Anxiety Nursing Interventions and Rationales

Anxiety Definition : A vague, uneasy feeling of discomfort or dread accompanied by an autonomic response, with the source often nonspecific or unknown to the individual; a feeling of apprehension caused by anticipation of danger. It is an altering signal that warns of impending danger and enables the individual to take measures to deal with threat.

Nursing Interventions and Rationales

1. Assess client’s level of anxiety and physical reactions to anxiety (e.g., tachycardia, tachypnea, nonverbal expressions of anxiety). Validate observations by asking client, “Are you feeling anxious now?”
Anxiety is a highly individualized, normal physical and psychological response to internal or external life events (Badger, 1994).

 

2. Use presence, touch (with permission), verbalization, and demeanor to remind clients that they are not alone and to encourage expression or clarification of needs, concerns, unknowns, and questions.
Being supportive and approachable encourages communication (Olson, Sneed, 1995).

 

3. Accept client’s defenses; do not confront, argue, or debate.
If defenses are not threatened, the client may feel safe enough to look at behavior (Rose, Conn, Rodeman, 1994).

 

4. Allow and reinforce client’s personal reaction to or expression of pain, discomfort, or threats to well-being (e.g., talking, crying, walking, other physical or nonverbal expressions).
Talking or otherwise expressing feelings sometimes reduces anxiety (Johnson, 1972).

 

5. Help client identify precipitants of anxiety that may indicate interventions.
Gaining insight enables the client to reevaluate the threat or identify new ways to deal with it (Damrosch, 1991).

 

6. If the situational response is rational, use empathy to encourage client to interpret the anxiety symptoms as normal.
Anxiety is a normal response to actual or perceived danger (Peplau, 1963).

 

7. If irrational thoughts or fears are present, offer client accurate information and encourage him or her to talk about the meaning of the events contributing to the anxiety.
This study shows that during diagnosis and management of cancer, highlighting the importance of the meaning of events to an individual is an important factor in making people anxious. Acknowledgment of this meaning may help to reduce anxiety (Stark, House, 2000).

 

8. Encourage the client to use positive self-talk such as “Anxiety won’t kill me,” “I can do this one step at a time,” “Right now I need to breathe and stretch,” “I don’t have to be perfect.”
Cognitive therapies focus on changing behaviors and feelings by changing thoughts. Replacing negative self-statements with positive self-statements helps to decrease anxiety (Fishel, 1998).

 

9. Avoid excessive reassurance; this may reinforce undue worry.
Reassurance is not helpful for the anxious individual (Garvin, Huston, Baker, 1992).

 

10. Intervene when possible to remove sources of anxiety.
Anxiety is a normal response to actual or perceived danger; if the threat is removed, the response will stop.

 

11. Explain all activities, procedures, and issues that involve the client; use nonmedical terms and calm, slow speech. Do this in advance of procedures when possible, and validate client’s understanding.
With preadmission patient education, patients experience less anxiety and emotional distress and have increased coping skills because they know what to expect (Review, 2000). Uncertainty and lack of predictability contribute to anxiety (Garvin, Huston, Baker, 1992).

 

12. Explore coping skills previously used by client to relieve anxiety; reinforce these skills and explore other outlets.
Methods of coping with anxiety that have been successful in the past are likely to be helpful again. Listening to clients and helping them to sort through their fears and expectations encourages them to take charge of their lives (Fishel, 1998).

 

13. Provide backrubs for clients to decrease anxiety.
In one study the dependent variable, anxiety, was measured prior to 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). In a discussion of the results of a systematic review of 22 articles examining the effect of massage on relaxation, comfort, and sleep, the most consistent effect of massage was reduction in anxiety. Out of 10 original research studies, 8 reported that massage significantly decreased anxiety or perception of tension (Richards, Gibson, Overton-McCoy, 2000).

