocrine/nonepithelial, tryptamine) was isolated and characterized by Maurice and strictly endocrine/epithelial), primary tumors in the Rapport in 1948. Five years later, Vittorio Erspamer gastrointestinal (GI) tract are of the former. demonstrated that EC cells produced serotonin, and 3 9 4 0 Neoplastic Gastrointestinal Pathology: An Illustrated Guide Fred Lembeck isolated serotonin from an ileal carcinoid. Andrew Schally and Roger Guillemin are credited with the codiscovery of somatostatin, for which in part they received (along with Rosalyn Yalow) the 1977 Nobel Prize in Physiology or Medicine. In 1979 Wilfried Bauer syn- thesized the somatostatin analogue octreotide, which has become a mainstay in the treatment of NETs. Jean-Claude Reubi, S.W. Lamberts, E.P. Krenning, and colleagues demonstrated high-level expression of somatostatin recep- tors in a subset of NENs, and in 1989 published the first study of the use of radiolabeled octreotide in the imag- ing of endocrine tumors (ie, somatostatin receptor scin- tigraphy) (Figure 3.1). The late 1990s saw the first trials of radiolabeled octreotide as a therapeutic agent (ie, pep- tide receptor radionuclide therapy). More recently (2011), positive clinical trials in pancreatic NETs have introduced mTOR inhibitors and sunitinib into the therapeutic arma- (A) mentarium. At present, high-throughput DNA sequencing holds promise to unlock the molecular genetic basis of this 4 HR IN-111 OCTREOTIDE class of tumors, which will hopefully suggest new avenues for directed biologic therapy. Based on histologic, histochemical, and clinical obser- vations, E.D. Williams and M. Sandler (1963) proposed that carcinoids, rather than representing a single mono- lithic entity, could be logically divided into foregut-, midgut-, and hindgut-derived types. In 1971 Jun Soga and Kenji Tazawa introduced a histologic-pattern-based clas- sification that correlates with the site of origin and biol- ogy. The WHO first published a histologic classification of endocrine tumors in 1980, which was substantially updated in 2000. This textbook makes use of the 2010 WHO Classification of gastroenteropancreatic (GEP) NENs, introduced in the fourth edition of the WHO GI Blue Book. These classifications will be discussed in more detail in the section on classification. HORMONE PRODUCTION IN NEUROENDOCRINE NEOPLASMS Although a myriad of immunostains for hormones are commercially available, these are generally of limited clinical utility outside of the context of neuropathologic examination of pituitary adenomas (eg, prolactin, adre- nocorticotropic hormone [ACTH], growth hormone). Immunohistochemical demonstration of hormones in (B) an NEN does not equate with functionality, which is instead defined by the presence of a characteristic clini- FIGURE 3.1 Neuroendocrine neoplasms, in particular cal syndrome attributable to hormone production by well-differentiated tumors, tend to express high the tumor (eg, Whipple’s triad with insulinoma; gluca- levels of somatostatin receptors, as illustrated by this gonoma syndrome; diabetes mellitus, steatorrhea, gall- immunohistochemical stain for somatostatin receptor stones, and h ypochlorhydria with somatostatinomas; type 2A in an ileal tumor (A). This expression is the basis Zollinger–Ellison syndrome (ZES); Verner–Morrison of somatostatin receptor scintigraphy, as demonstrated syndrome, carcinoid syndrome, and Cushing syndrome). by this OctreoScan showing extensive hepatic uptake in There are occasional situations in which hormone multiple foci (B). 3 Approach to Neuroendocrine Neoplasms 41 preparation (Figure 3.3B). Cytoplasm is moderate to abun- dant and may be granular (or less commonly microvesicu- lar, vacuolated, or containing “rhabdoid” inclusions). The neuroendocrine nature of these neoplasms is usually evi- dent on hematoxylin and eosin (H&E) staining, but can be confirmed with IHC for general neuroendocrine mark- ers (Figure 3.3C). Synaptophysin and chromogranin A are favored over CD56 and neuron-specific enolase (NSE), due to lack of specificity of the latter. The biology of NETs var- ies widely, ranging from entirely benign, to indolent and generally nonprogressive, to metastatic with long-term sur- vival, to metastatic and rapidly fatal. Improved prognosti- cation is an area of ongoing research. To this end, the past several years have seen the introduction of a new grading system for NETs based on mitotic rate and Ki-67 prolifera- tion index, and the American Joint Committee on Cancer (AJCC) has published, for the first time, an NET staging FIGURE 3.2 This patient presented with Whipple’s triad system (Figure 3.3D). and was found to have an insulinoma, as demonstrated by the diffuse, strong staining in the tumor and adjacent islets (insulin immunoperoxidase stain). The patient GENERAL FEATURES OF subsequently was diagnosed with a bronchopulmonary neuroendocrine tumor that did not express insulin, and NEUROENDOCRINE CARCINOMAS thus likely represented a new primary. Poorly differentiated NENs are referred to as neuroendo- crine carcinomas (NECs) in the WHO 2010 Classification. NEC encompasses small cell and large cell neuroendocrine immunohistochemistry (IHC) may be useful, however. carcinomas (as well as mixed small and large cell carci- Combined expression of insulin, glucagon, and soma- nomas). Small cell neuroendocrine carcinoma (SCNEC) tostatin favors islet hyperplasia over a pancreatic NET, typically demonstrates a diffuse growth pattern, although which is more likely to express a dominant hormone. In it may show some evidence of organoid architecture patients with a functional syndrome and multiple tumors (eg, peripheral palisading of nuclei or rosette forma- (eg, as often occurs in combined multiple endocrine neo- tion) (Figure 3.4A). Tumor cells are “small” (up to three plasia type 1 Zollinger-Ellison syndrome), hormone IHC times the diameter of a resting lymphocyte) with scant may be useful in identifying which tumor is responsible cytoplasm, finely (or sometimes coarsely) granular chro- for the syndrome. Finally, in a patient with a tumor matin, inconspicuous to absent nucleoli, and a tendency known to express a dominant hormone presenting with a for nuclear molding (Figure 3.4B). Mitotic activity and new tumor, hormone IHC can be useful in distinguishing necrosis are conspicuous. Encrustation of vessels by baso- a metastasis from a separate primary (Figure 3.2). philic material representing tumor DNA may be seen in up to a third of cases (referred to as the Azzopardi effect). SCNEC is often an “H&E diagnosis,” though the diagno- GENERAL FEATURES OF WELL- sis can be supported with IHC for general neuroendocrine DIFFERENTIATED NEUROENDOCRINE markers. In addition, tumors may show dot-like expres- TUMORS sion of broad-spectrum keratins, and TTF-1 is frequently expressed, regardless of the site of origin (Figures 3.4C–D). Well-differentiated NENs (formerly known as carcinoid Compared to SCNEC, large cell neuroendocrine tumors in the tubular gut or islet cell tumors in the pan- carcinoma (LCNEC) is more likely to demonstrate a creas) are referred to as NETs in the contemporary WHO “neuroendocrine” or organoid growth pattern and is (2010) Classification. They are characterized by a variety characterized by larger cell size, more voluminous cyto- of growth patterns, including nested, trabecular, gyriform, plasm, variable nuclear chromatin, and, typically, promi- glandular, tubuloacinar, pseudorosette-forming, solid, and nent nucleoli (Figure 3.5A–B). It is similarly mitotically mixed, which are collectively referred to as “organoid” active and prone to extensive necrosis. Because of substan- (Figure 3.3A). The nuclear chromatin is typically granu- tial morphologic overlap with non-neuroendocrine large lar, often referred to as “salt and pepper,” and nucleoli are cell undifferentiated carcinoma, the diagnosis formally generally inconspicuous, although there is variation from requires demonstration of a neuroendocrine immuno- case to case depending on the quality of the histologic phenotype (Figure 3.5C–D). LCNEC stains similarly to 42 Neoplastic Gastrointestinal Pathology: An Illustrated Guide (A) (B) (C) (D) FIGURE 3.3 The trabecular pattern seen in this rectal NET exemplifies organoid architecture (A). NETs typically have a “salt-and-pepper” nuclear chromatin pattern and inconspicuous nucleoli. Note also the occasional large nucleus at the upper left, as well as an adjacent mitotic figure (B). NETs express general neuroendocrine markers, as illustrated by this synaptophysin IHC stain (C). In the WHO 2010 system, neuroendocrine tumors are graded based on mitotic rate and Ki-67 proliferation index. This appendiceal tumor has a low proliferation index at 3.2% (D). SCNEC, though it is less likely to express TTF-1. Some reporting. Based on data from Surveillance, Epidemiology, tumors demonstrate mixed small cell and large cell mor- and End Results (SEER) registries, the annual age- phology and in others, tumor cells are neither small nor adjusted incidence has increased from 1.09/100,000 in large. In this latter group, the designation “neuroendo- 1973 to 5.25/100,000 in 2004. By comparison, the age- crine carcinoma with ‘intermediate cell’ morphology” adjusted incidence of colon cancer for 2007 to 2011 was may be used. Regardless of morphologic subtype or site of 43.7/100,000. Although these lesions are relatively uncom- origin, NECs are highly aggressive tumors. mon, because NETs are generally indolent, they are fairly prevalent. Based again on SEER data, Yao and colleagues estimated the 29-year-limited duration prevalence of EPIDEMIOLOGY NETs at 103,312 (35/100,000). This number refers to the number of people alive on a given date diagnosed with an NETs are uncommon but not rare, and their incidence is NET anytime in the preceding 29 years. This far exceeds rising, due at least in part to increased recognition and the 29-year-limited duration prevalence of gastric cancer 3 Approach to Neuroendocrine Neoplasms 4 3 (A) (B) (C) (D) FIGURE 3.4 Small cell NECs are composed of small oval- to spindle-shaped cells with a very high nucleus: cytoplasm (N:C) ratio and a diffuse growth pattern; tumor necrosis is evident at the upper

