Nursing Diagnosis: Fear Application of NANDA, NOC, NIC

Nursing Diagnosis: Fear
Pam B. Schweitzer and Gail B. Ladwig

NANDA Definition: Response to perceived threat that is consciously recognized as a danger

Defining Characteristics: Report of: apprehension; increased tension; decreased self-assurance; excitement; being scared; jitteriness; dread; alarm; terror; panic

Cognitive

Identifies object of fear; stimulus believed to be a threat; diminished productivity, learning ability, problem-solving ability

Behaviors

Increased alertness; avoidance or attack behaviors; impulsiveness; narrowed focus on "it" (i.e., the focus of the fear)

Physiological

Increased pulse; anorexia; nausea; vomiting; diarrhea; muscle tightness; fatigue; increased respiratory rate and shortness of breath; pallor; increased perspiration; increased systolic blood pressure; pupil dilation; dry mouth

Related Factors: Natural/innate origin (e.g., sudden noise, height, pain, loss of physical support); learned response (e.g., conditioning, modeling from or identification with others); separation from support system in potentially stressful situation (e.g., hospitalization, hospital procedures); unfamiliarity with environmental experience(s); language barrier; sensory impairment; innate releasers (neurotransmitters); phobic stimulus

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Fear Control

Client Outcomes

·         Verbalizes known fears

·         States accurate information about the situation

·         Identifies, verbalizes, and demonstrates those coping behaviors that reduce own fear

·         Reports and demonstrates reduced fear

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Coping Enhancement

Nursing Interventions and Rationales

·         Assess source of fear with client. Fear is a normal response to actual or perceived danger and helps mobilize protective defenses.

·         Have the client draw the object of their fear. This is a reliable assessment tool for children. Because human figure drawings are reliable tools for assessing anxiety and fears in children, practitioners should incorporate these drawings as part of their routine assessments of fearful children (Carroll, Ryan-Wenger, 1999).

·         Discuss situation with client and help distinguish between real and imagined threats to well-being. The first step in helping the client deal with fear is to collect information about the situation and its effect on the client and significant others (Bailey, Bailey, 1993).

·         If irrational fears based on incorrect information are present, provide accurate information. Correcting mistaken beliefs reduces anxiety (Beck, Emery, 1985).

·         If client's fear is a reasonable response, empathize with client. Avoid false reassurances and be truthful. Reassure clients that seeking help is both a sign of strength and a step toward resolution of the problem (Bailey, Bailey, 1993).

·         If possible, remove the source of the client's fear with accurate and appropriate amounts of information. Clients' uncertainty regarding the outcomes can lead to feelings of distress. In one study, the major strategy used to reduce distress was information management, in which the amount and type of incoming information was controlled (Shaw, Wilson, O'Brien, 1994). Fear is a normal response to actual or perceived danger; if the threat is removed, the response will stop.

·         If possible, help the client confront the fear. Self-discovery enhances feelings of control.

·         Stay with clients when they express fear; provide verbal and nonverbal (touch and hug with permission) reassurances of safety if safety is within control. The nurse's presence and touch demonstrate caring and diminish the intensity of feelings such as fear (Olson, Sneed, 1995). Of 376 patients surveyed in 20 family practices throughout Ontario, Canada, 66% believe touch is comforting and healing and view distal touches (on the hand and shoulder) as comforting (Osmun et al, 2000).

·         Explain all activities, procedures (in advance when possible), and issues that involve the client; use nonmedical terms; calm, slow speech; and verify client's understanding. Deficient knowledge or unfamiliarity is one factor associated with fear (Johnson, 1972; Garvin, Huston, Baker, 1992; Whitney, 1992).

·         Explore coping skills used previously by client to deal with fear; reinforce these skills and explore other outlets. Methods of coping with anxiety that have previously been successful are likely to be helpful again (Clunn, Payne, 1982).

·         Provide backrubs for clients to decrease anxiety. The dependent variable, anxiety, was measured before back massage, immediately following, and 10 minutes later on four consecutive evenings. There was a statistically significant difference in the mean anxiety (STAI) score between the back massage group and the no-intervention group (Fraser, Kerr, 1993).

·         Provide massage before procedures to decrease anxiety. Massage was done by parents before venous puncture of hospitalized preschoolers and school-age children. The results obtained indicated that massage had significant effect on nonverbal reactions, especially those related to muscular relaxation. (Garcia, Horta, Farias, 1997).