 

14. Provide massage before procedures to decrease anxiety.
In one study parents performed massage on their hospitalized preschoolers and school-age children before venous puncture. The results obtained indicate that massage had a significant effect on nonverbal reactions, especially those related to muscular relaxation (Garcia, Horta, Farias, 1997).

 

15. Use therapeutic touch 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). In a recent study, anxiety was significantly reduced in a therapeutic touch placebo condition. Healing touch may be one of the most useful nursing interventions available to reduce anxiety (Gagne and Toye in Fishel, 1998).

 

16. Provide clients with a means to listen to music of their choice. Provide a quiet place and encourage clients to listen for 20 minutes.
Music is a simple, inexpensive, esthetically pleasing means of alleviating anxiety. When allowed to participate in decision-making regarding their care, patients can regain a partial sense of control. As patient advocates, nurses should take advantage of the therapeutic effect of music by incorporating it into their plan of care (Evans, Rubio, 1994). Immediately and 1 hour after listening to music for 20 minutes in a quiet environment, reductions in heart rate, respiratory rate, and myocardial oxygen demand were significantly greater in the experimental group of patients with myocardial infarction than in the control group (White, 1999).

 

17. For the client experiencing preoperative anxiety, provide music of their choice for listening.
A study indicates that music combined with preoperative instruction can be more beneficial than preoperative instruction alone for reducing the anxiety of ambulatory surgery patients. Patients who listened to their choice of music before surgery in addition to receiving preoperative instruction had significantly lower heart rates than patients in the control group who received only preoperative instruction (Augustin, Hains, 1996).

 

18. Animal-assisted therapy (AAT) can be incorporated into the care of perioperative patients.
A study of perioperative clients has shown that interacting with animals reduces blood pressure and cholesterol, decreases anxiety, and improves a person’s sense of well-being ( Miller, Ingram, 2000).

 

19. Rule out withdrawal from alcohol, sedatives, or smoking as the cause of anxiety.
Withdrawal from these substances is characterized by anxiety (Badger, 1994).

 

20. Identify and limit, discontinue, or be aware of the use of any stimulants such as caffeine, nicotine, theophylline, terbutaline sulfate, amphetamines, and cocaine.
Many substances cause or potentiate anxiety symptoms.

 

Geriatric

1. Monitor client for depression. Use appropriate interventions and referrals.
Anxiety often accompanies or masks depression in elderly adults.

 

2. 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 illness (Halm, Alpen, 1993).

 

3. Observe for adverse changes if antianxiety drugs are taken.
Age renders clients more sensitive to both the clinical and toxic effects of many agents.

 

4. Provide a quiet environment with diversion.
Excessive noise increases anxiety; involvement in a quiet activity can be soothing to the elderly.

 

Multicultural

 

1. Assess for the presence of culture-bound anxiety states.
The context in which anxiety is experienced, its meaning, and responses to it are culturally mediated. The following culture-bound syndromes are related to anxiety: Susto-Latin America, Nervios-Latin America, Dhat-Asia, Koro-Southeast Asia, Kayak angst-Eskimo, Taijin kyousho-Japan, Nervous breakdown-African Americans (Kavanagh, 1999; Charron, 1998).

 

2. 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).

 

3. In the culturally diverse client identify how anxiety is manifested.
Anxiety is manifested differently from culture to culture through cognitive to somatic symptoms (Charron, 1998).

 

4. Acknowledge that value conflicts from acculturation stresses may contribute to increased anxiety.
Challenges to traditional beliefs and values are anxiety provoking (Charron, 1998).

 

 

Client/Family Teaching

 

1. Teach client and family the symptoms of anxiety.
If client and family can identify anxious responses, they can intervene earlier than otherwise (Reider, 1994). Information is empowering and reduces anxiety (Fishel, 1998).

 

2. Because intensive care unit (ICU) stays are increasingly shorter, provide written teaching information that is readily available to clients when they are transferred out.
Time constraints have become a barrier to effective teaching. A pamphlet (available in Spanish and English) has been developed to ease the move for patients, families, and critical care and medical nurses from a medical ICU (MICU) to a general floor. Reading this pamphlet has helped to reduce symptoms of anxiety (Maillet, Pata, Grossman, 1993).