right (A). Tumor cells have fine chromatin, inconspicuous nucleoli, and demonstrate nuclear molding (B). Dot-like keratin expression may be seen (C). TTF-1 expression is usually seen in lung primaries but is also frequently seen in extrapulmonary visceral NECs (D). (66K), pancreatic cancer (32K), and esophageal cancer patients with rectal tumors (median age 56), which tend (29K). Two thirds to three quarters of NETs arise in the to be incidentally detected at screening colonoscopy, and gastro-entero-pancreatic system, although the single most appendiceal tumors (median age 47), which tend to be frequently involved organ is the lung (25%–33%). In the incidentally detected in association with acute appendi- GI tract, tumors present in the following organs in order citis, are identified significantly earlier. Overall, 40% of of decreasing frequency: rectum, jejunoileum, pancreas, disease is localized, 19% is regional, and 21% is distantly stomach, duodenum, and appendix. Because the SEER reg- metastatic at presentation. Again, localized disease may be istries only capture “malignant” cases, rectal and appen- underreported to SEER, and practitioners at cancer centers diceal tumors, in particular, are likely underrepresented. will encounter more metastatic disease. The site of origin The male to female ratio is 1.1:1, although it varies is strongly correlated with biologic potential in NETs. For from site to site (eg, 1.4:1 in both jejunoileum and pancreas; example, while only 5% of rectal tumors are associated 0.9:1 in lung, stomach, and appendix). The median age with distant metastasis at presentation and the median sur- at presentation is 63 for both men and women, although vival is 240 months, those figures for pancreatic tumors 4 4 Neoplastic Gastrointestinal Pathology: An Illustrated Guide (A) (B) (C) (D) FIGURE 3.5 Compared to small cell NEC, large cell tumors are more likely to demonstrate organoid architecture (A). Tumor cells are larger with moderate amounts of cytoplasm and readily identifiable nucleoli (B). Convincing expression of at least one general neuroendocrine marker is required for the diagnosis, as illustrated here by chromogranin A (C) and synaptophysin (D) IHC. are 64% and 42 months. Additional details regarding rela- for patients with extensive-stage extrapulmonary visceral tive frequency, percentage of patients presenting with dis- NEC is similar to that for lung (median survival for lim- tant metastasis, and median survival for NETs stratified by ited-stage and extensive-stage disease of 16–24 months and the site of origin are provided in Table 3.1. 6–12 months, respectively), while median survival may be Extrapulmonary NECs are uncommon, with the slightly better for limited-stage disease (up to 43 months). annual incidence of Merkel cell carcinoma estimated at 1,600 and visceral extrapulmonary NEC at 1,000. Up to CLASSIFICATION OF a quarter of extrapulmonary visceral NECs arise in the GI NEUROENDOCRINE NEOPLASMS tract. Twenty-five percent to fifty percent of GI primaries arise in association with a non-neuroendocrine compo- Williams and Sandler Classifi cation nent, and an associated squamous or columnar dysplasia may be identified, regardless of the presence of a non-neu- Carcinoid tumors were originally described in the small roendocrine carcinoma (Figure 3.6A–B). The prognosis intestine, though it was subsequently discovered that 3 Approach to Neuroendocrine Neoplasms 4 5 TABLE 3.1 Site of Origin and Outcome in 35,825 suggested that these tumors could be classified based on Neuroendocrine Tumors From the Surveillance, embryologic origin: foregut, midgut, or hindgut. Typical Epidemiology, and End Results Registry (1973–2004) jejunoileal tumors, with nested architecture, a posi- tive argentaffin reaction, high serotonin content, and a Median propensity to give rise to the carcinoid syndrome are of Distant Survival Site of origin Frequency (%)* Metastasis (%) (Months) midgut origin. Foregut tumors include pulmonary, gas- tric, duodenal, and pancreatic primaries. These are more Foregut likely to show trabecular or mixed growth patterns, a negative argentaffin reaction, low serotonin content, Lung 27 28 193 and, with the exception of lung primaries, are unlikely Thymus 0.4 31 77 Stomach 6.0 15 124 to give rise to carcinoid syndrome. Hindgut tumors are Duodenum 3.8 9 99 nearly all rectal in origin. They tend to demonstrate tra- Pancreas 6.4 64 42 becular growth, produce a negative argentaffin reaction, Liver 0.8 28 23 have low serotonin content, and do not result in carci- Midgut noid syndrome. Jejunum/Ileum 13 30 88 Soga and Tazawa Classifi cation Appendix 3.0 12 NR Cecum 3.2 44 83 J. Soga and K. Tazawa (1971) proposed that carcinoid Colon 4.0 32 121 tumors could be classified based on their predominant histologic patterns (see Table 3.2 and Figure 3.7A–E). Hindgut They found that these histologic patterns correlated with Rectum 17 5 240 the site of origin, and thus, their classification scheme supplements that of Williams and Sandler. Midgut tumors Other/Unknown Primary 15 NA NS nearly always had a predominant nested growth pattern (type A), and were occasionally mixed, in which the sec- Source: Yao JC, et al. One hundred years after “carcinoid”: epidemiology of ondary growth pattern was apt to be pseudoglandular and prognostic factors in neuroendocrine tumors in 35,825 cases in the United States. J Clin Oncol. 2008;26(18):3063–3072. (type C). The most frequent predominant pattern in fore- Note: *data in this column based on years 2000–2004; NA, not applicable; NR, gut-derived tumors was trabecular or ribbon-like (type B), not reached; NS, not stated. though half of the tumors showed mixed patterns. They reported a predominance of mixed patterns in hindgut similar tumors arose in the lung and throughout the tumors, though in subsequent reports, and in our experi- tubal gut. E.D. Williams and M. Sandler (1963), based ence, rectal NETs typically demonstrate an anastomosing on histologic, biochemical, and clinical observations, trabecular pattern. (A) (B) FIGURE 3.6 Small cell NEC arising in association with Barrett esophagus with low-grade dysplasia (A). “Intermediate cell” NEC arising in association with a gastric adenoma (B). 4 6 Neoplastic Gastrointestinal Pathology: An Illustrated Guide TABLE 3.2 Soga and Tazawa Classification proliferation index, with the criteria differing slightly from site to site. While we have observed strong sup- Type Description Comment(s) port and use of the 2010 classification, the WHO 2000 Classification was not widely embraced by U.S. patholo- A Nested Typical of midgut tumors gists, and has been criticized for several reasons includ- B Trabecular Typical of rectal tumors C Pseudoglandular Characteristic of periampullary ing complexity, inclusion of features typically used to somatostatin-producing tumors; assign stage (local anatomic extent, gross local invasion, also common as a secondary metastasis), and lack of comfort with the “benign behav- pattern in midgut tumors ior” category. This final criticism has been supported by D Diffuse Prognostically adverse Mixed Any combination Common outside of the midgut and the recognition that, on occasion, even small NETs may of the above- rectum metastasize (see the following discussion of jejunoileal mentioned four tumors). Of note, the gastro-entero-pancreatic neuroen- patterns docrine neoplasia classification is entirely different from the 2004 WHO Classification of Tumours of the Lung, Pleura, Thymus, and Heart. WHO 2010 CLASSIFICATION OF GASTROENTEROPANCREATIC FEATURES OF NEUROENDOCRINE TUMORS NEUROENDOCRINE EPITHELIAL NEOPLASMS BY ANATOMIC SITE As discussed in the preceding paragraphs, in the 2010 Esophagus WHO Classification of gastro-entero-pancreatic neuro- Esophageal NETs are rare, representing 0.06% (n = 6) of endocrine neoplasms, well-differentiated neoplasms are 13,175 “carcinoid” tumors reported to SEER registries classified as “neuroendocrine tumors,” while poorly dif- from 1973 to 1999. They have been described arising de ferentiated examples are referred to as “neuroendocrine novo or in association with an invasive adenocarcinoma. carcinomas.” NETs are further stratified into G1 and G2 based on mitotic rate and/or Ki-67 proliferation index. NECs are by definition G3 (see Table 3.3). Up to 40% of Stomach NETs that appear G1 by mitotic count are found to be Gastric NETs arise in three distinctive clinical settings, G2 based on Ki-67 IHC, while up to a third of tumors with implications for prognosis and management (sum- that are G2 by mitotic count have proliferation indices marized in Table 3.5). Type I tumors, representing 70% greater than 20%, upgrading them to G3 (see Table 3.4). to 80%, arise in autoimmune atrophic gastritis. Type II This data highlights the importance of performing Ki-67 tumors (5%–10%) arise in combined MEN1–ZES. Type IHC in all morphologically well-differentiated NENs, III tumors (20%–25%) arise sporadically. Type I and II even those found to be G2 by mitotic count. For these tumors are found in the gastric body, are typically con- grade-discrepant cases, the WHO recommends assign- fined to the mucosa or submucosa, and have a tendency ing the higher grade. This classification scheme also to be multifocal (Figure 3.9A–B). They are composed contains the category “mixed adenoneuroendocrine car- of enterochromaffin-like (ECL) cells (ie, histamine- cinoma” (MANEC), defined as a mixed tumor with at producing) and are driven by hypergastrinemia. Patients least 30% of each component. Most MANECs consist with small type I and II tumors may be managed with of NEC with a coexistent component of adenocarcinoma endoscopic removal and surveillance, while patients with (Figure 3.8A–E). The WHO specifically states that ade- type II tumors additionally benefit from removal of the nocarcinomas in which scattered neuroendocrine cells gastrinoma, in which case their NET(s) may spontane- are identified immunohistochemically (reported in up to ously regress. Hypergastrinemia-driven tumors, especially 40% of cases) are not considered to be MANECs. type I, are indolent. In a series of 193 gastric NETs, there The 2010 WHO Classification supplants the WHO were no tumor-related deaths in 152 type I tumors and 1 2000 Classification, in which well-differentiated tumors (8%) in 12 type II tumors. were classified as well-differentiated endocrine tumor Type III tumors are nearly always solitary and may (WDET) or well-differentiated endocrine carcinoma arise anywhere in the stomach. They, too, are generally (WDEC) based on the absence or presence of gross local composed of ECL-cells, although approximately 25% are invasion or metastasis. WDETs were further stratified composed of alternative cell types (eg, gastrin, somatosta- into “benign behavior” or “uncertain behavior” based tin, or serotonin-producing). Type III tumors are inherently on a combination of angioinvasion, perineural invasion, aggressive. They tend to invade the muscularis propria local anatomic extent, size, mitotic count, and Ki-67 or beyond and demonstrate frequent lymphovascular 3 Approach to Neuroendocrine Neoplasms 47 (A) (B) (C) (D) (E) FIGURE 3.7 These pancreatic NENs illustrate the types of tumors within the Soga and Tazawa classification: Type A, nested (A); type B, trabecular (B); type C, pseudoglandular (C); and type D, diffuse (D). This tumor has mixed types A and C, as well as spindle cell morphology (E). All of these tumors except for “D” are well-differentiated. 4 8 Neoplastic Gastrointestinal Pathology: An Illustrated Guide TABLE 3.3 Grading of Gastroenteropancreatic Neuroendocrine Epithelial Neoplasms—Comparison of World Health Organization 2010 and 2000 Systems WHO 2010 Category Defined by Neuroendocrine tumor (NET) G1 • Well-differentiated histology • <2 mitotic figures per 10 high-power fields (HPFs) and/or • Ki-67 proliferation index ≤2% Neuroendocrine tumor (NET) G2 • Well-differentiated histology • 2–20 mitotic figures per 10 HPF and/or • Ki-67 proliferation index 3%–20% Neuroendocrine carcinoma (NEC) G3 • Poorly differentiated histology • >20 mitotic figures per 10 HPF and/or • Ki-67 proliferation index >20% Mixed adenoneuroendocrine carcinoma (MANEC) • Mixed tumor with at least 30% of each component WHO 2000 Category Defined by Well-differentiated endocrine tumor (WDET)* • Well-differentiated histology • No gross local invasion or metastasis Well-differentiated endocrine carcinoma (WDEC) • Well-differentiated histology • Gross local invasion and/or metastasis Poorly differentiated endocrine carcinoma (PDEC)/small cell • Poorly differentiated histology carcinoma Mixed exocrine–endocrine carcinoma (MEEC) • Mixed tumor with endocrine component comprising at least 1/3 Note: *WDETs were further divided into “benign behavior” and “uncertain behavior” based on features including angioinvasion, perineural invasion, local anatomic extent, size, mitotic count, and Ki-67 proliferation index with criteria differing slightly based on primary site; for example, for pancreas “benign behavior” = nonangioinvasive, <2 cm, ≤2 mitotic figures and ≤2% Ki-67 positive cells per 10 HPF and “uncertain behavior” = 1 or more of the following: ≥2 cm, >2 mitotic figures per 10 HPF, >2% Ki-67 positive cells per 10 HPF, and angioinvasive. TABLE 3.4 Grade Discordance in Neuroendocrine Tumors Based on Mitotic Rate Versus Ki-67 Proliferation Index Ki-67 Proliferation Ki-67 Proliferation Ki-67 Proliferation Mitotic Figures per 10 HPF Index ≤ 2% Index 2%–20% Index > 20% <2 (n = 41) 25 (61%) 16 (39%) None 2–20 (n = 13) None 9 (69%) 4 (31%) Source: Rege TA, King EE, Barletta JA, Bellizzi AM. Ki-67 proliferation index in pancreatic endocrine tumors: comparison