·         Use therapeutic touch (TT) and healing touch techniques. Various techniques that involve intention to heal, laying on of hands, clearing the energy field surrounding the body, and transfer of healing energy from the environment through the healer to the subject can reduce anxiety (Fishel, 1998). Anxiety was reduced significantly in a TT group but was unchanged in a TT placebo group. Healing touch may be one of the most useful nursing interventions available to reduce anxiety (Fishel, 1998).

·         Refer for cognitive behavioral group therapy. In this study of 253 persons with neck or back pain, the experimental group who received the standardized six-session cognitive behavioral group sessions had significantly better results with regard to fear avoidance beliefs than the comparison group (Linton, Ryberg, 2001).

·         Animal-assisted therapy (AAT) can be incorporated into the care of perioperative patients. In a study done on perioperative clients, interacting with animals was shown to reduce blood pressure and cholesterol, decrease anxiety, and improve a person's sense of well-being (Miller, Ingram, 2000).

Refer to care plans for Anxiety and Death Anxiety.

Geriatric

·         Establish a trusting relationship so that all fears can be identified. An elderly client's response to a real fear may be immobilizing.

·         Monitor for dementia and use appropriate interventions. Fear may be an early indicator of disorientation or impaired reality testing in elderly clients.

·         Note if the client is irritable and is blaming others. Recent findings in nursing research support the presence of these other behaviors as symptoms of depression (Proffitt, Augspurger, Byrne, 1996).

·         Provide a protective and safe environment, use consistent caregivers, and maintain the accustomed environmental structure. Elderly clients tend to have more perceptual impairments and adapt to changes with more difficulty than younger clients, especially during an illness.

·         Observe for untoward changes if antianxiety drugs are taken. Advancing age renders clients more sensitive to both the clinical and toxic effects of many agents.

Multicultural

·         Assess for the presence of culture-bound anxiety/fear states. The context in which anxiety/fear is experienced, its meaning, and responses to it are culturally mediated (Kavanagh, 1999; Charron, 1998).

·         Assess for the influence of cultural beliefs, norms, and values on the client's perspective of a stressful situation. What the client considers stressful may be based on cultural perceptions (Leininger, 1996).

·         Identify what triggers fear response. Arab Muslim clients may express a high correlation between fear and pain (Sheets, El-Azhary, 1998).

·         Identify how the client expresses fear. Research indicates that the expression of fear may be culturally mediated (Shore, Rapport, 1998).

·         Validate the client's feelings regarding fear. Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).

Home Care Interventions

·         During initial assessment, determine whether current or previous episodes of fear relate to the home environment (e.g., perception of danger in home or neighborhood or of relationships that have a history in the home). Investigating the source of the fear allows the client to verbalize feelings and determine appropriate interventions.

·         Identify with client what steps may be taken to make the home a "safe" place to be. Identifying a given area as a safe place reduces fear and anxiety when the client is in that area.

·         Encourage the client to seek or continue appropriate counseling to reduce fear associated with stress or to resolve alterations in thought processes. Correcting mistaken beliefs reduces anxiety.

·         Encourage the client to have a trusted companion, family member, or caregiver present in the home for periods when fear is most prominent. Pending other medical diagnoses, a referral to homemaker/home health aide services may meet this need. Creating periods when fear and anxiety can be reduced allows the client periods of rest and supports positive coping.

·         Offer to sit with a terminally ill client quietly as needed by the client or family, or provide hospice volunteers to do the same. Terminally ill clients and their families often fear the dying process. The presence of a nurse or volunteer lets clients know they are not alone. Fears are reduced, and the dying process becomes more easily tolerated.

Client/Family Teaching

·         Teach client the difference between warranted and excessive fear. Different interventions are indicted for rational and irrational fears.

·         Teach stress management interventions to clients who experience emotions of fear. Acute stress caused by strong emotions such as fear can sometimes cause sudden death in people with underlying coronary artery disease (Pashkow, 1999).

·         Teach families to share personal stories about an illness using the computer-based psychoeducational application experience journal. The educational journal was reported to be useful for increasing understanding of familial feelings for families facing pediatric illness (Demaso et al, 2000).

·         Teach client to visualize or fantasize absence of the fear or threat and successful resolution of the conflict or outcome of the procedure.

·         Teach client to identify and use distraction or diversion tactics when possible. Early interruption of the anxious response prevents escalation (Pope, 1995).

