Nursing Care Plan: Grieving, anticipatory related to perceived, actual, or potential loss of physiopsychosocial well-being, personal possessions, or SO and cultural beliefs about aging/debilitation.

Scientific Basis:
Anticipatory grieving is a state in which an individual grieves before an actual loss. It may apply to individuals who have had a perinatal loss of a body part or to patients who have received a terminal diagnosis for themselves or a loved one. Intense mental anguish or a sense of deep sadness may be experiences by patients and their families as they face long-term illness or disability. Grief is an aspect of the human condition that touches every individual, but how an individual or a family system responds to loss and how grief is expressed varies widely. That process is strongly influenced by factor such as age, gender, and culture, as well as personal and intrafamilial reserves and strengths. The nurse must recognize the anticipatory grief is real grief and that, in all likelihood, as the loss actually occurs, it will evolve into grief based on an accomplished event. The nurse will encounter the patient and family experiencing anticipatory grief in the hospital setting, but increasingly, with more hospice services provided in the community, the nurse will find patient struggling with these issues in their own homes where professional help may be limited or fragmented. This care plan discusses measures the nurse can use help the patient and family members begin the process of grieving.

Grief is the emotional reaction to loss or perceived loss (is felt by the person but is intangible to others; loss of youth, financial independence, and of a valued environment), anticipatory loss, in which a person displays loss and grief behaviors for a loss that has yet to take place. Individual diagnosis with severe diseases perceives a threat to life, health, self-esteem and role. The threat may be viewed as a loss or potential loss. Grief is the process of making loss a reality. Anyone experiencing or perceiving a loss must grieve. The actual grief process may begin with anticipation for the loss.

Neal, et al, 2004; Gulanick, 2007; Taylor, et al, 2005


Intervention and Rationale

I: Assess emotional state. Note cultural beliefs, expectations.
R: Anxiety and depression are common reactions to changes/losses associated with long-term illness or debilitating condition. In addition, changes in neurotransmitter levels (e.g., increased monoamine oxidase [MAO] and serotonin levels with decreased norepinephrine) may potentiate depression in elderly patients. Personal expectations may affect response to change.

I: Determined as to what stage is the client in grieving.
R: To provide appropriate care.

I: Denial: Be aware of avoidance behaviors: anger, withdrawal, and so forth. Allow client to talk about what he or she chooses, and do not try to force client to “face the facts”;
R: Denying the reality of diagnosis and/or prognosis is an important phase in which client protects self from the pain and reality of the threat of loss. Each person does this in an individual manner based on previous experiences with loss and cultural/ religious factors.

I: Anger: Note behaviors of withdrawal, lack of cooperation, and direct expression of anger. Be alert to body language and check meaning with client, noting congruency with verbalizations. Encourage/allow verbalization of anger, acknowledge feelings, set limits regarding destructive behavior;
R: Denial gives way to feelings of anger, rage, guilt, and resentment. Client may find it difficult to express anger directly and may feel guilty about normal feelings of anger. Although staff may have difficulty dealing with angry behaviors, acceptance allows patient to work through the anger and move on to more effective coping behaviors.

I: Bargaining: Be aware of statements such as “. . . if I do this, my problem will be fixed.” Allow verbalization without confrontation about realities;
R: Bargaining with care providers or God often occurs and may be helpful in beginning resolution and acceptance. Patient may be working through feelings of guilt about things done or undone.

I: Depression: Give client permission to be where he or she is. Provide hope within parameters of individual situation without giving false reassurance. Provide comfort and availability, as well as caring for physical needs;
R: When patient can no longer deny the reality of the loss, feelings of helplessness and hopelessness replace feelings of anger. Client needs information that this is a normal progression of feelings.

I: Acceptance: Respect client’s needs and wishes for
quiet, privacy, and/or talking.
R: Having worked through the denial, anger, and depression, client often prefers to be alone and does not want to talk much at this point. Client may still cling to hope, which can be sustaining through whatever is happening at this point.

I: Review past life experiences/ previous loss, role changes and coping skills, noting strengths/ success.
R: Useful in dealing with current situation and problem solving existing needs.

I: Make time to listen to client. Encourage free expression of hopeless feelings and desire to die.
R: It is more helpful to allow these feelings to be expressed and dealt with than to deny or ignore them.

I: Assess suicidal potential.
R: May be related to physical disease, social isolation, and grief. Note: Studies indicate women are three times as likely to attempt suicide; however, men are three times as likely to succeed.

I: Involve SO in discussions and activities to the level of their willingness.
R: When SOs are involved, there is more potential for successful problem solving. Note: SO may not be available or may not choose to be involved.

I: Provide liberal touching as individually accepted.
R: Conveys sense of concern/closeness to reduce feelings of isolation and enhance sense of self-worth. Note: Touch may be viewed as a threat by some patients and escalate feelings of agitation/anger.