with mitotic count, interobserver variability, and impact on grading. Mod Pathol. 2011;24(1S):372A. invasion (Figure 3.9C–D). They are managed with gas- Duodenum trectomy and regional lymph node dissection. In the series of 193 tumors mentioned in the preceding paragraph, While the vast majority of duodenal NETs (90% or above) 7 (26%) of 27 type III tumors resulted in tumor-related arise sporadically, they may also arise in association with deaths. MEN1 or neurofibromatosis type 1 (NF1). The biology In the stomach, intramucosal tumors greater than of sporadic duodenal tumors appears to be somewhat less 500 μm and submucosally invasive tumors are classi- aggressive than sporadic gastric tumors. Tumors tend to fied as NETs, while lesions measuring 150 to 500 μm be small and superficial, and those less than 1 to 2 cm are termed neuroendocrine dysplasias, and those less may be managed endoscopically, while larger tumors or than 150 μm classified as hyperplasias. The distinction those with evident lymph node metastases require sur- of these seems arbitrary, and lesions as small as 200 μm gical resection. Duodenal NETs demonstrate the entire have been shown to be neoplastic based on molecular range of organoid architectural patterns, and tumors studies. are often “mixed.” Peptide hormones can be detected in 3 Approach to Neuroendocrine Neoplasms 4 9 (A) (B) (C) (D) (E) FIGURE 3.8 Neuroendocrine carcinoma arising in association with a rectal adenoma/adenocarcinoma (A). The neuroendocrine component expresses synaptophysin diffusely and strongly (B). Higher power view demonstrating the juxtaposition of an adenoma (top left) with the neuroendocrine carcinoma (C). This right colon cancer arose in association with a tubulovillous adenoma (D). Synaptophysin is expressed by more than 30% of tumor cells (E). 5 0 Neoplastic Gastrointestinal Pathology: An Illustrated Guide TABLE 3.5 Clinicopathologic Types of Gastric Neuroendocrine Tumors Type Disease Association Relative Frequency Focality Biology I Autoimmune atrophic gastritis 70%–80% of gastric NETs Multifocal Indolent II Combined 5%–10% Multifocal Intermediate MEN1–ZES III None (sporadic) 20%–25% Unifocal Aggressive (A) (B) (C) (D) FIGURE 3.9 This patient underwent gastrectomy for approximately 50 neuroendocrine tumors arising in the context of autoimmune atrophic gastritis (type I). Note the nodularity, erythema, and decreased rugae in the gastric body (A). A representative section of the NEN from this patient also shows adjacent pancreatic acinar (P), intestinal (I), and antral/ pyloric (A) metaplasia (B). Gross photograph of a transmurally invasive gastric tumor arising sporadically (type III) (C). The tumor has invaded beyond the muscularis propria into the subserosa (dashed line highlights this boundary); perineural (*) and lymphovascular invasion (arrow) are evident (D). 3 Approach to Neuroendocrine Neoplasms 51 more than 95%, including serotonin (40%), somatosta- ganglion cells may be singly dispersed or form clusters. In tin (50%), and gastrin (60%), but expression is only very the largest published series of 51 cases, 49 occurred in the rarely associated with a functional syndrome, and thus duodenum and all behaved in a benign fashion. Tumors peptide-hormone IHC is not routinely recommended. may rarely metastasize to regional lymph nodes, and even Twenty to sixty percent of MEN1 patients are found to more rarely to distant sites, but even in these settings, the have multiple duodenal gastrinomas, which are typically clinical course may be indolent. This entity is discussed in quite small (up to 0.5 cm) and difficult to identify, even greater detail in Chapters 5 and 9. in a resection specimen. As discussed in the preceding section, these may be associated with ECL-cell tumors Jejunum and Ileum in the stomach. Patients with MEN1 may also manifest multiple gastrin and/or somatostatin-expressing neuroen- Jejunoileal NETs are among the most aggressive, with docrine hyperplasias (see previous definition) and small a median survival of 88 months. In the Armed Forces NETs in the duodenum, and multiple glucagon/pancre- Institute of Pathology (AFIP) series of jejunoileal tumors, atic polypeptide-expressing neuroendocrine hyperplasias the proportion of patients presenting with localized, and microadenomas in the pancreas. Again, the distinc- regional, and distant metastatic disease was approxi- tion between these terms seems arbitrary, as lesions as mately equal. Seventy-seven percent of 159 tumors small as 200 μm have been shown to be neoplastic based invaded beyond the muscularis propria, and small tumors on loss of heterozygosity for MEN1. were frequently metastatic. For example, 17% of sub- One percent of NF1 patients manifest somatostatin- mucosal tumors involved regional lymph nodes (without producing tumors. These characteristically demonstrate distant metastasis), while 25% were associated with dis- type C histology and psammomatous calcifications, and tant metastasis; 21% of tumors less than 1 cm involved are present at the ampulla (Figure 3.10A–B). Similar tumors regional lymph nodes (without distant metastasis), as did are also seen sporadically, and thus, although the so-called 29% of tumors 1 to 2 cm; 29% of 1 to 2 cm tumors were “psammomatous somatostatinoma” should prompt con- associated with distant metastasis. sideration of NF1, it is not an NF1-defining lesion. The ratio of ileal to jejunal tumors is 6.5:1. Rarely, One final distinctive tumor in this area is worthy morphologically and biologically similar tumors are of mention. Gangliocytic paraganglioma demonstrates detected in a Meckel’s diverticulum. Twenty-five percent triphasic histology with neuroendocrine, spindle cell of jejunoileal NETs are multiple (Figure 3.12A). Whereas (Schwann cells and axons), and ganglion cell compo- multiple NETs in the pancreas suggest a hereditary can- nents, present in variable proportions (Figure 3.11). The cer predisposition syndrome (especially MEN1), the same (A) (B) FIGURE 3.10 Somatostatin-expressing NETs may arise sporadically or in association with neurofibromatosis type I. They typically arise around the ampulla, demonstrate type C growth, and have intraluminal calcifications; given this growth pattern, it may be mistaken for adenocarcinoma (A). Somatostatin expression is demonstrated by immunohistochemistry (B). 5 2 Neoplastic Gastrointestinal Pathology: An Illustrated Guide for acute appendicitis (Figure 3.13A). According to SEER data, about one-third are not localized at the time of diag- nosis. While most of these tumors pursue a benign clinical course, it is important for pathologists to recognize and report characteristics associated with increased aggressive- ness, particularly tumor size greater than 2 cm. Moreover, the North American Neuroendocrine Tumor Society (NANETS) recommends right hemicolectomy in patients with an appendiceal NET found to exhibit one or more of the features listed in Table 3.6. Most appendiceal NETs are composed of sero- tonin-producing EC cells, similar to jejunoileal tumors (Figure 3.13B). They typically have type A predominant or mixed architectural patterns. Ten to twenty percent of tumors are composed of L cells (g lucagon-like peptide- 1-producing); many of these have either tubular or tubu- lar and trabecular architecture and have been referred to FIGURE 3.11 Gangliocytic paragangliomas have as “tubular carcinoids” (Figure 3.13C–D). Given their triphasic histology with neuroendocrine, spindle cell, and growth pattern and the fact that they often do not express ganglion cell components. This tumor type typically arises chromogranin A (although they do express synaptophy- in a periampullary location. sin), tubular carcinoids may be mistaken for adenocarci- noma. Tubular carcinoids are typically minute and pursue a benign clinical course. Occasional appendiceal NETs show cytoplasmic microvesicular change and/or vacuoliza- does not hold true at this anatomic site. Jejunoileal NETs tion (Figure 3.13E). These tumors are referred to as clear are not associated with a known cancer syndrome, though cell NETs, and this appears to represent a degenerative up to 5% of patients have a first-degree relative with the phenomenon in otherwise typical EC-cell tumors. Clear same tumor type. The presence of multifocal disease may cell NETs express general neuroendocrine markers, but do be prognostically adverse, though in the AFIP series this not express mucins (Figure 3.13F). did not remain significant in a multivariate analysis. Goblet cell carcinoid is an unusual tumor that is virtu- Greater than 90% of these tumors demonstrate the ally restricted to the appendix. It demonstrates circumfer- type A (nested) growth pattern histologically, sometimes ential appendiceal involvement and appears to “drop off” mixed with type C (pseudoglandular) (Figure 3.12B). the crypt bases, without an overlying in situ component The cytoplasm is typically replete with eosinophilic (Figure 3.14A). Histologically, the tumor invades as small granules containing serotonin, which is immunohisto- crypts composed of mixtures of relatively bland goblet, chemically detectable in approximately 90% of tumors enteroendocrine, and Paneth cells, recapitulating the (Figure 3.12C). Tumors with high serotonin content reduce crypts of Lieberkühn (thus one of the alternative designa- silver salts to metallic silver (the basis of the argentaffin tions “crypt cell carcinoma”) (Figure 3.14B). In the WHO reaction), which was used in the pre-IHC era to support a 2010 Classification, goblet cell carcinoids and adenocar- diagnosis of carcinoid tumor. Serotonin is responsible for cinomas (including signet ring cell and poorly differenti- the “carcinoid syndrome,” which is only seen in 5% of ated types) arising in goblet cell carcinoids are considered patients with jejunoileal NETs in the AFIP series (in the mixed adenoneuroendocrine tumors although their classi- setting of large volume hepatic disease). More frequently, fication as such is not universally accepted. These tumors patients present with obstruction, abdominal pain, or must be distinguished from appendiceal involvement by GI bleeding. Serotonin (and/or related peptides) induces metastatic adenocarcinoma; the characteristic circumfer- fibroelastosis, and segments of small intestine contain- ential growth pattern and invasion as identifiable crypts ing transmural invasion by tumor are often “kinked,” suggest the diagnosis. These tumors are tumor, node, while mesenteric vessels frequently demonstrate elastosis, metastasis (TNM)-staged and are generally managed as an underrecognized cause of intestinal ischemia in these adenocarcinomas. patients (Figure 3.12D–E). Colorectum Appendix The vast majority of colorectal NETs involve the rectum. Appendiceal NETs tend to involve the appendiceal tip, and In the AFIP series of 84 colonic tumors, 81 involved the often present incidentally at the time of appendectomy rectum and 3 the distal sigmoid. Tumors are typically 3 Approach to Neuroendocrine Neoplasms 5 3 (A) (B) (C) (D) (E) FIGURE 3.12 Twenty-five percent of jejunoileal tumors are multifocal (A) as shown in this resection specimen containing multiple white-tan nodules (arrows). Type A growth predominates in jejunoileal neuroendocrine tumors, but is sometimes mixed with type C, as in this example; note also the dense eosinophilic cytoplasmic granularity (B). Higher power of another tumor demonstrates cytoplasmic granularity (C). Transmurally invasive tumors tend to “kink” segments of intestine, leading to obstruction (D). Mesenteric vascular elastosis is common; note especially the marked adventitial elastosis (E, arrows). 