·         Teach clients to use guided imagery when they are fearful: have them use all senses to visualize a place that is "comfortable and safe" for them. Results from this study showed that the psychological intervention of guided imagery significantly improved subjects' perceived quality of life and decreased fears (Moody, Fraser, Yarandi, 1993).

·         Teach client to allow fearful thoughts and feelings to be present until they dissipate. Purposefully and repetitively allowing and even devoting time and energy to a thought reduces associated anxiety (Beck, Emery, 1985).

·         Teach use of appropriate community resources in emergency situations (e.g., hotlines, emergency rooms, law enforcement, judicial systems). Serious emergencies need immediate assistance to ensure the client's safety.

·         Encourage use of appropriate community resources in nonemergency situations (e.g., family, friends, neighbors, self-help and support groups, volunteer agencies, churches, recreation clubs and centers, seniors, youths, others with similar interests).

·         Teach client appropriate use of ordered medications.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nursing Diagnosis: Impaired Skin integrity
Diane Krasner

NANDA Definition: Altered epidermis and/or dermis
Defining Characteristics: Invasion of body structures; destruction of skin layers (dermis); disruption of skin surface (epidermis)
Related Factors:

External

Hyperthermia; hypothermia; chemical substance (e.g., incontinence); mechanical factors (e.g., friction, shearing forces, pressure, restraint); physical immobilization; humidity; extremes in age; moisture; radiation; medications

Internal

Altered metabolic state; altered nutritional state (e.g., obesity, emaciation); altered circulation; altered sensation; altered pigmentation; skeletal prominence; developmental factors; immunological deficit; alterations in skin turgor (change in elasticity); altered fluid status

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Tissue Integrity: Skin and Mucous Membranes

·         Wound Healing: Primary Intention

·         Wound Healing: Secondary Intention

Client Outcomes

·         Regains integrity of skin surface

·         Reports any altered sensation or pain at site of skin impairment

·         Demonstrates understanding of plan to heal skin and prevent reinjury

·         Describes measures to protect and heal the skin and to care for any skin lesion

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Incision Site Care

·         Pressure Ulcer Care

·         Skin Care: Topical Treatments

·         Skin Surveillance Wound Care

Nursing Interventions and Rationales

·         Assess site of skin impairment and determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, skin tear) (Krasner, Sibbald, 1999). Prior assessment of wound etiology is critical for proper identification of nursing interventions (van Rijswijk, 2001).

·         Determine that skin impairment involves skin damage only (e.g., partial-thickness wound, stage I or stage II pressure ulcer). Classify superficial pressure ulcers in the following manner:

o Stage I: Observable pressure-related alteration of intact skin with indicators as compared with the adjacent or opposite area on the body that may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues (National Pressure Ulcer Advisory Panel, 1999).

o Stage II: Partial-thickness skin loss involving epidermis or dermis superficial ulcer that appears as an abrasion, blister, or shallow crater (National Pressure Ulcer Advisory Panel, 1999).

NOTE: For wounds deeper into subcutaneous tissue, muscle, or bone (stage III or stage IV pressure ulcers), see the care plan for Impaired Tissue integrity.

·         Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether client is experiencing changes in sensation or pain. Pay special attention to high-risk areas such as bony prominences, skinfolds, the sacrum, and heels. Systematic inspection can identify impending problems early (Bryant, 1999).

·         Monitor client's skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing.

·         Individualize plan according to client's skin condition, needs, and preferences. Avoid harsh cleansing agents, hot water, extreme friction or force, or cleansing too frequently (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

·         Monitor client's continence status, and minimize exposure of skin impairment and other areas to moisture from incontinence, perspiration, or wound drainage.

·         If client is incontinent, implement an incontinence management plan to prevent exposure to chemicals in urine and stool that can strip or erode the skin. Refer to a urologist or gastroenterologist for incontinence assessment (Doughty, 1991; Wound, Ostomy, and Continence Nurses Society, 1992, 1994; Fantl et al, 1996).

·         For clients with limited mobility, use a risk-assessment tool to systematically assess immobility-related risk factors (van Rijswijk, 2001). A validated risk-assessment tool such as the Norton or Braden scale should be used to identify clients at risk for immobility-related skin breakdown (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

·         Do not position client on site of skin impairment. If consistent with overall client management goals, turn and position client at least every 2 hours. Transfer client with care to protect against the adverse effects of external mechanical forces such as pressure, friction, and shear.