I: Identify spiritual concerns. Discuss available resources and encourage participation in religious activities as appropriate.
R: Search for meaning is common to those facing changes in life. Participation in religious/spiritual activities can provide sense of direction and peace of mind.

I: Assist with/plan for specifics as necessary (e.g., Advance Directives to determine code status/Living Will wishes, making of will, funeral arrangements if appropriate).
R: Having these issues resolved can help client/SO deal with the grieving process and may provide peace of mind.

I: Provide an open, nonjudgmental environment. Used therapeutic communication skills of active listening acknowledgment.
R: Promotes and encourages realistic dialogue about feeling and concerns.

I: Encourage verbalization of thought/concerns
R: Client may feel supported in expression for feelings by the understanding that deep and often conflicting emotions are normal and experienced by others in this difficult situation.

I: Reinforced teaching regarding disease process and treatments and provided information as requested.
R: Client/significant others benefits from factual information. Individuals may ask direct questions and honest answers promote trust and reassurance that corrects information will be given.

I: Provided realistic information about health status without false reassurance or taking away life
R: Defensive retreat occurs weeks to months after loss. Pt attempts to maintain what he has been lost; denial, wishful thinking, unwillingness to participate in self-care and indifference may be seen.

I: Recognize that each client is unique and will progress at own pace.
R: Time frames vary widely. Cultural, religious, ethnic, individual differences impact on manner of grieving.

I: Establish rapport with client and significant others. Listen and encourage pt significant others to verbalize feelings.
R: This open lines of communication and facilitate successful resolution of grief.

I: Accepted need to deny loss as part of normal grief process.
R: Realization occurs weeks to months after loss. Reality continues to be over whelming sadness, anger, guilt, hostility may be seen.

I: Be honest in answering questions, providing information.
R: Enhances sense of trust and nurse-client relationship.

I: Discuss issues, such as what is in the power of the individual to change and what is beyond control.
R: Recognition of these factors helps client focus energy for maximal benefit/ outcome.

Doenges, et al, 2002, Gulanick, 2007; Kruse, et al, 2003

Nursing Care Plan: Grieving, anticipatory related to perceived, actual, or potential loss of physiopsychosocial well-being, personal possessions, or SO and cultural beliefs about aging/debilitation.

Scientific Basis:
Anticipatory grieving is a state in which an individual grieves before an actual loss. It may apply to individuals who have had a perinatal loss of a body part or to patients who have received a terminal diagnosis for themselves or a loved one. Intense mental anguish or a sense of deep sadness may be experiences by patients and their families as they face long-term illness or disability. Grief is an aspect of the human condition that touches every individual, but how an individual or a family system responds to loss and how grief is expressed varies widely. That process is strongly influenced by factor such as age, gender, and culture, as well as personal and intrafamilial reserves and strengths. The nurse must recognize the anticipatory grief is real grief and that, in all likelihood, as the loss actually occurs, it will evolve into grief based on an accomplished event. The nurse will encounter the patient and family experiencing anticipatory grief in the hospital setting, but increasingly, with more hospice services provided in the community, the nurse will find patient struggling with these issues in their own homes where professional help may be limited or fragmented. This care plan discusses measures the nurse can use help the patient and family members begin the process of grieving.

Grief is the emotional reaction to loss or perceived loss (is felt by the person but is intangible to others; loss of youth, financial independence, and of a valued environment), anticipatory loss, in which a person displays loss and grief behaviors for a loss that has yet to take place. Individual diagnosis with severe diseases perceives a threat to life, health, self-esteem and role. The threat may be viewed as a loss or potential loss. Grief is the process of making loss a reality. Anyone experiencing or perceiving a loss must grieve. The actual grief process may begin with anticipation for the loss.

Neal, et al, 2004; Gulanick, 2007; Taylor, et al, 2005


Intervention and Rationale

I: Assess emotional state. Note cultural beliefs, expectations.
R: Anxiety and depression are common reactions to changes/losses associated with long-term illness or debilitating condition. In addition, changes in neurotransmitter levels (e.g., increased monoamine oxidase [MAO] and serotonin levels with decreased norepinephrine) may potentiate depression in elderly patients. Personal expectations may affect response to change.

I: Determined as to what stage is the client in grieving.
R: To provide appropriate care.

I: Denial: Be aware of avoidance behaviors: anger, withdrawal, and so forth. Allow client to talk about what he or she chooses, and do not try to force client to “face the facts”;
R: Denying the reality of diagnosis and/or prognosis is an important phase in which client protects self from the pain and reality of the threat of loss. Each person does this in an individual manner based on previous experiences with loss and cultural/ religious factors.