 

3. Help client to define anxiety levels (from “easily tolerated” to “intolerable”) and select appropriate interventions.
Mild anxiety enhances learning and adaptation, but moderate to severe anxiety may impede or immobilize progress (Peplau, 1963).

 

4. Consider referral for the prescription of antianxiety medications for clients who have panic disorder (PD) associated with anxiety.
PD may be treated with drugs, psychosocial intervention, or both. In a recent study, the combination of imipramine and cognitive-behavioral therapy appeared to confer limited advantage acutely but more substantial advantage by the end of maintenance (Barlow et al, 2000).

 

5. Teach client techniques to self-manage anxiety.
Mental health interventions during hospitalization should emphasize teaching patients to manage their own anxiety instead of directly intervening to reduce current levels of anxiety (Rose, Conn, Rodeman, 1994).

 

6. Teach client to identify and use distraction or diversion tactics when possible.
Early interruption of the anxious response prevents escalation.

 

7. Teach client to allow anxious thoughts and feelings to be present until they dissipate.
Allowing and even devoting time and energy to a thought, purposefully and repetitively, reduces associated anxiety (Beck, Emery, 1985).

 

8. Teach progressive muscle relaxation techniques.
In one study, a significant reduction in anxiety level was obtained by using progressive muscle relaxation interventions (Weber, 1996).

 

9. Teach relaxation breathing for occasional use: client should breathe in through nose, fill slowly from abdomen upward while thinking “re,” and then breathe out through mouth, from chest downward, and think “lax.”
Anxiety management training effectively treats both specific and generalized anxiety (Fishel, 1998).

 

10. Teach client to visualize or fantasize about the absence of anxiety or pain, successful experience of the situation, resolution of conflict, or outcome of procedure.
Use of guided imagery has been useful for reducing anxiety (Weber, 1996).

 

11. Teach relationship between a healthy physical and emotional lifestyle and a realistic mental attitude.
Health and well-being are influenced by how well-defined and met needs are in areas of safety, diet, exercise, sleep, work, pleasure, and social belonging. Exercise is an excellent means of decreasing anxiety (Fishel, 1998). Results of cross-sectional and longitudinal studies seem to indicate that aerobic exercise training has antidepressant and anxiolytic effects and protects against harmful consequences of stress (Salmon, 2000).

 

12. Teach use of appropriate community resources in emergency situations (e.g., suicidal thoughts), such as hotlines, emergency rooms, law enforcement, and judicial systems.
The method of suicide prevention found to be most effective is a systematic, direct-screening procedure that has a high potential for institutionalization (Shaffer, Craft, 1999).

 

13. Encourage use of appropriate community resources: family, friends, neighbors, self-help and support groups, volunteer agencies, churches, clubs and centers for recreation, and other persons with similar interests.
One of the most reassuring elements of care includes access to the family (Fishel, 1998). Vicarious experience provided through dyadic support is effective in helping patients undergoing cardiac surgery to cope with surgical anxiety and in improving self-efficacy expectations and self-reported activity after surgery (Parent, Fortin, 2000).

 

14. Provide family members with information to help them to distinguish between a panic attack and serious physical illness symptoms. Instruct family members to consult a health care professional if they have questions.
Education on managing anxiety disorders must include family members because they are the ones usually called upon to take the client for emergency care. Family members can be expert informants because of their familiarity with the client’s history and symptoms (Fishel, 1998).

Chronic Pain Nursing Interventions and Rationales

Nursing Interventions and Rationales

1. Determine whether client is experiencing pain at time of initial interview. If so, intervene at that time to provide pain relief.
The intensity, character, onset, duration, and aggravating and relieving factors of pain should be assessed and documented during the initial evaluation of the patient (American Pain Society Quality of Care Committee, 1995; JCAHO, 2000).