·         Evaluate for use of specialty mattresses, beds, or devices as appropriate (Fleck, 2001). If the goal of care is to keep a client (e.g., a terminally ill client) comfortable, turning and repositioning may not be appropriate. Maintain the head of the bed at the lowest possible degree of elevation to reduce shear and friction, and use lift devices, pillows, foam wedges, and pressure-reducing devices in the bed. Evaluate for the use of specialty mattresses or beds as appropriate (Krasner, Rodeheaver, Sibbald, 2001; Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Wilson, 1994).

·         Implement a written treatment plan for topical treatment of the site of skin impairment. A written plan ensures consistency in care and documentation (Maklebust, Sieggreen, 1996). Topical treatments must be matched to the client, wound, and setting (Krasner, Sibbald 1999).

·         Select a topical treatment that will maintain a moist wound-healing environment and that is balanced with the need to absorb exudate. Caution should always be taken not to dry out the wound (Bergstrom et al, 1994).

·         Avoid massaging around the site of skin impairment and over bony prominences. Research suggests that massage may lead to deep-tissue trauma (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

·         Assess client's nutritional status. Refer for a nutritional consult, and/or institute dietary supplements as necessary. Inadequate nutritional intake places individuals at risk for skin breakdown and compromises healing (Demling, De Santi, 1998).

Home Care Interventions

·         Instruct and assist client and caregivers to remove or control impediments to wound healing (e.g., management of underlying disease, improved approach to client positioning, improved nutrition). Wound healing can be delayed or fail totally if impediments are not controlled (Krasner, Sibbald, 1999).

·         Initiate a consultation in a case assignment with a wound, ostomy, continence nurse (WOC nurse) to establish a comprehensive plan as soon as possible.

Client/Family Teaching

·         Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing. Early assessment and intervention help prevent serious problems from developing.

·         Teach client to use a topical treatment that is matched to the client, wound, and setting. The topical treatment must be adjusted as the status of the wound changes (van Rijswijk, 2001; Krasner, Sibbald, 1999; Ovington, 1998).

·         If consistent with overall client management goals, teach how to turn and reposition at least every 2 hours. If the goal of care is to keep a client (e.g., terminally ill client) comfortable, turning and repositioning may not be appropriate (Krasner, Rodeheaver, Sibbald, 2001; Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

·         Teach client to use pillows, foam wedges, and pressure-reducing devices to prevent pressure injury.

Nursing Diagnosis: Ineffective Airway clearance
Betty J. Ackley

NANDA Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

Defining Characteristics: Dyspnea; diminished breath sounds; orthopnea; adventitious breath sounds (crackles, wheezes); cough, ineffective or absent; sputum production; cyanosis; difficulty vocalizing; wide-eyed; changes in respiratory rate and rhythm; restlessness

Related Factors:

Environmental

Smoking; smoke inhalation; second-hand smoke

Obstructed Airway

Airway spasm; retained secretions; excessive mucus; presence of artificial airway; foreign body in airway; secretions in bronchi; exudate in alveoli

Physiological

Neuromuscular dysfunction; hyperplasia of bronchial walls; chronic obstructive pulmonary disease; infection; asthma; allergic airways

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Respiratory Status: Ventilation

·         Respiratory Status: Airway Patency

·         Respiratory Status: Gas Exchange

·         Aspiration Control

Client Outcomes

·         Demonstrates effective coughing and clear breath sounds; is free of cyanosis and dyspnea

·         Maintains a patent airway at all times

·         Relates methods to enhance secretion removal

·         Relates the significance of changes in sputum to include color, character, amount, and odor

·         Identifies and avoids specific factors that inhibit effective airway clearance

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Airway Management

·         Airway Suctioning

·         Cough Enhancement

Nursing Interventions and Rationales

·         Auscultate breath sounds q __ h(rs). Breath sounds are normally clear or scattered fine crackles at bases, which clear with deep breathing. The presence of coarse crackles during late inspiration indicates fluid in the airway; wheezing indicates an airway obstruction.

·         Monitor respiratory patterns, including rate, depth, and effort. A normal respiratory rate for an adult without dyspnea is 12 to 16. With secretions in the airway, the respiratory rate will increase.