5 4 Neoplastic Gastrointestinal Pathology: An Illustrated Guide (A) (B) (C) (D) (E) (F) FIGURE 3.13 Appendiceal neuroendocrine tumors are typically incidentally discovered in the appendiceal tip at the time of appendectomy for acute appendicitis (A). Most tumors are composed of EC cells, similar to jejunoileal primaries (B). Occasional tumors are composed of L cells, which may demonstrate trabecular (C) or tubular architecture (D). Clear cell FchIGanUgReE m 3a.1y3 m anifest as cytoplasmic vacuolization or microvesiculation (E). This appears to represent a degenerative change in otherwise typical EC-cell tumors. The clear cell change is due to cytoplasmic lipid accumulation, and mucin stains, like this alcian blue, are negative (F). 3 Approach to Neuroendocrine Neoplasms 5 5 incidentally discovered, small, and benign. In the SEER database of 4,701 tumors (1973–2004), the median size was 0.6 cm, and 4% and 2.4% of patients presented with regional and distant metastatic disease, respectively. Similarly, in the AFIP series, 3.6% of patients presented with lymph node metastases. Surgical series have iden- tified size greater than 1 cm and lymphovascular inva- sion as features associated with aggressive behavior, and patients with these features may undergo resection with lymph node dissection. Histologically, rectal NETs typi- cally demonstrate type B (trabecular) growth, are com- posed of L cells, and may fail to stain for chromogranin A (Figure 3.15A–B). Ninety percent express prostatic acid phosphatase, and as such, they may be mistaken for locally advanced prostate cancer in small, crushed biopsies. (A) CLINICAL SIGNIFICANCE OF RECOGNIZING NEUROENDOCRINE EPITHELIAL NEOPLASMS The correct diagnosis of NET has prognostic and ther- apeutic significance, relative to the diagnosis of non- neuroendocrine tumors. For example, multiple small NETs arising in a background of autoimmune atrophic gastritis and small, solitary tumors in the duodenum or rectum may be managed endoscopically, whereas similarly sized adenocarcinomas at these anatomic locations might result in a resection. Patients with resected NETs meta- static to regional lymph nodes have not been shown to benefit from adjuvant chemotherapy, while such therapy is the norm in colorectal adenocarcinoma. In patients pre- (B) senting with extensive hepatic metastases, a

diagnosis of non-neuroendocrine carcinoma is considered incurable FIGURE 3.14 Goblet cell carcinoids invade disease, and patients receive palliative chemotherapy. In circumferentially (A). They are composed of crypt- like structures with an admixture of bland goblet and NET, patients with less than “diffuse, multifocal liver enteroendocrine cells (B). metastases” may be offered surgery with curative intent. Complete resection (R0/R1) is associated with a 5-year survival of 60% to 80%, double that of patients whose liver metastases are not resected. Although it is recog- TABLE 3.6 NANETS Recommendations for Right Hemicolectomy in Appendiceal Neuroendocrine Tumors nized that this benefit may in part reflect a selection bias, it is clinically significant nonetheless. Patients in whom Tumor size > 2 cm (or if size cannot be determined) hepatic disease is unresectable may still be candidates for Tumor location in base of appendix tumor ablation, especially in the face of a functional syn- Positive margins on appendectomy Lymphovascular invasion drome. The associated primary tumors, especially jejuno- Mesoappendiceal invasion ileal ones, may also be resected to prevent complications G2 (and goblet cell carcinoid) including obstruction and ischemia. Gross mesenteric nodal involvement NECs often present with distant metastases, in which case the chemotherapy (a platinum-based agent and eto- Source: Boudreaux JP, Klimstra DS, Hassan MM, Woltering EA, Jensen RT, Goldsmith SJ, Nutting C, Bushnell DL, Caplin ME, Yao JC; North American poside) is the same regardless of the site of origin. Patients Neuroendocrine Tumor Society (NANETS). The NANETS consensus guideline with extrapulmonary visceral NECs with locoregional for the diagnosis and management of neuroendocrine tumors: well-differen- tiated neuroendocrine tumors of the jejunum, ileum, appendix, and cecum. disease may undergo resection and then receive adjuvant Neuroendocrinology. 2012;95(2):135–156. chemotherapy. 5 6 Neoplastic Gastrointestinal Pathology: An Illustrated Guide (A) (B) FIGURE 3.15 Rectal neuroendocrine tumors frequently exhibit an anastomosing trabecular architecture (A). Chromogranin A is negative in up to half, similar to other L-cell tumors (B). DIFFERENTIAL DIAGNOSIS chromogranin, however, nor epithelial membrane antigen (EMA). IHC for broad-spectrum keratins is often weak The primary entities in the differential diagnosis of and patchy. If a diagnosis of adrenal cortical carcinoma is well-differentiated NETs include non-neuroendocrine suspected, more specific immunostains including melan-A carcinomas, neuroendocrine hyperplasias, and NECs. (clone A103), inhibin, and steroidogenic factor 1 may be Periampullary somatostatin-expressing tumors, appendi- helpful (Figure 3.16E). ceal tubular carcinoids, and other tumors exhibiting type Glomus tumors, especially in the stomach, may be B or C histology may be mistaken for adenocarcinoma. mistaken for NETs, especially since they often express Tumors with nested growth may be mistaken for squa- synaptophysin (albeit weakly) (Figure 3.16F–G). Tumors mous cell carcinoma or solid adenocarcinoma, and clear are often multinodular and/or plexiform, and tend to cell NETs may be mistaken for “foamy gland” adeno- grow within blood vessel walls (subendothelially). Tumor carcinoma. Furthermore, NETs may produce luminal or cells are round with moderate amounts of eosinophilic stromal mucin, a potential source of diagnostic confusion to clear cytoplasm. Demonstration of strong smooth (Figure 3.16A). Rectal NETs usually express prostatic acid muscle actin expression is useful in securing the diagnosis phosphatase and may be mistaken for prostatic adeno- (Figure 3.16H). carcinoma. In all these instances, neuroendocrine chro- Neuroendocrine tumors may be mistaken for NECs as matin may be evident, although its “obviousness” varies well. This may be a particular problem in small or crushed from case to case. NETs are also characterized by relative specimens (Figure 3.16I–J). In contrast to NETs, NECs monomorphism, which is often punctuated by scattered have high nucleus: cytoplasm ratios and are highly prolif- large cells (so-called “endocrine atypia”), while non-NECs erative, generally with readily observable mitotic activity tend to exhibit greater pleomorphism (Figure 3.16B). In and abundant karyorrhectic debris. Tumor necrosis is often the liver, tumors composed of large, polygonal cells may prominent, although it tends to be “punctate” in G2 NETs, be mistaken for hepatocellular carcinoma as well. When and is rarely observed in G1 tumors. Ki-67 IHC readily dis- a tumor diagnosis is in question, pathologists should con- tinguishes NET from NEC and is strongly recommended if sider NET and have a low threshold for ordering IHC for there is any concern about the diagnosis of NEC, especially general neuroendocrine markers. in small, crushed biopsies (Figure 3.16 K–L). Adrenal cortical carcinomas may also be mistaken for The primary entities in the differential diagnosis of NETs. These tumors are often cytologically diverse, with NECs also include non-neuroendocrine carcinomas, as wildly pleomorphic areas alternating with deceptively well as other high-grade round cell tumors, and chronic bland ones (Figure 3.16C). At least half of these tumors inflammation. NECs should show characteristic cytomor- express synaptophysin, and this in large part leads to the phology and demonstrate diffuse expression of at least one diagnostic confusion (Figure 3.16D). They do not express general neuroendocrine marker. Significant pleomorphism, 3 Approach to Neuroendocrine Neoplasms 57 although it may be encountered focally in NEC, suggests chromatin. Given its relative monomorphism and occa- the diagnosis of a non-neuroendocrine carcinoma. sionally prominent nucleoli, cases may be mistaken for Small cell neuroendocrine carcinoma is rarely mis- high-grade prostatic adenocarcinoma, and given its fre- taken for a non-neuroendocrine carcinoma. Basaloid quently nested architecture, squamous cell carcinoma squamous cell carcinoma can exhibit overlapping mor- and solid adenocarcinoma may also enter the differential. phologic features on occasion, though, and thus it may be The previously mentioned panel of immunohistochemical prudent to perform a limited immunohistochemical panel stains is similarly useful in this situation, as well. in many cases (eg, a general neuroendocrine marker such NECs must also be distinguished from other round as synaptophysin, a broad-spectrum keratin, and possibly cell tumors including lymphomas, melanomas, and some p63, TTF-1, and/or cytokeratin [CK]20). Large cell neu- sarcomas. NECs should express broad-spectrum kera- roendocrine carcinoma is rarer and thus less familiar, and tins, which may appear perinuclear or dot-like, as well generally does not demonstrate typical neuroendocrine as general neuroendocrine markers. CD45 is helpful in (A) (B) (C) (D) FIGURE 3.16 Neuroendocrine tumors, like this appendiceal tubular carcinoid, may produce luminal or stromal mucin, though intracytoplasmic mucin is uncommon (A, mucicarmine). Scattered larger nuclei are common in well-differentiated NETs, and do not affect grading (B). A core biopsy of this adrenal cortical carcinoma demonstrates monomorphous, low- grade cytomorphology and granular chromatin, initially diagnosed as an NET (C). Synaptophysin expression is seen in about half of adrenal cortical carcinomas (D). (continued) 5 8 Neoplastic Gastrointestinal Pathology: An Illustrated Guide (E) (F) (G) (H) (I) (J) FIGURE 3.16 (continued) 3 Approach to Neuroendocrine Neoplasms 5 9 (K) (L) FIGURE 3.16 (continued) Negative chromogranin A and positive melan-A immunostains suggest the correct diagnosis (E, melan-A IHC). This gastric glomus tumor was also initially diagnosed as a neuroendocrine tumor (F). Weak staining for synaptophysin in glomus tumors may lead to diagnostic confusion as well (G). Glomus tumors consistently demonstrate strong staining with antibodies to smooth muscle actin (H). This pancreatic neuroendocrine tumor, with vesicular rather than granular chromatin, was initially diagnosed as a poorly differentiated neuroendocrine carcinoma based on morphology (I). Mitotic figures were rare, and the Ki-67 proliferation index was 1.4%, confirming the diagnosis of NET (J, Ki-67 IHC). This rectal neuroendocrine tumor was concerning for NEC because the crushed foci on the right were worrisome for small cell carcinoma (K). A Ki-67 proliferation index of 3.9% confirms the diagnosis of a G2 neuroendocrine tumor (L, Ki-67 IHC). excluding lymphoma, and S100 for excluding melanoma. CDX2) and thus IHC for general neuroendocrine mark- Among sarcomas, desmoplastic small round cell tumor ers is performed (Figure 3.18B–C). As discussed previ- (dot-like immunopositivity for desmin, NSE, and nuclear ously, GI tract adenocarcinomas frequently (up to 40% WT-1 with antibodies to the carboxy but not the amino of tumors) contain scattered neuroendocrine cells, but by terminus), Ewing sarcoma (diffuse, strong membranous definition 30% of cells must show neuroendocrine differ- CD99), rhabdomyosarcoma (desmin, myogenin, MyoD1 entiation