I: Anger: Note behaviors of withdrawal, lack of cooperation, and direct expression of anger. Be alert to body language and check meaning with client, noting congruency with verbalizations. Encourage/allow verbalization of anger, acknowledge feelings, set limits regarding destructive behavior;
R: Denial gives way to feelings of anger, rage, guilt, and resentment. Client may find it difficult to express anger directly and may feel guilty about normal feelings of anger. Although staff may have difficulty dealing with angry behaviors, acceptance allows patient to work through the anger and move on to more effective coping behaviors.

I: Bargaining: Be aware of statements such as “. . . if I do this, my problem will be fixed.” Allow verbalization without confrontation about realities;
R: Bargaining with care providers or God often occurs and may be helpful in beginning resolution and acceptance. Patient may be working through feelings of guilt about things done or undone.

I: Depression: Give client permission to be where he or she is. Provide hope within parameters of individual situation without giving false reassurance. Provide comfort and availability, as well as caring for physical needs;
R: When patient can no longer deny the reality of the loss, feelings of helplessness and hopelessness replace feelings of anger. Client needs information that this is a normal progression of feelings.

I: Acceptance: Respect client’s needs and wishes for
quiet, privacy, and/or talking.
R: Having worked through the denial, anger, and depression, client often prefers to be alone and does not want to talk much at this point. Client may still cling to hope, which can be sustaining through whatever is happening at this point.

I: Review past life experiences/ previous loss, role changes and coping skills, noting strengths/ success.
R: Useful in dealing with current situation and problem solving existing needs.

I: Make time to listen to client. Encourage free expression of hopeless feelings and desire to die.
R: It is more helpful to allow these feelings to be expressed and dealt with than to deny or ignore them.

I: Assess suicidal potential.
R: May be related to physical disease, social isolation, and grief. Note: Studies indicate women are three times as likely to attempt suicide; however, men are three times as likely to succeed.

I: Involve SO in discussions and activities to the level of their willingness.
R: When SOs are involved, there is more potential for successful problem solving. Note: SO may not be available or may not choose to be involved.

I: Provide liberal touching as individually accepted.
R: Conveys sense of concern/closeness to reduce feelings of isolation and enhance sense of self-worth. Note: Touch may be viewed as a threat by some patients and escalate feelings of agitation/anger.

I: Identify spiritual concerns. Discuss available resources and encourage participation in religious activities as appropriate.
R: Search for meaning is common to those facing changes in life. Participation in religious/spiritual activities can provide sense of direction and peace of mind.

I: Assist with/plan for specifics as necessary (e.g., Advance Directives to determine code status/Living Will wishes, making of will, funeral arrangements if appropriate).
R: Having these issues resolved can help client/SO deal with the grieving process and may provide peace of mind.

I: Provide an open, nonjudgmental environment. Used therapeutic communication skills of active listening acknowledgment.
R: Promotes and encourages realistic dialogue about feeling and concerns.

I: Encourage verbalization of thought/concerns
R: Client may feel supported in expression for feelings by the understanding that deep and often conflicting emotions are normal and experienced by others in this difficult situation.

I: Reinforced teaching regarding disease process and treatments and provided information as requested.
R: Client/significant others benefits from factual information. Individuals may ask direct questions and honest answers promote trust and reassurance that corrects information will be given.

I: Provided realistic information about health status without false reassurance or taking away life
R: Defensive retreat occurs weeks to months after loss. Pt attempts to maintain what he has been lost; denial, wishful thinking, unwillingness to participate in self-care and indifference may be seen.

I: Recognize that each client is unique and will progress at own pace.
R: Time frames vary widely. Cultural, religious, ethnic, individual differences impact on manner of grieving.

I: Establish rapport with client and significant others. Listen and encourage pt significant others to verbalize feelings.
R: This open lines of communication and facilitate successful resolution of grief.

I: Accepted need to deny loss as part of normal grief process.
R: Realization occurs weeks to months after loss. Reality continues to be over whelming sadness, anger, guilt, hostility may be seen.

I: Be honest in answering questions, providing information.
R: Enhances sense of trust and nurse-client relationship.

I: Discuss issues, such as what is in the power of the individual to change and what is beyond control.
R: Recognition of these factors helps client focus energy for maximal benefit/ outcome.

Doenges, et al, 2002, Gulanick, 2007; Kruse, et al, 2003

Nursing Care Plan: Knowledge, deficient regarding condition, treatment program, self-care, and discharge needs related to lack of exposure and information, misinterpretation of information and unfamiliarity with information resources.

Scientific Basis:

A deficit in knowledge is commonly experienced by individuals coping with new medical diagnosis varied pharmacological and treatment regimens, unfamiliar and often complex problems, as well as by individuals entering stages or role relationships that demand new pattern of response.