·         Monitor blood gas values and pulse oxygen saturation levels as available. Normal blood gas values are a PO2 of 80 to 100 mm Hg and a PCO2 of 35 to 45 mm Hg. An oxygen saturation of less than 90% indicates problems with oxygenation. Hypoxemia can result from ventilation-perfusion mismatches secondary to respiratory secretions.

·         Position client to optimize respiration (e.g., head of bed elevated 45 degrees and repositioned at least every 2 hours). An upright position allows for maximal air exchange and lung expansion; lying flat causes abdominal organs to shift toward the chest, which crowds the lungs and makes it more difficult to breathe. Studies have shown that in mechanically ventilated clients receiving enteral feedings, there is a decreased incidence of nosocomial pneumonia if the client is positioned at a 45-degree semirecumbent position as opposed to a supine position (Torres, Serra-Battles, Ros, 1992; Drakulovic et al, 1999).

·         If the client has unilateral lung disease, alternate a semi-Fowler's position with a lateral position (with a 10- to 15-degree elevation and "good lung down") for 60 to 90 minutes. This method is contraindicated for a client with a pulmonary abscess or hemorrhage or with interstitial emphysema. Gravity and hydrostatic pressure allow the dependent lung to become better ventilated and perfused, which increases oxygenation (Yeaw, 1992; Smith-Sims, 2001).

·         Help client to deep breathe and perform controlled coughing. Have client inhale deeply, hold breath for several seconds, and cough two to three times with mouth open while tightening the upper abdominal muscles. This technique can help increase sputum clearance and decrease cough spasms (Celli, 1998). Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective.

·         If the client has COPD, consider helping the client use the "huff cough." The client does a series of coughs while saying the word "huff." This technique prevents the glottis from closing during the cough and is effective in clearing secretions in the centra airways (Lewis, Heitkemper, Dirksen, 1999).

·         Encourage client to use incentive spirometer. The incentive spirometer is an effective tool that can help prevent atelectasis and retention of bronchial secretions (Peruzzi, Smith, 1995).

·         Assist with clearing secretions from pharynx by offering tissues and gentle suction of the oral pharynx if necessary. Do not do nasotracheal suctioning. It is preferable for the client to cough up secretions. In the debilitated client, gentle suctioning of the posterior pharynx may stimulate coughing and help remove secretions; nasotracheal suctioning is dangerous because the nurse is unable to hyperoxygenate before, during, and after to maintain adequate oxygenation (Peruzzi, Smith, 1995).

·         Observe sputum, noting color, odor, and volume. Normal sputum is clear or gray and minimal; abnormal sputum is green, yellow, or bloody; malodorous; and often copious.

·         When suctioning an endotracheal tube or tracheostomy tube for a client on a ventilator, do the following:

o Hyperoxygenate before, between, and after endotracheal suction sessions. Nursing research has demonstrated that the client should be hyperoxygenated during suctioning (Winslow, 1993a).

o Use a closed, in-line suction system. The closed, in-line suction system is associated with a decrease in nosocomial pneumonia (Deppe et al, 1990; Johnson et al, 1994; Mathews, Mathews, 2000), reduced suction-induced hypoxemia, and fewer physiological disturbances (including decreased development of dysrhythmia) and often saves money (Carroll, 1998).

o Avoid saline instillation during suctioning. Saline instillation before suctioning has an adverse effect on oxygen saturation (Ackerman, Mick, 1998; Winslow, 1993b; Raymond, 1995).

·         Document results of coughing and suctioning, particularly client tolerance and secretion characteristics such as color, odor, and volume.

·         Provide oral care every 4 hours. Oral care freshens the mouth after respiratory secretions have been expectorated. Research is promising on the use of chlorhexidine oral rinses after oral care to reduce bacteria, and possibly reduce the incidence of nosocomial pneumonia (Kollef, 1999).

·         Encourage activity and ambulation as tolerated. If unable to ambulate client, turn client from side to side at least every 2 hours. Body movement helps mobilize secretions. The supine position and immobility have been shown to predispose postoperative clients to pneumonia (Brooks-Brunn, 1995). See interventions for Impaired gas exchange for further information on positioning a respiratory client.

·         Encourage increased fluid intake of up to 3000 ml/day within cardiac or renal reserve. Fluids help minimize mucosal drying and maximize ciliary action to move secretions (Carroll, 1994). Some clients cannot tolerate increased fluids because of underlying disease.

·         Administer oxygen as ordered. Oxygen has been shown to correct hypoxemia, which can be caused by retained respiratory secretions.