before a diagnosis of MANEC can be assigned. positivity), and poorly differentiated synovial sarcoma A diagnosis of “poorly differentiated (adeno)carcinoma (TLE1) are often differential considerations. In crushed with neuroendocrine features” is ambiguous, and strongly small biopsies, IHC for broad-spectrum keratins (and/ discouraged, because it is frustrating for clinicians who or general neuroendocrine markers) and CD45 may be do not know whether to give chemotherapy for adenocar- used to distinguish NEC from chronic inflammation cinoma (eg, FOLFOX) or NEC (eg, cisplatin/etoposide). (Figure 3.17A–B). NETs, especially in the stomach, ampulla, and pan- True MANECs of the tubal gut are rare, and com- creas, occasionally entrap benign glands or ductules bined adenocarcinoma–NEC is the most commonly (Figure 3.18D), mimicking a component of adenocarci- encountered. In these cases, the key is recognizing areas noma. In a true MANEC, the non-neuroendocrine com- of typical small cell or large cell NEC in addition to areas ponent must be overtly cytologically malignant. of adenocarcinoma. Not uncommonly, poorly differentiated carcinomas (usually adenocarcinomas) are mistakenly classified as GENERAL APPROACH TO DIAGNOSIS MANECs, and a diagnosis is rendered such as “poorly AND REPORTING OF PRIMARY differentiated (adeno)carcinoma with neuroendocrine fea- NEUROENDOCRINE TUMORS tures” or “poorly differentiated (adeno)carcinoma with neuroendocrine differentiation.” This situation often To summarize, there are five key aspects to the diagnosis occurs in the setting of an especially high-grade, solid of an NET: adenocarcinoma (Figure 3.18A) in which a diagnosis of • Recognition of a histologic pattern suggestive of NEC is contemplated (eg, a medullary-type microsatellite NET. unstable tumor that has lost expression of CK20 and/or • Performance of supportive diagnostic IHC as needed. 6 0 Neoplastic Gastrointestinal Pathology: An Illustrated Guide (A) (B) FIGURE 3.17 Crushed foci of small cell NEC in small biopsies must be distinguished from chronic inflammation (A). Pan-cytokeratin positivity confirms the diagnosis of carcinoma (B). • Assessment of the mitotic index. least 40 fields and the WHO GI Blue Book recommends • Performance of Ki-67 IHC to assess proliferation examining at least 50 fields in areas of greatest mitotic index. activity. It is useful to scan at low power looking for any • Consideration of associated conditions. mitotic activity, and to begin the count in a field contain- ing a mitotic figure. Mucosal biopsies (and core biopsies As discussed previously in the section on morphology, of metastatic lesions) rarely contain the requisite number NETs characteristically demonstrate one or more “organ- of fields, and in these instances it is helpful to report pre- oid” architectural patterns. Chromatin is typically “salt cisely what was observed (eg, 1 mitotic figure in 7 HPF). and pepper” and nucleoli are generally inconspicuous, but Ki-67 IHC is essential for correct WHO 2010 NET there is variation from case to case. Tumors appear to arise grading, and some authorities perform Ki-67 staining on “de novo,” without an associated precursor lesion, with both biopsies and resections of primary NETs. The prolif- the exception of type I and II gastric NETs that arise in eration index is generally quantified in one of three ways: the context of neuroendocrine hyperplasia, and very rare tubal gut NETs that appear to arise in association with a • Estimation by regular light microscopy. columnar dysplasia (eg, tubular adenoma) (Figure 3.19). • Manual counting of a digitally captured image. As noted previously in the “General Features” sec- • Automated image analysis. tions, the most useful supportive diagnostic immunostains Many experienced pathologists estimate (“eyeball”) include the general neuroendocrine markers chromogranin proliferation indices with confidence, though this takes A and synaptophysin. In a recent consensus conference of some practice. For example, many cases clearly have NET experts, however, 53% agreed that “routine immu- a proliferation index of less than 2%, while others are nohistochemical staining is not necessary to diagnose his- clearly greater than 5% or greater than 20%. For cases tologically typical examples of well-differentiated NETs in the 2% to 5% range and those around 20%, it is use- (carcinoid tumors) of the ileum, appendix, and stomach or ful to formally count at least 500 tumor cells (generally certain pancreatic endocrine tumors.” If general neuroen- 500–1,000) in the areas of highest labeling (so-called “hot docrine markers are performed, it is often useful to do two spots”). Of note, the AJCC Cancer Staging Manual rec- markers in tandem. As discussed previously in the section ommends counting 2,000, and the WHO GI Blue Book on hormone expression, IHC for peptide hormones is only 500–2,000, nuclei. A 400× HPF generally includes at least appropriate in

very select circumstances. 500 tumor nuclei. It can be very helpful to take a digital Once a diagnosis of NET is rendered, the mitotic photomicrograph, which can then be printed out and the count and proliferation index should be assessed. Mitotic nuclei “checked off” as they are counted (Figure 3.20). counts are expressed per 10 high-power fields (HPFs). The It may be easier to count the positive nuclei on the com- AJCC Cancer Staging Manual recommends evaluating at puter monitor, especially if the printout is in black and 3 Approach to Neuroendocrine Neoplasms 61 (A) (B) (C) (D) FIGURE 3.18 This poorly differentiated adenocarcinoma (A, note the scattered small droplets of intracytoplasmic mucin) was initially interpreted as a “poorly differentiated adenocarcinoma with neuroendocrine differentiation,” based in part on this chromogranin A immunostain showing occasional positive cells (B). PMS2 immunostain from the same case demonstrates absent expression in tumor cells with intact internal control staining (C); the tumor was also MLH1 deficient, while MSH2 and MSH6 were intact. Tumors with deficient DNA mismatch repair function, particularly those with solid growth patterns or that lack typical markers of GI differentiation, are especially apt to be overinterpreted as showing “neuroendocrine differentiation.” Neuroendocrine tumors entrapping benign non-neoplastic glands or ducts are occasionally misinterpreted as mixed adenoneuroendocrine carcinomas (D). white. Results are expressed in percentage. One may also programs such as ImmunoRatio have recently become state either the numerator and denominator, and/or state available as well (153.1.200.58:8080/immunoratio). that the proliferation index was “formally quantified.” Pertinent associated conditions should also be Although seemingly complicated, this entire process takes reported. In gastric NETs, these include autoimmune atro- about 5 minutes. The utility of automated image analy- phic gastritis and MEN1–ZES. The presence of a corpus- sis has been limited by the cost (exceeding 100K) and restricted chronic gastritis with pyloric, intestinal, and thus availability of image analyzers. Counting nontumor pancreatic acinar metaplasia and ECL-cell hyperplasia is cells (eg, tumor infiltrating lymphocytes are often Ki-67 typical of autoimmune gastritis. Patients with ZES dem- positive) is a source of error. Free online image analysis onstrate giant rugal folds with parietal cell hypertrophy 6 2 Neoplastic Gastrointestinal Pathology: An Illustrated Guide specimens of jejunoileal tumors, mesenteric vessels should be examined for vascular elastosis. A report on the biopsy of a primary NET should include the tumor type, tumor size, and WHO 2010 grade, followed by the mitotic rate, the Ki-67 prolifera- tion index, the presence or absence of nonischemic tumor necrosis, and any associated conditions. For resection specimens, a synoptic reporting form is recommended (see Table 3.7). APPROACH TO METASTATIC NEUROENDOCRINE TUMORS OF UNKNOWN ORIGIN The same five key aspects discussed in the prior section regarding primary NETs apply to the diagnosis and report- FIGURE 3.19 Compared to neuroendocrine carcinomas, ing of metastatic NETs. Although some consider Ki-67 well differentiated neuroendocrine tumors only rarely arise IHC to be optional in this setting, particularly in resected in association with a columnar dysplasia. This gastric metastases, there is evidence that the proliferation index in tumor is present in a background of polypoid low-grade metastases predicts progression-free survival. There is one intestinal type dysplasia. additional critical element in the metastatic setting, which is determination of the site of origin. Ten to twenty percent of all NETs present as metastases of unknown origin, even and hyperplasia and ECL-cell hyperplasia. The presence of after investigations including computed tomography, mag- multiple duodenal or pancreatic NETs suggests the diag- netic resonance imaging, positron emission tomography, nosis of MEN1. A periampullary, type C, somatostatin- and upper and lower endoscopy. OctreoScan (somatostatin expressing NET raises the differential of NF1. In resection receptor scintigraphy) is able to localize the primary in up to 40% of these, but is limited by a range of detection of around 2 cm. In patients who are surgically explored, many occult primaries are of jejunoileal origin, followed by pan- creas. Occult primaries average about 1.5 cm (recall that the frequencies of regional and distant disease for jejunoileal tumors this size in the AFIP series were each 33%). Determination of the site of origin is both prognosti- cally and therapeutically significant. In the SEER dataset, the median survival for patients with distant disease from jejunoileal and pancreatic NETs was 56 and 24 months, respectively. While somatostatin analogues are the main- stay of medical antiproliferative therapy in metastatic jejunoileal tumors, there are several additional options including alkylating agents, mTOR inhibitors, and tyro- sine kinase inhibitors in pancreatic NETs. IHC can be useful in assigning the primary site in metastatic NETs of unknown origin. Around 90% of jejunoileal metastases express CDX2, which is typically diffuse and strong (Figure 3.21). Although up to 15% of FIGURE 3.20 To manually count a Ki-67 immunolabeled pancreatic NETs also express CDX2, in one recent study slide, a photomicrograph of a proliferation index “hot spot” these tumors always coexpressed the transcription factors is taken. The brown staining nuclei are counted (53), as PAX6 and/or islet 1. Many laboratories have found that are the total neuroendocrine tumor nuclei (1363), to arrive polyclonal PAX8 antibodies, which cross-react with PAX4 at a proliferation index of 3.9%. The photomicrograph has and PAX6, are fairly sensitive and specific for pancreatic been segmented to facilitate counting (courtesy of Frank primaries. Prostatic acid phosphatase, expressed in most A. Mitros, MD). rectal NETs, is also detected in at least 40% of jejunoileal 3 Approach to Neuroendocrine Neoplasms 6 3 TABLE 3.7 Sample Gastroenteropancreatic Neuroendocrine Neoplasm Synoptic Report Format Tumor Diagnosis ([well-differentiated] neuroendocrine tumor; [poorly differentiated] neuroendocrine carcinoma): Tumor Site (eg, terminal ileum, pancreas, etc.): Tumor Size (cm): Tumor Focality (unifocal, multifocal): Mitotic Rate (assess 50 HPF in most mitotically active areas; report average per 10 HPF): Proliferation Index (% Ki-67 labeled nuclei in areas of highest labeling; assess 500–2,000 cells): Grade (WHO 2010): ___ G1: mitotic rate <2 per 10 HPF AND proliferation index ≤2% ___ G2: mitotic rate 2–20 per 10 HPF OR proliferation index 3%–20% ___ G3: mitotic count >20 per 10 HPF OR proliferation index >20% (vast majority of G3 