Some patients may have access to information or know where to seek it, others may have providers who are not teaching them or who cannot be understood. This lack of an open information, flowing relationship with provider often causes the client to misinterpret information or forget it because of the disuse/ lack of reinforcement for correct use.

Because of the patient’s education is considered a skill reimbursed by Medicare & other commercial insurance carriers. It is important for the nurse to include knowledge deficit in the plan of care. The deficit in knowledge may relate to clients lack of information about their disease process, medication or resources

Patients needs to be aware of the activities that reduce the risk, signs and symptoms of complications, and what to do when the condition manifest.

Kozier, et al, 2007; Perry and Potter, 2002


Intervention and Rationale

I: Assess motivation and willingness of client.
R: Some clients are ready to learn soon after they are diagnosed

I: Assess ability to learn or perform desired health-related care.
R: Cognitive impairments need to be identified so an appropriate teaching plan can be designed.

I: Identify any existing misconceptions regarding materials to be taught.
R: This provides starting point in education.

I: Determine cultural influences on health teaching.
R: Providing a climate of acceptance allows clients to be themselves and to hold their own beliefs as appropriate.

I: Determine client’s learning style especially if client had learned and retained new information in the past.
R: Some persons may prefer written over visual materials, or they may prefer group versus individual instruction. Matching the learner’s preferred style with the educational method facilitates success in mastery of knowledge.

I: Determine client’s baseline of knowledge regarding the disease process.
R: Provides information regarding understanding of the patient’s knowledge.

I: Review pathophysiology of condition and signs/symptoms of possible complications, e.g., gangrene and further amputation.
R: Provides a knowledge base from which client can make
informed choices and understand/identify healthcare needs.

I: Instruct client/ family in disease process, progression, what to expect, and answer all questions honestly.
R: Promotes optimal learning environment when client show willingness to learn. Family members may assist with helping the client to make informed choices regarding the treatment. Anxiety or large volumes of instruction may impede comprehension and limit learning.

I: Encourage questions.
R: Learners often feel shy or embarrassed about asking questions and often wants permission to ask them.

I: Provide an atmosphere of respect, openness, trust, collaboration, quiet without interruption.
R: This is especially important when providing education to the clients with different values and beliefs about health and illness, and it allows more concentration to the topic being discussed.

I: Explain purpose of activity restrictions and need for balance between activity/rest.
R: Rest reduces oxygen and nutrient needs of compromised tissues and decreases risk of fragmentation of thrombosis. Balancing rest with activity prevents exhaustion and further impairment of cellular perfusion.

I: Establish appropriate exercise/activity program
R: Aids in developing collateral circulation, enhances venous return, and prevents recurrence.
I: Problem-solve solutions to predisposing factors that may be present, e.g., employment that requires prolonged standing/sitting, wearing restrictive clothing(girdles/garters),
R: Actively involves patient in identifying and initiating lifestyle/ behavior changes to promote health and prevent recurrence of condition/development of complications.

I: Recommend sitting with feet touching the floor, avoiding crossing of legs.
R: Prevents excess pressure on the popliteal space.

I: Stress importance of medical follow-up/laboratory testing.
R: Understanding that close supervision of anticoagulant therapy is necessary (therapeutic dosage range is narrow and complications may be deadly) promotes client participation.

I: Instruct in meticulous skin care of lower extremities, e.g.,
prevent/promptly treat breaks in skin and report development of lesions/ulcers or changes in skin color.
R: Chronic venous congestion/postphlebotic syndrome ma develop (especially in presence of severe vascular involvement and/or recurrent episodes), potentiating risk of stasis ulcers/infection.

I: Focus teaching sessions on a single concept or idea.
R: This allows the learner to concentrate more completely on material being discussed. Highly anxious and older clients have reduced short-term memory and benefit from mastery of one concept at a time.

I: Document progress of teaching and learning.
R: This allows additional teaching to be based on what the learner has completed, thus enhancing the learner’s self-efficacy and encouraging the most cost-effective teaching.

Gulanick, 2007; Doenges, et. al, 2006; Kruse, et. al. 2003

Nursing Care Plan: Self-Esteem, situational low related to biophysical, psychosocial, cognitive, perceptual, cultural, and/or spiritual crisis, e.g., changes in health, status/body image, role performance, personal identity; loss of control of some aspect of life, maturational transitions, and perceived/anticipated failure at life event(s).

Scientific Basis:

Self-esteem is one’s judgment of one’s own worth, that is, how that person’s standards and performances compare to others and to one’s ideal self. As an adult, a person who has high self-esteem has feelings of significance, of competence, of the ability to cope with life, and of control over one’s destiny, stress related to prolonged illness can substantially lower a person’s self-esteem. In health care, persons who believe that their condition is viewed negatively by society may have lower self-esteem.