·         Administer medications such as bronchodilators or inhaled steroids as ordered. Watch for side effects such as tachycardia or anxiety with bronchodilators, inflamed pharynx with inhaled steroids. Bronchodilators decrease airway resistance secondary to bronchoconstriction.

·         Provide postural drainage, percussion, and vibration as ordered. Chest physical therapy helps mobilize bronchial secretions; it should be used only when prescribed because it can cause harm if client has underlying conditions such as cardiac disease or increased intracranial pressure (Peruzzi, Smith, 1995).

·         Refer for physical therapy or respiratory therapy for further treatment.

Geriatric

·         Encourage ambulation as tolerated without causing exhaustion. Immobility is often harmful to the elderly because it decreases ventilation and increases stasis of secretions, leading to atelectasis or pneumonia (Hoyt, 1992; Tempkin, Tempkin, Goodman, 1997).

·         Actively encourage the elderly to deep breathe and cough. Cough reflexes are blunted and coughing is decreased in the elderly (Sparrow, Weiss, 1988).

·         Ensure adequate hydration within cardiac and renal reserves. The elderly are prone to dehydration and therefore more viscous secretions because they frequently use diuretics or laxatives and forget to drink adequate amounts of water (Hoyt, 1992).

Home Care Interventions

·         Assess home environment for factors that exacerbate airway clearance problems (e.g., presence of allergens, lack of adequate humidity in air, stressful family relationships).

·         Limit client exposure to persons with upper respiratory infections.

·         Provide/teach percussion and postural drainage per physician orders. Teach adaptive breathing techniques. Adaptive breathing, percussion, and postural drainage loosen secretions and allow more effective oxygenation.

·         Determine client compliance with medical regimen.

·         Teach client when and how to use inhalant or nebulizer treatments at home.

·         Teach client/family importance of maintaining regimen and having prn drugs easily accessible at all times. Success in avoiding emergency or institutional care may rest solely on medication compliance or availability.

·         Identify an emergency plan, including criteria for use. Ineffective airway clearance can be life threatening.

·         Refer for home health aide services for assist with ADLs. Clients with decreased oxygenation and copious respiratory secretions are often unable to maintain energy for ADLs.

·         Assess family for role changes and coping skills. Refer to medical social services as necessary. Clients with decreased oxygenation are unable to maintain role activities and therefore experience frustration and anger, which may pose a threat to family integrity.

·         Provide family with support for care of a client with a chronic or terminal illness. Severe compromise to respiratory function creates fear in clients and caregivers. Fear inhibits effective coping.

Client/Family Teaching

·         Teach importance of not smoking. Be aggressive in approach, ask to set a date for smoking cessation, and recommend nicotine replacement therapy (nicotine patch or gum). Refer to smoking cessation programs, and encourage clients who relapse to keep trying to quit. All health care clinicians should be aggressive in helping smokers quit (AHCPR Guidelines, 1996).

·         Teach client how to use a flutter clearance device if ordered, which vibrates to loosen mucus and gives positive pressure to keep airways open. This device has been shown to effectively decrease mucous viscosity and elasticity (App et al, 1998), increase amount of sputum expectorated (Langenderfer, 1998; Bellone et al, 2000), and increase peak expiratory flow rate (Burioka et al, 1998).

·         Teach client how to use peak expiratory flow rate (PEFR) meter if ordered and when to seek medical attention if PEFR reading drops. Also teach how to use metered dose inhalers and self-administer inhaled corticosteroids following precautions to decrease side effects (Owen, 1999).

·         Teach client how to deep breathe and cough effectively. Teach how to use the ELTGOL method-an airway clearance method that uses lateral posture and diferent lung volumes to control expiratory flow of air to avoid airway compression. Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective. The ELTGOL method was shown to be more effective in secretion removal in chronic bronchitis than postural drainage (Bellone et al, 2000).

·         Teach client/family to identify and avoid specific factors that exacerbate ineffective airway clearance, including known allergens and especially smoking (if relevant) or exposure to second-hand smoke.

·         Educate client and family about the significance of changes in sputum characteristics, including color, character, amount, and odor. With this knowledge the client and family can identify early the signs of infection and seek treatment before acute illness occurs.

·         Teach client/family need to take antibiotics until prescription has run out. Taking the entire course of antibiotics helps to eradicate bacterial infection, which decreases lingering, chronic infection.