2. Ask client to describe past and current experiences with pain and effectiveness of the methods used to manage the pain, including experiences with side effects, typical coping responses, and how he or she expresses pain.
A number of concerns (barriers) may affect client’s willingness to report pain and use analgesics (Ward et al, 1993).

3. Describe the adverse effects of unrelieved pain.
Numerous pathophysiological and psychological morbidity factors may be associated with pain (McCaffery, Pasero, 1999; Page, Ben-Eliyahu, 1997; Puntillo, Weiss, 1994).

4. Tell client to report pain location, intensity, and quality when experiencing pain.
The intensity of pain and discomfort should be assessed and documented after any known pain-producing procedure, with each new report of pain, and at regular intervals (American Pain Society Quality of Care Committee, 1995; JCAHO, 2000).

5. Ask client to maintain a diary of pain ratings, timing, precipitating events, medications, treatments, and what works best to relieve pain.
Systematic tracking of pain appears to be an important factor in improving pain management (Faries et al, 1991; JCAHO, 2000).

6. Determine client’s current medication use.
To aid in planning pain treatment, obtain a medication history (Acute Pain Management Guideline Panel, 1992).

7. Explore need for medications from the three classes of analgesics: opioids (narcotics), non-opioids (acetaminophen, Cox-2 inhibitors, and nonsteroidal antiinflammatory drugs [NSAIDs]), and adjuvant medications. For chronic neuropathic pain, consider adjuvant medications that are analgesic, such as anticonvulsants and antidepressants. Some types of pain respond to non-opioid drugs alone.
However, if pain is not responding, consider increasing the dosage or adding an opioid. At any level of pain, analgesic adjuvants may be useful (American Pain Society, 1999). Analgesic combinations may enhance pain relief (McCaffery, Pasero, 1999).

8. The oral route is preferred. If client is receiving parenteral analgesia, use an equianalgesic chart to convert to an oral or another noninvasive route as smoothly as possible. (See Appendix E for an equianalgesic chart.)
The least invasive route of administration capable of providing adequate pain control is recommended. The oral route is the most preferred because it is the most convenient and cost effective. Avoid the intramuscular (IM) route because of unreliable absorption, pain, and inconvenience (Jacox et al, 1994).

9. Obtain a prescription to administer a non-opioid, unless contraindicated, around the clock (ATC).
NSAIDs act mainly in the periphery to inhibit the initiation of pain signals (Dahl, Kehlet, 1991). The analgesic regimen should include a non-opioid drug ATC, even if pain is severe enough to require the addition of an opioid (American Pain Society, 1999).

10. For persistent cancer pain, obtain a prescription to administer opioid analgesics.
When pain persists or increases, an opioid such as codeine or hydrocodone should be added to the non-opioid (Jacox et al, 1994). If this is not effective, switch to morphine or other single-entity opioids.

11. Establish ATC dosing and administer supplemental opioid doses as needed to keep pain ratings at or below an acceptable level.
A PRN order for a supplementary opioid dose between regular doses is an essential backup (American Pain Society, 1999).

12. Ask client to describe appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments to improve these functions. Always obtain a prescription for a peristaltic stimulant to prevent opioid-induced constipation.
Because there is great individual variation in the development of opioid-induced side effects, they should be monitored and, if their development is inevitable (e.g., constipation), prophylactically treated. Opioids cause constipation by decreasing bowel peristalsis (Jacox et al, 1994; McCaffery, Pasero, 1999).

13. Explain pain management approach that has been ordered, including therapies, medication administration, side effects, and complications.
One of the most important steps toward improved control of pain is a better client understanding of the nature of pain, its treatment, and the role client needs to play in pain control (Jacox et al, 1994).

14. Discuss client’s fears of undertreated pain, addiction, and overdose.
A number of concerns (barriers) may affect patients’ willingness to report pain and use analgesics (Ward et al, 1993). Because of the many misconceptions regarding pain and its treatment, education about the ability to control pain effectively and correction of myths about the use of opioids should be included as part of the treatment plan (McCaffery, Pasero, 1999). Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with addiction (Jacox et al, 1994).