tumors are morphologically poorly differentiated) Nonischemic Tumor Necrosis (present, absent): Extent of Invasion (eg, for tubal gut, depth of invasion into/through gut wall; for pancreas, invasion into peripancreatic soft tissue, duodenum, ampulla, or extrapancreatic common bile duct): Resection Margins (mucosal, mesenteric, radial, as appropriate; positive, negative): Distance to Closest Margin (specify which margin): Lymphovascular Invasion (present, absent): Perineural Invasion (present, absent): Associated Diseases (eg, atrophic gastritis; MEN1; mesenteric vascular elastosis, functional syndrome): Regional Lymph Nodes (positive/total): Pathologic Staging (pTNM) (the following apply to WDNET; PDNEC staged according to site-specific TNM guidelines for carcinoma): TNM Descriptors (required only if applicable): ___ m (multiple) ___ r (recurrent) ___ y (posttreatment) Stomach Primary Tumor (T): ___ TX: Primary tumor cannot be assessed ___ T0: No evidence of primary tumor ___ Tis: Carcinoma in situ/dysplasia (tumor size less than 0.5 mm, confined to mucosa) ___ T1: Tumor invades lamina propria or submucosa and size 1 cm or less ___ T2: Tumor invades muscularis propria or more than 1 cm in size ___ T3: Tumor invades subserosa ___ T4: Tumor invades visceral peritoneum or other organs/structures Duodenum/Ampulla/Jejunum/Ileum Primary Tumor (T): ___ TX: Primary tumor cannot be assessed ___ T0: No evidence of primary tumor ___ T1: Tumor invades lamina propria or submucosa and size 1 cm or less (small intestine); tumor 1 cm or less (ampulla) ___ T2: Tumor invades muscularis propria or size >1 cm (small intestine); size > 1 cm (ampulla) ___ T3: Tumor invades subserosa (jejunum, ileum); or pancreas or retroperitoneum (duodenum, ampulla); or nonperitonealized tissues (any) ___ T4: Tumor invades visceral peritoneum or other organs/structures Pancreas Primary Tumor (T): ___ TX: Primary tumor cannot be assessed ___ T0: No evidence of primary tumor (continued) 6 4 Neoplastic Gastrointestinal Pathology: An Illustrated Guide TABLE 3.7 Sample Gastroenteropancreatic Neuroendocrine Neoplasm Synoptic Report Format (continued) ___ T1: Tumor limited to the pancreas, size 2 cm or less ___ T2: Tumor limited to the pancreas, size >2 cm ___ T3: Tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery ___ T4: Tumor involves the celiac axis or the superior mesenteric artery Appendix Primary Tumor (T): ___ TX: Primary tumor cannot be assessed ___ T0: No evidence of primary tumor ___ T1a: Tumor size 1 cm or less ___ T1b: Tumor size >1 cm but ≤2 cm ___ T2: Tumor size >2 cm but ≤4 cm or extension to the cecum ___ T3: Tumor size >4 cm or extension to the ileum ___ T4: Tumor invades other organs/structures Colon/Rectum Primary Tumor (T): ___ TX: Primary tumor cannot be assessed ___ T0: No evidence of primary tumor ___ T1a: Tumor invades lamina propria or submucosa and size 1 cm or less ___ T1b: Tumor invades lamina propria or submucosa and size 1–2 cm ___ T2: Tumor invades muscularis propria or size more than 2 cm ___ T3: Tumor invades subserosa or nonperitonealized pericolorectal tissues ___ T4: Tumor invades visceral peritoneum or other organs/structures Regional Lymph Nodes (N): ___ NX: Regional lymph nodes cannot be assessed ___ N0: No regional lymph node metastasis ___ N1: Regional lymph node metastasis Distant Metastasis (M): ___ M1: Distant metastasis Note: MX and M0 no longer exist as pathologic M stage designations. The pathologic stage based on available pathologic material is: __pT__N__M__ The optimal tissue block for molecular studies on tumor is: The optimal tissue block for molecular studies on nontumor is: Abbreviations: WDNET, well-differentiated neuroendocrine tumor; PDNEC, poorly differentiated neuroendocrine carcinoma. primaries. For laboratories that do not have PAX6, islet 1, or polyclonal PAX8 antibodies, progesterone receptor is a good substitute, as it is detected in two thirds of pan- creatic tumors. TTF-1 is specific, though fairly insensi- tive (30%–40%) for bronchopulmonary primaries. The immunophenotype of NETs by site of origin is summa- rized in Table 3.8. Morphology is complementary to the results of IHC. Metastases from occult ileal and pancreatic primaries are most likely; most ileal tumors will demonstrate type A histology and contain eosinophilic cytoplasmic granules, while pancreatic tumors can show any growth pattern. GENERAL APPROACH TO DIAGNOSIS AND REPORTING OF NEUROENDOCRINE CARCINOMAS FIGURE 3.21 Ninety percent of tumors of midgut origin, like this ileal primary, express CDX2, while only 15% of Of the five key aspects discussed in the preceding sec- pancreatic tumors do. Pancreatic tumors may express PR, tion on general approach to neuroendocrine tumors, the PAX6, and/or islet 1, while midgut tumors do not. first two are also germane to the diagnosis of an NEC: 3 Approach to Neuroendocrine Neoplasms 6 5 TABLE 3.8 Immunophenotype of Neuroendocrine Tumors by Site of Origin Site Marker Lung Jejunoileum Pancreas Rectum TTF-1 30%–40% <1% <1% <1% CDX2 <5% >90% 15% 20%–30% Polyclonal PAX8/ 5% <1% 60%–70% 60% monoclonal PAX6 Islet 1 <10% <5% 70%–90% 85% PR 5% 5% 60%–70% 20% PrAP <1% 40%–60% 5% 90% recognition of a suggestive histologic pattern and perfor- mance of supportive diagnostic IHC. Ki-67 IHC is gen- erally not needed, as tumors are by definition G3. Small cell neuroendocrine carcinomas generally demonstrate a diffuse growth pattern, with “small” cell size, little cyto- plasm, finely granular chromatin, inconspicuous to absent nucleoli, and prominent nuclear molding. Large cell neu- roendocrine carcinoma may show organoid architecture, “large” cell size with more abundant cytoplasm, vari- able chromatin, and prominent nucleoli. In the GI tract, SCNEC is more common in the esophagus and anus, while LCNEC predominates elsewhere. Twenty-five to fifty percent of GI NECs arise in association with a non- neuroendocrine carcinoma. Depending on the morphology, immunostains may be important for tumor diagnosis. NECs should express at least one general neuroendocrine marker, preferably dif- FIGURE 3.22 NECs tend to express multiple transcription fusely and strongly, as well as broad-spectrum keratins (eg, factors irrespective of site of origin, like p63 in this CAM5.2). In occasional instances in which synaptophysin metastasis from a lung primary. and chromogranin A are negative, TTF-1 or dot-like keratin expression may serve as surrogate “neuroendocrine mark- ers.” Extrapulmonary visceral NECs also express TTF-1 in 40% to 50% of cases; CK20 is rarely expressed, and when noted “gastritis” in the body of the stomach and a normal it is, it is often focal. Aside from these two markers, in con- antrum. Five random biopsies, encompassing proximal trast to NETs, IHC is not useful in

assigning the site of and distal stomach, were taken (Figures 3.23A–C), show- origin in NECs. In fact, NECs frequently express multiple ing features suggestive of autoimmune gastritis. A special transcription factors irrespective of the site of origin, a phe- stain for Helicobacter was negative. One biopsy frag- nomenon that has been referred to as “transcription factor ment contained a 0.17 cm NET (Figure 3.23D) that also infidelity” (Figure 3.22). According to the AJCC Cancer expressed chromogranin A and had a low Ki-67 prolifera- Staging Manual, NECs are staged identically to non-neuro- tion index of 1% (Figure 3.23E). endocrine carcinomas, and organ-specific synoptic reports The patient was found to have antiparietal and intrin- for carcinomas of the same site may be utilized. sic factor antibodies and a serum gastrin of 896 pg/mL (reference range 0–100). The patient was taken off his proton pump inhibitor, so as not to further exacerbate the SPECIFIC ILLUSTRATIVE EXAMPLES hypergastrinemia driving the ECL-cell proliferation. Endoscopy was repeated at 6 months, with topo- Case 1 graphic mapping of the stomach. Another NET was detected in a random biopsy from the proximal greater A 66-year-old man with a history of gastroesophageal curvature (Figure 3.23F); tumor was no longer present on reflux disease (GERD) symptoms, including dyspha- the slide prepared for Ki-67 staining. In addition, random gia, was referred for upper endoscopy. The endoscopist biopsies from the lesser curve demonstrated high-grade 6 6 Neoplastic Gastrointestinal Pathology: An Illustrated Guide (A) (B) (C) (D) (E) (F) FIGURE 3.23 (continued) 3 Approach to Neuroendocrine Neoplasms 67 (G) (H) (I) (J) FIGURE 3.23 Fragments of gastric corpus demonstrate chronic gastritis with pancreatic acinar, intestinal, and antral/ pyloric metaplasia, as well as a suggestion of neuroendocrine hyperplasia (A). Neuroendocrine hyperplasia seen at higher power (B) and confirmed by chromogranin A immunostain highlighting micronodular hyperplasia (C). A 0.17 cm NET was also present, composed of cords of cells (D). The lesion had a low Ki-67 proliferation index of 1% (E). The second endoscopy showed a second NET in a random biopsy from the proximal greater curvature (F). Random biopsies from the lesser curve also demonstrated high-grade glandular dysplasia (G), as well as a focus suspicious for intramucosal adenocarcinoma (H). A third small NET was detected at subsequent endoscopy (I), with a proliferation index of 7% (J). glandular dysplasia (Figure 3.23G), as well as a focus sus- lymphadenopathy. The patient was referred to surgery for picious for intramucosal adenocarcinoma (Figure 3.23H). consideration of gastrectomy. Endoscopy was repeated 1 week later, this time with This case highlights some of the clinical and patho- endoscopic ultrasound. A small nodule was detected along logic aspects of type I gastric NETs, as well as a rela- the lesser curvature (Figure 3.23I), and an endoscopic tively uncommon associated condition, the latter of mucosal resection was performed, revealing another which is driving clinical management. The initial biopsy NET. A Ki-67 immunostain demonstrated a prolifera- series demonstrated autoimmune atrophic gastritis, and tion index of 7% (Figure 3.23J). The ultrasound portion this diagnosis was supported by the subsequent labora- of the examination failed to detect foci of invasion or tory studies. Around 10% of patients with autoimmune 6 8 Neoplastic Gastrointestinal Pathology: An Illustrated Guide atrophic gastritis develop NETs. Tumors tend to be small, Case 2 superficial, and relatively innocuous, as seen on this case. Proliferation indices are usually low. The higher prolifera- A 64-year-old man with a history of coronary artery tion index in the final NET is unusual and may denote a disease and diverticular disease presented with a few more aggressive clinical course. Patients with small type months of left lower quadrant pain and diarrhea. A I gastric NETs can often be managed with endoscopic CT of the abdomen and pelvis was ordered to evaluate removal and surveillance. In this case, the initial diag- for probable diverticulitis. It instead demonstrated mul- nosis of an NET arising in autoimmune gastritis led to tiple lesions throughout the liver, measuring up to 8.5 endoscopic follow-up at 6 months. High-grade glandu- cm. An ultrasound-guided liver biopsy was performed lar dysplasia (at least) was detected on random biopsies. (Figure 3.24A–C), and a diagnosis of metastatic well- According to the American Society for Gastrointestinal differentiated NET, WHO 2010 grade 2 was rendered. An Endoscopy guidelines, gastrectomy or endoscopic resec- OctreoScan demonstrated uptake in multiple liver lesions tion is recommended in the face of a diagnosis of high- but failed to localize the primary (Figure 3.24D). Based grade dysplasia. Given that the glandular dysplasia is on the morphology and CDX2 expression, a jejunoileal endoscopically inapparent, the former is a