Often client experience emotional crisis because of the physical effect of the disease. A client may have a grief of these perceived changes in the body image. The feelings of loss on the visibility of the loss, the function of the loss and the amount investment.

The state in which an individual who previously had positive self-esteem, experiences negative feelings about self in response to an event (loss, change), continuation of these negative self-appraisals over time can lead to chronic low self-esteem.

Moyet, 2006; Berman, et al, 2008; Ignatavicius and Workman, 2002



Intervention and Rationale

I: Ask what client would like to be called.
R: Shows courtesy/respect and acknowledges person.

I: Identify SO from whom client derives comfort and who should be notified in case of emergency.
R: Allows provisions to be made for specific person(s) to visit or remain close, and provides needed support for client. Note: May or may not be legal next of kin.

I: Identify basic sense of self-esteem; image client has of existential, physical, psychological self. Identify locus of control.
R: May provide insight into whether this is a single episode or recurrent/chronic situation and can help determine needs and treatment plan. It is helpful to know whether the individual’s locus of control is internal or external to provide most helpful interventions.

I: Determine client’s perception of threat to self.
R: client’s perception is more important than what is really happening and needs to be dealt with before reality can be addressed.

I: Active-Listen client concerns and fears.
R: Conveys sense of caring and can be helpful in identifying patient’s needs, problems, and coping strategies and how effective they are. Provides opportunity to duplicate and begin a problem-solving process.

I: Assess degree to which patient feels loved and respect by others.
R: The manner in which one treated by others influence self-esteem. Feeling loved and respected despite disabilities implies that one is valued by others support self-esteem.

I: Encourage verbalization of feelings, accepting what is said.
R: Helps client/SO begin to adapt to change, and reduces anxiety about altered function/lifestyle.

I: Discuss stages of grief and the importance of grief work.
R: Grieving is a necessary step for integration of change/loss into self-concept.

I: Provide non threatening environment, listen and accept client as presented.
R: Promotes feelings of safety, encouraging verbalization

I: Observe nonverbal communication, e.g., body posture and movements, eye contact, gestures, use of touch.
R: Nonverbal language is a large portion of communication and therefore is extremely important. How the person uses touch provides information about how it is accepted and how comfortable the individual is with being touched.

I: Reflect back to client what has been said, e.g., “it upset you when he told you that.”
R: Clarification and verification of what has been heard promotes understanding and allows client to validate information, otherwise assumptions may be inaccurate.

I: Observe and describe behavior in objective terms.
R: All behavior has meaning, some of which is obvious and some of which needs to be identified. This is a process of educated guesswork and requires validation by client.

I: Identify age and developmental level.
R: Age is an indicator of the stage of life patient is experiencing, e.g., adolescence, middle age. However, developmental level may be more important than chronological age in anticipating and identifying some of client’s needs. Some degree of regression occurs during illness, depending on many factors such as the normal coping skills of the individual, the severity of the illness, and family/cultural expectations.

I: Discuss client’s view of body image and how illness/ condition might affect it.
R: Client’s perception of a change in body image may occur suddenly or over time (e.g., actual loss of a body part through injury/surgery, or a perceived loss) or be a continuous subtle process (e.g., chronic illness or aging). Awareness can alert the nurse to the need for appropriate interventions tailored to the individual need.

I: Encourage discussion of physical changes in a simple, direct, and factual manner. Give realistic feedback and discuss future options, e.g., rehabilitation services.
R: Provides opportunity to begin incorporating actual changes in an accepting and hopeful atmosphere.

I: Acknowledge efforts at problem solving, resolution of current situation, and future planning.
R: Provides encouragement and reinforces continuation of desired behaviors.

I: Recognize client’s pace for adaptation to demands of current situation.
R: Failure to acknowledge client’s need to take time and/or pressuring client to “get on with it” conveys a lack of acceptance of the person as an individual and may result in feelings of lowered self-esteem.

I: Introduce tasks at client’s level of functioning, progressing to more complex activities as tolerated.
R: Provides opportunity for client to experience successes, reaffirming capabilities and enhancing self-esteem.

I: Ascertain how client sees own role within the family system, e.g., breadwinner, homemaker, husband/father.
R: Illness may create a temporary or permanent problem in role expectations. Sexual role and how client views self in relation to the current illness also play important parts in recovery.

I: Assist client/SO with clarifying expected roles and those that may need to be relinquished or altered.
R: Provides opportunity to identify misconceptions and begin to look at options; promotes reality orientation.

I: Determine client awareness of own responsibility for dealing with situation, personal growth.
R: Conveys confidence in client’s ability to cope. When client acknowledges own part in planning and carrying out treatment plan, he has more investment in following through on decisions that have been made.