15. Review client’s pain diary, flow sheet, and medication records to determine overall degree of pain relief, side effects, and analgesic requirements for an appropriate period (e.g., one week).
Systematic tracking of pain appears to be an important factor in improving pain management (Faries et al, 1991; JCAHO, 2000).

16. Obtain prescriptions to increase or decrease analgesic doses when indicated. Base prescriptions on the client’s report of pain severity and the comfort/function goal and response to previous dose in terms of relief, side effects, and ability to perform the daily activities and the prescribed therapeutic regimen.
Opioid doses should be adjusted individually to achieve pain relief with an acceptable level of adverse effects (Jacox et al, 1994; McCaffery, Pasero, 1999).

17. If opioid dose is increased, monitor sedation and respiratory status for a brief time.
Patients receiving long-term opioid therapy generally develop tolerance to the respiratory depressant effects of these agents (Jacox et al, 1994; McCaffery, Pasero, 1999).

18. In addition to the use of analgesics, support the client’s use of nonpharmacological methods to control pain, such as distraction, imagery, relaxation, massage, and heat and cold application.
Cognitive-behavioral strategies can restore clients’ sense of self-control, personal efficacy, and active participation in their own care (Jacox et al, 1994).

19. Teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions.
Nonpharmacological interventions should be used to supplement, not replace, pharmacological interventions (Acute Pain Management Guideline Panel, 1992).

20. Plan care activities around periods of greatest comfort whenever possible.
Pain diminishes activity (Jacox et al, 1994; McCaffery, Pasero, 1999).

21. Ask clients to describe their appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments directed toward improving these functions.
Because there is great individual variation in the development of opioid-induced side effects, clinicians should monitor and, if development is inevitable, prophylactically treat them (Jacox et al, 1994).

22. Explore appropriate resources for management of pain on a long-term basis (e.g., hospice, pain care center).
Most patients with cancer or chronic nonmalignant pain are treated for pain in outpatient and home care settings. Plans should be made to ensure ongoing assessment of the pain and the effectiveness of treatments in these settings (Jacox et al, 1994).

23. If client has progressive cancer pain, assist client and family with handling issues related to death and dying.
Peer support groups and pastoral counseling may increase the client’s and family’s coping skills and provide needed support (Jacox et al, 1994).

24. If client has chronic nonmalignant pain, assist client and family with minimizing effects of pain on interpersonal relationships and daily activities such as work and recreation.
Pain reduces clients’ options to exercise control, diminishes psychological well-being, and makes them feel helpless and vulnerable. Therefore clinicians should support active client involvement in effective and practical methods to manage pain (Hitchcock, Ferrell, McCaffery, 1994; Jacox et al, 1994).

Geriatric

1. Always take an elderly client’s reports of pain seriously and ensure that the pain is relieved.
In spite of what many professionals and clients believe, pain is not an expected part of normal aging (McCaffery, Pasero, 1999).

2. When assessing pain, speak clearly, slowly, and loudly enough for client to hear; repeat information as needed. Be sure client can see well enough to read pain scale (use enlarged scale) and written materials.

3. Handle client’s body gently. Allow client to move at own speed.

4. Use NSAIDs with caution and avoid ATC NSAID dosing.
Opioids ATC are preferable to chronic NSAID administration in the elderly client because of an increased risk for NSAID adverse effects (American Geriatric Society Panel on Chronic Pain in Older Persons, 1998).

5. Use acetaminophen and NSAIDs with low side effect profiles such as choline and magnesium salicylates (Trilisate) and diflunisal (Dolobid). Watch for side effects such as GI disturbances and bleeding problems.
Elderly clients are at increased risk for gastric and renal toxicity from NSAIDs (Griffin et al, 1991; Acute Pain Management Guideline Panel, 1992).