strong consid- origin was strongly favored. eration. Gastric cancer develops in 1% to 3% of patients The patient underwent surgical exploration and 16 with autoimmune atrophic gastritis. nodules, ranging in size from 0.2 to 1 cm, were palpated (A) (B) (C) (D) FIGURE 3.24 (continued) 3 Approach to Neuroendocrine Neoplasms 6 9 (E) (F) (G) FIGURE 3.24 A low-power view shows nests of cells within fibrous stroma (A). The tumor is composed of nests of uniform cells with scattered larger nuclei (B). There is prominent eosinophilic cytoplasmic granularity. The tumor expressed CDX2 consistent with gastrointestinal origin (C). OctreoScan shows uptake in multiple liver lesions but did not localize the primary (D). The ileal resection showed 16 tumors along a 50 cm segment of ileum (E). Typical features of a midgut NET were seen (F). Proliferation indices were 1.3% in the primary tumor, 4.1% in the mesenteric lesion, and 10.8% in the liver metastasis (G). along a 50 cm length of ileum, which was excised detecting the site of origin, the characteristically aggres- (Figure 3.24E). Multiple liver metastases were resected sive biology of jejunoileal NETs, and caveats as regards and ablated also, though several small liver metastases the determination of proliferation index in NETs. The were left behind. Histology showed features of a typical histology in the liver core biopsy is classic for a midgut midgut NET (Figure 3.24F), also involving lymph nodes NET (nested growth pattern; eosinophilic cytoplasmic and liver; the tumor was staged as pT2 N1 M1. Ki-67 granularity). Once the neuroendocrine nature of this immunohistochemistry was performed on a representative neoplasm is recognized on the liver biopsy, a reasonable primary tumor, a mesenteric deposit, and a liver metas- IHC panel might include chromogranin A and synap- tasis, demonstrating proliferation indices of 1.3%, 4.1%, tophysin (to confirm neuroendocrine nature); Ki-67 (to and 10.8%, respectively (Figure 3.24G). The patient was assess proliferation index); and CDX2, PR (or PAX6 or started on long-acting octreotide. Islet 1 or polyclonal PAX8), and TTF-1 (to suggest the This case highlights the typical presentation of site of origin). Given the classic histology in this case, one a metastatic NET of initially occult origin, clues to could make an argument for limiting the “site of origin” 70 Neoplastic Gastrointestinal Pathology: An Illustrated Guide IHC to CDX2. CK7 and CK20 are less useful markers Case 3 for assigning the site of origin in NETs due to variability in staining. A 73-year-old man presented to the Emergency Up to 20% of NETs present as metastases of occult Department with 4 weeks of headaches and 10 days of origin. The most likely primary sites are jejunoileum, fol- progressively unsteady gait. A head CT demonstrated lowed by pancreas. An OctreoScan failed to highlight the right frontal (3 × 3 cm) and left cerebellar (5 × 4 cm) primary tumors in this patient, which is not unexpected cystic lesions. The patient was admitted, and a follow-up given their small size. MRI with contrast revealed that these lesions were ring- Historically, NETs of this size would have been con- enhancing (Figure 3.25A). Neurosurgery was consulted, sidered benign, but as illustrated in the AFIP series and and a posterior fossa craniotomy with tumor debulking in this case, even small jejunoileal tumors are frequently was planned. In the meantime, CT of the chest, abdo- metastatic. Twenty-five percent of jejunoileal NETs are men, and pelvis demonstrated a 9 cm long segment of multifocal, which may be associated with a more adverse midesophageal thickening with associated necrotic medi- prognosis. astinal adenopathy, multiple liver lesions, and nodular The Ki-67 proliferation index in the initial liver thickening of bilateral adrenal glands, suspicious for biopsy in this case was originally estimated (“eye- metastatic disease. A specimen from the cranial deb- balled”) as 1%. Although there were areas in the tumor ulking showed abundant high-grade tumor with exten- in which the proliferation index was that low, it was not sive necrosis, admixed with fragments of cerebellum uniform throughout, as is typical. Manual counting of (Figure 3.25B–F). Given the CT findings and the results a digitally captured image subsequently demonstrated a of IHC, an initial diagnosis of metastatic esophageal proliferation index in the WHO 2010 G2 range. Ki-67 adenocarcinoma was favored. IHC was repeated on the resection specimen (primary Another pathologist noted that in addition to lack- tumor, regional disease, distantly metastatic disease). ing glands, papillae, or mucin, the tumor cells were fairly Since the tumor was already G2 on the biopsy, an argu- monomorphous, and areas of trabecular architecture ment could be made that repeating these studies on the were seen (Figure 3.25G). Basophilic material encrusting resection was not necessary. However, a proliferation thin-walled blood vessels was identified in necrotic areas index of 10.8% on a resected metastasis (versus 3% on (Figures 3.25H–I). Diffuse, strong staining for chromo- a biopsied metastasis) was of interest to the clinician. A granin A and synaptophysin (Figures 3.25J–K) supported reasonable approach is to repeat Ki-67 IHC on at least a diagnosis of LCNEC, presumably from the esophagus. one primary tumor and one metastatic tumor in resected Upon further questioning, the patient related a 2-month specimens. history of dysphagia and 40-pound weight loss. The (A) (B) FIGURE 3.25 MRI with contrast showed ring-enhancing cranial lesions (A). The cranial debulking showed a high grade neoplasm with extensive necrosis, admixed with fragments of cerebellum (B). (continued) 3 Approach to Neuroendocrine Neoplasms 71 (C) (D) (E) (F) (G) (H) FIGURE 3.25 (continued) At higher power, viable tumor surrounds small blood vessels (C). An initial panel of immunostains showed that the tumor expresses CK7 (D), CK20 (E), and CDX2 (F), but not TTF-1 or prostate-specific antigen (PSA). The tumor cells were noted to be fairly monomorphous, and areas of trabecular architecture were seen (G). (continued) 72 Neoplastic Gastrointestinal Pathology: An Illustrated Guide (I) (J) (K) FIGURE 3.25 (continued) Basophilic material encrusts thin-walled blood vessels (Azzopardi effect), and there is extensive necrosis (H–I). The tumor cells diffusely and strongly expressed chromogranin A (J) and synaptophysin (K), supporting a diagnosis of LCNEC. patient underwent a course of whole brain irradiation, but in NECs, because they typically express multiple transcrip- given his declining performance status chemotherapy was tion factors regardless of primary site. The tumor followed deferred, and he was placed in hospice. a typical aggressive clinical course. This case highlights the difficulty in recognizing LCNECs. A diagnosis of solid esophageal adenocarci- noma was strongly entertained, which seemed to be cor- SELECTED REFERENCES roborated by the results of initial immunostains (positivity for CK7/CK20/CDX2). 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Any pathologist phocytes in the GI tract and elsewhere, and to demon- who regularly encounters GI specimens is likely to come strate aberrant expression of antigen(s) associated with across cases that either contain overt lymphoma, or find- various hematolymphoid neoplasms. ings suspicious for lymphoma, with some frequency. Thus, it is important to have a coherent and pragmatic approach B Lymphocytes to evaluation and diagnosis when confronted with such specimens. The “front-line” pathologist may be able to The pattern of antigen expression by normal B lympho- make a definite diagnosis in many cases by using such an cytes depends somewhat on their level of maturity (or approach and, for rarer or more equivocal entities, can degree of differentiation), as well as their associated loca- at least initiate the diagnostic process and facilitate fur- tion in lymphoid tissues. Normal B cells typically express ther testing. This chapter outlines a pragmatic approach the pan-B cell antigens CD20 and CD79a. CD19 is also to the workup of lymphomas in the GI tract, beginning expressed by all B cells, but is not usually the target of with a review of the basics of lymphoid populations and tissue-based immunohistochemistry. Normal B cells also the general principles related to lymphoid tissue in the GI express the transcription factor PAX-5 in their nuclei, as tract, followed by a brief overview of specific lymphomas well as surface immunoglobulins. Immunoglobulin (Ig) encountered in this organ system. A paraffin-embedded expression reaches its fullest form in plasma cells (derived tissue-based approach, using immunohistochemistry for from B cells), and these immunoglobulins consist of a vari- diagnosis, is emphasized, as this is routinely available to ety of heavy chain types (IgM, IgG, IgA, IgD, and IgE) most pathologists. In addition, this discussion will focus that are associated with either kappa or lambda light chain on mature B and T lymphocytes, as the vast majority of expression. The normal pattern of expression of these hematolymphoid neoplasms encountered in the GI tract light chains results in about two-thirds of cells expressing involve mature lymphoid subtypes. Individual lymphomas kappa light chain, and the other one-third lambda light will be explored in greater detail in Chapters 8, 9, and 11. chain. Demonstration of exclusive kappa or lambda light chain expression by plasma cells or B lymphocytes (the latter usually accomplished by flow cytometry) is a con- BASICS OF LYMPHOID ANTIGENS venient method to establish the clonality of a lymphoid population. Other antigens expressed by subpopulations B and T lymphocytes normally express a variety of anti- of B cells can give rise to subtypes of B cell lymphoma, gens on their surfaces and/or in the cytoplasm, many of meaning that patterns of antigen expression are useful 75 76 Neoplastic Gastrointestinal Pathology: An Illustrated Guide in diagnosing these lymphomas. For instance, CD10 and BCL-6 are expressed by follicle center B lymphocytes as well as follicular lymphoma (FL), and plasma cells express CD38 and CD138, as do neoplasms with plasmacytic dif- ferentiation. Aberrant expression of antigens not normally expressed by B cells can also be helpful in lymphoma diag- nosis. Expression of