I: Assess impact of illness/surgery on sexuality.
R: Sexuality encompasses the whole person in the total environment. Many times problems of illness are superimposed on already existing problems of sexuality and can affect client’s sense of self-worth. Some problems are more obvious than others, such as illness involving the reproductive parts of the body. Others are less obvious, such as sexual values, role in family, e.g., wage earner and parent.

I: Be alert to comments and innuendos, which may mean client has a concern in the area of sexuality.
R: People are often reluctant and/or embarrassed to ask direct questions about sexual/sexuality concerns.

I: Be aware of caregiver’s feelings about dealing with the subject of sexuality.
R: Nurses/caregivers are often as reluctant and embarrassed in dealing with sexuality issues as most clients.

I: Provide information and referral to hospital and community resources.
R: Enables client/SO to be in contact with interested groups with access to assistive and supportive devices, services, and counseling.

I: Support participation in group/community activities, e.g., assertiveness classes, volunteer work, support groups.
R: Promotes skills of coping and sense of self-worth.

I: May refer to psychiatric support/therapy group, social services, as indicated.
R: May be needed to assist client/SO to achieve optimal recovery.

I: May refer to appropriate resources for sex therapy as need indicates.
R: May be someone with comfort level and knowledge who is available, or may be necessary to refer to professional resources for additional help and support.

Doenges, et al, 2008; Kruse, et al, 2003; Gulanick, 2007

Nursing Care Plan: Spiritual distress related to physical/ psychological stress; energy-consuming anxiety, situation, loss(es)/intense suffering, separation from religious/cultural ties, and challenged belief and value system.

Scientific Basis:

Spiritual distress is an experience of profound disharmony in the person’s belief or value system that threatens the meaning of his or her life. During spiritual distress the patient loses hope, questions his or her belief system, or feels separated from his or her personal source of comfort and strength. Pain, chronic or terminal illness, impending surgery, and the death or illness of loved ones are crises that may cause spiritual; distress. Being physically separated from family and family culture contributes to feeling alone and abandoned. Nurses in the hospital, home care, and ambulatory settings can assist the patient in reestablishing a sense of spiritual being.

Spirituality refers to that of being human that seeks meaningfulness through intra-, inter-, and transpersonal connection. Spirituality generally involves a belief in a relationship with some power, creative force, divine being, or infinite source of energy.

Spiritual distress refers to a change to the spiritual well-being or the belief system that provides strength, hope, and meaning to life. Some factors that may be associated with or contribute to person’s spiritual concerns. Physiologic problems, treatment related concerns, and situational concerns. Physiologic problems include having a medical diagnosis of a terminal of debilitating disease, experience pain, experiencing the loss of a body part or function. Treatment related factors include recommendation to dietary restriction, surgery, amputation of a body part.

Carpenito-Moyet, 2006; Gulanick, 2007; Berman, et al, 2008


Intervention and Rationale

I: Determine client’s religious/spiritual orientation, current involvement, and presence of conflicts.
R: Provides baseline for planning care and accessing appropriate resources.

I: Be aware of influence of caregiver’s belief system.
R: It is still possible affect to be helpful to client while remaining neutral/ not espousing own beliefs.

I: Establish environment that promotes free expression of feelings and concerns. Provide calm, peaceful setting when possible.
R: Promotes awareness and identification of feelings so they can be dealt with.

I: Listen to client/SO’s reports/expressions of anger, concern, alienation from God, belief that situation is a punishment for wrongdoing, and so forth.
R: Helpful to understand client/SO’s point of view and how they are questioning their faith in the face of tragedy.

I: Note sense of futility, feelings of hopelessness and helplessness, lack of motivation to help self.
R: These thoughts and feelings can result in the client feeling paralyzed and unable to move forward to resolve the situation.

I: Listen to expressions of inability to find meaning in life, reason for living. Evaluate for suicidal ideation.
R: May indicate need for further intervention to prevent suicide attempt.

I: Determine support systems available to client/SO(s).
R: Presence or lack of support systems can affect client’s recovery.

I: Ask how you can be most helpful. Convey acceptance of client’s spiritual beliefs/concerns.
R: Promotes trust and comfort, encouraging client to be open about sensitive matters.

I: Make time for nonjudgmental discussion of philosophic issues/questions about spiritual impact of current events/situation.
R: Helps client to begin to look at basis for spiritual confusion. Note: There is a potential for care provider’s belief system to interfere with client finding own way. Therefore it is most beneficial to remain neutral and not espouse own beliefs.

I: Discuss difference between grief and guilt and help client to identify and deal with each, assuming responsibility for own actions, expressing awareness of the consequences of acting out of false guilt.
R: Blaming self for what has happened impedes dealing with the grief process and needs to be discussed and dealt with.

I: Use therapeutic communication skills of reflection and Active-Listening.
R: Helps client find own solutions to concerns.
I: Discuss use of/provide opportunities for client/SO to experience meditation, prayer and forgiveness. Provide information that anger with God is a normal part of the grieving process.
R: Can help to heal past and present pain.

I: Assist client to develop goals for dealing with life situation.
R: Enhances commitment to goal, optimizing outcomes and promoting sense of hope.

I: Develop therapeutic nurse-client relationship. Ask how you can be most helpful. Convey acceptance of client’s spiritual beliefs/ concerns.
R: Promotes trust and comfort, encouraging client to be open about sensitive matters.

I: Help client find a reason for living.
R: Promotes sense of hope and willingness to continue efforts to improve situation.

I: Identify and may refer to resources that can be helpful (e.g., pastoral/parish nurse or religious counselor, crisis counselor, psychotherapy)
R: Specific assistance may be helpful to recovery, (e.g., relationship problems, suicidal ideation).

I: Encourage participation in support groups if possible.
R: Discussing concerns and questions with others can help client resolve feelings.

Doenges, et al, 2002; Gulanick, 2007

Nursing Care Plan: Activity Intolerance related to generalized weakness, sedentary lifestyle, insufficient sleep or rest periods and pain.

Scientific Basis:

Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in older patients with a history of orthopedic, cardiopulmonary, diabetic, or pulmonary related problems. The aging process itself causes reduction in muscle strength and function, which can impair the ability to maintain activity.

Activity may also related to factors such as obesity, malnourishment, anemia, side of effects of medication, or are to reduce as depression or lack of confidence to exert oneself. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity. And assist the client to maintain a satisfactory quality of life.

Gulanick, 2007


Intervention and Rationale

I: Monitor vital signs before and immediately after activity.
R: Vital signs should return to baseline levels in 3 minutes. The development of dyspnea may indicate a need for an alteration in exercise regimen or medication.

I: Identify causative factors leading to intolerance of activity.
R: To plan for appropriate intervention.

I: Determine the client’s perception of cause of fatigue or activity intolerance.
R: These may be temporary or permanent, physical, psychological.

I: Asses the client’s level of mobility.
R: This aids in defining what the client is capable of, which is necessary before setting realistic goals.

I: Assess nutritional status.
R: Adequate energy reserves are required for activity.

I: Assess potential for physical injury with activity. Including safety of the immediate environment.
R: Injury may be related to falls, or overexertion. Obstacles such as throw rugs, toys etc which can impede one’s ability to ambulate safely.

I: Assess the need for ambulation aids: cane or equipment modification for activities of daily living (ADLs).
R: Some aids may require more energy expenditure for clients who have reduced upper arm strength. Adequate assessment of energy requirements is indicated.

I: Assess vital signs such as the heart rate.
R: Heart rate should not increase more than 20 to 30 beats/minute above resting with routine activities. This number will change depending on the intensity of exercise the client is attempting.

I: Check for orthostatic blood pressure.
R: Older clients are more susceptible to drops in blood pressure with position change.

I: Monitor the client’s sleep patter and amount of sleep achieved over the past few days.
R: Difficulties sleeping need to be addressed before activities progression can be achieved.

I: Assess emotional response to change in physical status.
R: Depression resulting from the inability to perform required activities can further aggravate activity intolerance.

I: Establish guidelines and goals of activity with the clients and caregiver.
R: Motivation is enhanced if the client participates in goal setting. Depending on the etiological factors of activity intolerance, some clients may be able to live independently and work outside the home. Other clients with chronic debilitating disease may remain.

I: Encourage adequate rest periods, especially before meals, other ADLs, exercise sessions, and ambulation.
R: Rest between activities provides time for energy conservation and recovery. Heart rate recovery following activity is greatest at the beginning of a rest period.

I: Refrain from performing nonessential procedures.
R: Clients with limited activity tolerance need to prioritize tasks.

I: Anticipate the client’s need.
R: This reduces risk for falling while reaching.

I: Assist with ADLs as indicated: however, avoid doing for client what they can do for themselves.
R: Assisting the client with ADLs allows for conservation of energy/ caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the client’s activity tolerance and self-esteem.

I: Encourage physical activity consistent with client’s energy resources.
R: This promotes a sense of autonomy while being realistic about capabilities.

I: Assist client to plan with activities for times when they have most energy.
R: This promotes a sense of autonomy while being realistic about capabilities.

I: Encourage verbalization of feelings regarding limitations.
R: Acknowledgment that living with activity intolerance is both physically and emotionally difficult aids coping.

I: Encourage active ROM exercises. If further reconditioning is needed, confer with rehabilitation personnel.
R: Exercise maintains muscle strength.

I: Provide emotional support while increasing activity. Promote positive attitude regarding abilities
R: Clients may be fearful of overexertion. Appropriate supervision during early efforts can enhance confidence.