the T cell marker CD5 is characteris- tic of certain B cell lymphomas, and expression of BCL-2 characterizes the majority of B cell lymphomas regardless of type, but is diagnostically useful in selected situations. T Lymphocytes Like B lymphocytes, T cells have a normal antigen expres- sion pattern that varies with their maturity and function. The pan-T cell markers, expressed by all mature T lym- phocytes, are CD2, CD3, CD5, and CD7. Depending on FIGURE 4.1 Peyer’s patch in the terminal ileum. The their function, T cells may also express either CD4 (gener- terminal ileum contains a variable lymphoid population, ally, the helper T cell phenotype) or CD8 (the cytotoxic typically most prominent in younger patients. The phenotype). Analogous to surface Ig expression, T cells lymphocytes are a mixture of B cells, organized into express surface receptors (T cell receptors [TCRs]) that follicular structures with surrounding mantle, and are most often composed of alpha and beta chains (α/β). surrounding T cells, recapitulating the structures of lymph Receptors composed of gamma and delta (α/β) chains are node cortex. In this example, note the mild distortion less common, and there is no definitive marker of clonality of mucosal architecture by the large lymphoid follicle, complete with polarized germinal center. The surface in T cells analogous to the light chains in B lymphocytes. epithelium overlying the follicle and the epithelium of the Of the four types of TCR chains, only the beta chain has surrounding crypts contain infiltrating lymphocytes, a routinely available antibodies for immunohistochemistry. normal finding in this situation. Natural killer (NK) cells express a mixture of T cell anti- gens (CD2, CD7 and, occasionally, CD5), with other anti- gens including CD16, CD56, CD57, and CD94. They do not express TCR chains or surface CD3. One important or germinal centers (Figure 4.2A), which are surrounded by caveat is that CD56, like CD138 on plasma cells, is not a mantle and marginal zones (also composed of B lympho- specific marker and can be found in a variety of malignan- cytes), while T cells fill the interfollicular areas (Figure 4.2B). cies including carcinomas and neuroendocrine tumors. In addition to the B and T cell populations, the follicular Just as aberrant gain of expression by lymphocytes structures contain a meshwork of follicular dendritic cells, (eg, CD5 in B cells) can characterize lymphoid neoplasms, which express CD21 and CD23 (Figure 4.2C). aberrant loss of normal markers can also be helpful. Thus, Ig light-chain-negative plasma cells are aberrant by defini- tion, as are B cells lacking the pan-B cell antigens previ- UNIQUE FEATURES OF GASTROINTESTINAL ously described in the “B Lymphocytes” section. Similarly, LYMPHOID TISSUE T cells lacking one or more of the pan-T cell antigens should raise the suspicion of a T cell lymphoma, as should The diagnosis of lymphomas in the GI tract has some cells expressing both CD4 and CD8 (“double positive”), unique aspects and challenges. First, many lymphoid pro- or neither of these antigens (“double negative”). An impor- cesses in the GI tract are sampled, at least initially, by a tant caveat associated with this principle is that reactive T small biopsy obtained endoscopically. For this reason, the cells in intense inflammatory reactions may have dimin- pathologist is quite dependent on the endoscopic descrip- ished expression of CD7 and occasionally of CD5. tion of the process or lesion during the assessment of a Finally, normally organized lymphoid tissues have a putatively atypical lymphoid population. As an example, characteristic expression of antigens reflecting the composi- an “atypical lymphoid infiltrate” in a gastric biopsy may tion and organization of a mixture of T and B cells. This become much more ominous when associated with the pattern is best illustrated in normal lymph nodes, but analo- endoscopic description of a mass or large ulcer. The often gous patterns of expression can be found in the GI tract, limited nature of a biopsy sample can also make it dif- particularly those areas with well-organized lymphoid pop- ficult to fully assess the architectural features and extent ulations such as Peyer’s patches commonly seen in the distal of a lymphoid infiltrate that would be easier to diagnose if ileum (Figure 4.1). B cells are organized into follicles and/ more tissue were sampled. This also means that obtaining 4 General Approach to Lymphomas of the Gastrointestinal Tract 77 (A) (B) (C) FIGURE 4.2 Immunostaining pattern of reactive follicles/germinal centers. In this example, an intensely reactive lymphoid infiltrate in an appendix is composed of both primary follicles and germinal centers with surrounding mantle zones, all of which are positive for CD20 (A). Surrounding these structures are normal T cells, positive for CD3 (B). Finally, a CD23 stain (C) highlights the meshwork of follicular dendritic cells in the germinal centers, as well as some activated B cells in the mantle zones around the germinal centers. tissue for ancillary studies often used to diagnose lym- The GI tract also has normal lymphoid populations phoma, such as flow cytometry and molecular diagnostics that vary depending on the site, and GI lymphoid tissue may be very difficult, such that optimizing an immunohis- can easily expand, or new foci can develop, in response tochemical approach to diagnosis is often the most helpful to a variety of stimuli. The lymphoid tissue in the GI tract tactic. One must also, however, take care in the applica- can be divided into so-called “native” mucosa-associated tion of immunohistochemistry to the investigation of a lymphoid tissue (MALT) and “acquired” MALT. Native lymphoid population in the GI tract; the combination of a MALT is epitomized by Peyer’s patches of the distal ileum, comprehensive “lymphoma panel” of immunostains may, which are well-developed lymphoid follicles with germinal in fact, provide too much information, which increases the centers that are most prominent in young patients. These complexity of the assessment. This may be a particular can sometimes create a nodular endoscopic appearance in problem in the context of a very small sample where the the terminal ileum, or may be perceived as small, sessile architecture and arrangement of the cells is already dif- “polyps,” prompting a biopsy during endoscopic exami- ficult to gauge. nation. When exuberant, this normal lymphoid tissue can 78 Neoplastic Gastrointestinal Pathology: An Illustrated Guide mildly alter the mucosal architecture, and some of the lym- decision about when the line from “reactive” to “neoplas- phocytes can encroach on the overlying mucosa or on the tic” has been crossed. It is particularly important, therefore, underlying muscularis mucosae. Either of these features to understand and correlate the clinical presentation and can be misinterpreted as an ominous sign, potentially endoscopic appearance with the histologic findings when leading to the attribution of the descriptor “atypical.” investigating an infiltrate of acquired lymphoid tissue, in Similar lymphoid aggregates can be seen in and around order to avoid an overdiagnosis of lymphoma. In addition, the appendix, and a protrusion or eversion of appendiceal some low-grade lymphomas arising in a background of tissue into the cecum can be interpreted as a “mass” that, inflammation and acquired MALT may be treated by very when sampled by biopsy, contains a sea of lymphocytes conservative therapy aimed at eradication of the inciting that may raise the specter of lymphoma as well. Individual entity (ie, H. pylori), and this adds another layer of com- lymphoid aggregates can occur anywhere in the GI tract, plexity to the issue, particularly when it comes to follow-up and are sampled frequently as tiny polyps, particularly as biopsies to assess disease progression and/or response. endoscope technology improves and makes smaller and smaller mucosal “abnormalities” visible. If native MALT creates problems of interpretation, GENERAL PRINCIPLES OF acquired MALT can present even more of a challenge. GASTROINTESTINAL LYMPHOMA DIAGNOSIS The paradigm of acquired lymphoid tissue in the GI tract is that associated with Helicobacter pylori infection in the As noted in the Introduction, the GI tract is, overall, the stomach. This infection classically results in a dense, band- most common extranodal site of involvement by lym- like lymphoplasmacytic infiltrate in the superficial gastric phomas, accounting for 4% to 20% of all non-Hodgkin mucosa (Figure 4.3B) that is frequently accompanied by lymphomas (depending on what literature is cited). In well-formed lymphoid follicles in the deeper mucosa, com- addition, hematolymphoid neoplasms tend to hover in a plete with germinal centers and surrounding mantle and “no-man’s land” between the subdisciplines of gastroin- marginal zones (Figure 4.3A). Other inflammatory condi- testinal pathology and hematopathology. Gastrointestinal tions can initiate the development of or markedly expand pathologists may fear that they are missing subtleties of existing lymphoid tissue within the GI tract and, because lymphoma diagnosis, while hematopathologists worry the underlying inflammatory condition can put the patient that they may miss an important feature of the precursor at risk of developing both epithelial and lymphoid neo- process or another entity coexisting with the lymphoma. plasia, the problem with acquired MALT often involves a As a result, such cases are often traded back and forth (A) (B) FIGURE 4.3 This low-power view of H. pylori gastritis highlights the typical, band-like superficial lymphoplasmacytic infiltrate involving the foveolar/pit compartment of the mucosa (A). This is punctuated by deeper lymphoid aggregates, including a well-formed germinal center in this case that spans almost the entire depth of the mucosa. Higher magnification reveals the prominent plasma cell component of the lamina propria inflammation, in this case involving gastric oxyntic mucosa (B). In addition, the chronic inflammation is accompanied by neutrophils infiltrating the epithelium of the deep pits and the transition between foveolar and gland epithelium (the so-called “mucous neck” region). Photomicrographs courtesy of H. D. Appelman, MD. 4 General Approach to Lymphomas of the Gastrointestinal Tract 79 between experts in both fields before a diagnosis is settled pitfalls in GI lymphoma diagnosis. Table 4.1 summarizes upon. Thankfully, however, common entities remain com- the antigen expression patterns of the lymphomas dis- mon in the GI tract as elsewhere. cussed here. The most frequent lymphomas involving the GI tract are B cell lymphomas, as is the case everywhere in the body. Diffuse Large B Cell Lymphoma Most lymphomas of the GI tract involve the stomach and the small intestine, followed by the colon. Lymphomas Diffuse large B cell lymphoma (DLBCL) is the most com- involving the esophagus and the solid GI organs (liver and mon lymphoma affecting the GI tract. This lymphoma is, pancreas) are very rare. by definition, composed of diffuse sheets of intermediate- As noted earlier, correlation with the clinical impres- to-large B lymphocytes that typically have a high prolif- sion and, particularly, the endoscopic appearance asso- erative rate, vesicular nuclei, and scant cytoplasm. The ciated with a lymphoid population sampled by biopsy neoplastic lymphocytes are dyscohesive, and obliterate the is crucial to an effective diagnostic approach. Atypical underlying tissue architecture as they infiltrate. A helpful populations associated with a large destructive mass or clue to cell size is to compare the nuclei of the neoplastic malignant-appearing ulcer may be fairly easy to evaluate, lymphocytes to those of residual endothelial cells, which whereas those coming from endoscopically normal (or are a good internal measure of “large.” DLBCL may arise very subtly abnormal) mucosa can pose a significant chal- de novo, or may evolve from a pre-existing low-grade lenge. This challenge applies to both the clinical and the lymphoma, which may still be found lurking in the back- pathology side of the equation. If an outright diagnosis of ground if not completely replaced by the large cell process. lymphoma is made on a biopsy taken from endoscopically Immunohistochemically, DLBCL is characterized by normal mucosa, it can be nearly impossible for the endos- positivity for pan-B cell markers such as CD20 and PAX-5. copist to return to the same site to monitor or resample This type of lymphoma also commonly expresses BCL-2, the disease process. By the same token, very compelling and may exhibit staining by the markers of follicle center histologic evidence of malignancy in the context of only cell differentiation, BCL-6 and CD10, depending on the a subtle macroscopic abnormality (or a nebulous and ran- specific subtype. It is negative for T cell markers such as domly sampled finding such as “gastritis” or “erythema”) CD3 (although about 10% may stain with CD5), and for should prompt consideration of rebiopsy or more exten- cyclin-D1. DLBCL is a clinically aggressive lymphoma that sive