I: Encourage the client to choose activities gradually build endurance.
R: Physically inactive clients need to improve functional capacity through repetitive exercises over a longer period of time. Strength training is valuable in enhancing endurance for many ADLs.

I: May provide the client with the adaptive equipment needed for completing ADL activities.
R: Appropriate aids will enable the client to achieve optimal independence for self-care.

I: Teach the client and caregivers to recognize signs of physical over activity.
R: This promotes awareness of when to reduce activity.

I: Involve client and caregivers in goal setting and care planning.
R: Setting, attainable goals can increase self-confidence and self-esteem.

I: Assist in assigning priority to activities to accommodate energy levels.
R: With a reduced functional capacity, pacing of priority tasks first may be better meet the client’s needs.

I: Teach ROM and strengthening exercises.
R: Exercise promotes increased venous return, prevents contractures, and maintain / increases muscle strength.

I: Encourage client to verbalize concerns about discharge and home environment.
R: This can reduce feelings of anxiety and fear and open doors for ongoing communication.

I: Teach conservation techniques, such as the following:
R: These reduces oxygen consumption, allowing more prolonged activities.

I: Sitting to do the task.
R: Standing requires more work.

I: Change position often.
R: This distributes work to different muscles to avoid fatigue.

I: Pushing rather than pulling.
R: This reduces metabolic work.

I: Sliding rather than lifting.
R: This reduces upper body work.

I: Working at an even pace.
R: This allows enough time so not all work is completed in a short period.

I: Placing frequently used items within easy reach.
R: This avoids bending and reaching.

I: Resting at least 1 hour after meals before starting a new activity.
R: Energy is needed to digest food.

I: Organizing a work-rest-work schedule.
R: This reduces strain on energy resources.

Doenges, et al, 2008; Gulanick, 2007; Kruse, et al, 2003

Nursing Care Plan: Acute pain related to diminished arterial circulation and oxygenation of tissues with production/ accumulation of lactic acid in tissues, and inflammatory process.

Scientific Basis:

Buerger’s disease is an inflammatory of small and medium arteries and veins that leads to vascular obstruction. At first, pain in the palm of the hand and arch of the foot is the main symptoms. Pain becomes more severe with disease progressions, and as ischemia affects the nerves, the client may experience numbness, burning pain when at rest, and decreased sensation in the hands and lower extremities.

Pain is highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by sufferer.

Gulanick, 2007; White, 2002


Intervention and Rationale

I: Assess degree and characteristics of discomfort/pain. Note guarding of extremity. Palpate leg with caution.
R: Degree of pain is directly related to extent of circulatory deficit, inflammatory process, degree of tissue ischemia, and extent of edema associated with thrombus development. Changes in characteristics of pain may indicate progression of problem/development of complications.

I: Assess for referred pain as appropriate.
R: To help determine possibility of underlying condition or organ dysfunction requiring treatment.

I: Maintain bed rest during acute phase
R: Reduces discomfort associated with muscle contraction and movement.

I: Anticipate need for pain relief.
R: One can most effectively deal with pain by preventing it. Early detection and intervention may decrease the total amount of analgesic required.

I: Monitory severity of pain rating scale. Note location, quality and associated manifestation of skin, aggregation factors that increase pain and factors that alleviate the pain.
R: The single most reliable indicator of the existence of pain is the client’s self report.

I: Elevate affected extremity.
R: Encourages venous return to facilitate circulation, reducing stasis/edema formation.

I: Encourage client to change position frequently
R: Decreases/prevents muscle fatigue, helps minimize muscle spasm, maximize circulation to tissues.

I: Monitor vital signs, noting elevated temperature.
R: Elevations in heart rate may indicate increased pain/discomfort or occur in response to fever and inflammatory process. Fever can also increase client’s discomfort.

I: Provide rest periods to facilitate comfort, sleep, and relaxation.
R: The client’s experiences of pain may become exaggerated as the result of fatigue.

I: Help the client use non-pharmacological methods to control pain such as listening to music, watching TV and therapeutic massage.
R: Cognitive and behavioral strategies can restore client’s sense of control, personal efficiency and active participation in care, and by using mental picture distract oneself from painful stimuli, and heightens one’s concentration upon non-painful stimuli to decrease awareness and experience of pain.

I: Plan care activities around periods of greatest comfort whenever possible.
R: Pain diminishes activity or participation.

I: Note non-verbal cues e.g. restlessness, reluctance to move, tachycardia, diaphoresis etc.
R: Non-verbal cues maybe both physiological and psychological and maybe used in conjunction with verbal cues to identify extent of severity of the problem.

Gulanick, 2007; Doenges, et al, 2006; Kruse, et al, 2003