6. Avoid or use with caution drugs with a long half-life, such as the NSAID piroxicam (Feldene), the opioids methadone (Dolophine) and levorphanol (Levo-Dromoran), and the benzodiazepine diazepam (Valium).
A higher prevalence of renal insufficiency in the elderly than in younger persons can result in toxicity from drug accumulation (American Pain Society, 1999; Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999).

7. In an elderly client, avoid the use of opioids with toxic metabolites, such as meperidine (Demerol) and propoxyphene (Darvon, Darvocet).
Meperidine’s metabolite, normeperidine, can produce CNS irritability, seizures, and even death; propoxyphene’s metabolite, norpropoxyphene, can produce both CNS and cardiac toxicity. Both of these metabolites are eliminated by the kidneys, making meperidine and propoxyphene particularly poor choices for elderly clients, many of whom have at least some degree of renal insufficiency (Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999).

Multicultural

1. Assess pain in a culturally diverse client using a self-report 0 to 10 numerical pain rating scale or the Wong Baker Faces pain rating scale. Use a scale that has been translated into client’s native language if necessary.
Inadequate pain management is widespread, especially among minority groups, and a major reason is the failure to assess pain properly. The more cultural differences between patient and nurse, the more difficult it is for the nurse to assess and treat pain. Self-report of pain is the single most reliable indicator of pain, regardless of culture (McCaffery, 1999; McCaffery, Pasero, 1999).

2. Administer analgesics on a preventive basis to keep pain ratings at or below an acceptable level.

3. Assess for the influence of cultural beliefs, norms, and values on the client’s perception and experience of pain.
The client’s experience of pain may be based on cultural perceptions (Leininger, 1996).

4. Assess for the role of fatalism on the client’s beliefs regarding their current state of comfort.
Fatalistic perspectives in some African-American and Latino populations involve the belief that you cannot control your own fate and influence your health behaviors (Philips, Cohen, Moses, 1999; Harmon, Castro, Coe, 1996).

5. Incorporate folk health care practices and beliefs into care whenever possible.
Incorporating folk health care beliefs and practices into pain management care increased compliance with the treatment plan (Juarez, Ferrell, Borneman, 1998).

6. Use a family-centered approach when working with Latino, Asian American, African-American, and Native American clients.
Involving family in pain management care increased compliance with the treatment regimen (Juarez, Ferrel, Borneman, 1998).

7. Use culturally relevant pain scales (e.g., the Oucher scale) to assess pain in the client. Culturally diverse clients may express pain differently than clients from the majority culture.
The Oucher scale has African-American and Hispanic versions and is used to assess pain in children (Beyer, Denyes, Villarruel, 1992).

8. Ensure that directions for medications are available in the client’s language of choice and are understood by client and caregiver.
Bilingual instructions for medications increased compliance with the pain management plan (Juarez, Ferrell, Borneman, 1998).

9. Validate the client’s feelings and emotions regarding current health status.
Validation lets the client know 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

1. Review with client and caregivers the cause(s) of pain and the medical regimen specific to the cause. Assess client knowledge and teach disease process as necessary.
Compliance with the medical regimen for diagnoses involving pain improves the likelihood of successful management (Humphrey, 1994).

2. Develop a full medication profile, including medications prescribed by all physicians and all over-the-counter medications. Assess for drug interactions. Instruct client to refrain from mixing medications without physician approval.
Pain medications may significantly impact or be impacted by other medications and may cause severe side effects. Some combinations of drugs are specifically contraindicated (Jacox et al, 1994).

3. Assess client and family knowledge of side effects and safety precautions associated with pain medications (e.g., use caution when operating machinery when opioids are initiated or dose has been increased).
The cognitive effects of opioids usually subside within a week of initial dosing or dose increases (McCaffery, Pasero, 1999). The use of long-term opioid treatment does not appear to affect neuropsychological performance. Pain itself may deteriorate performance of neuropsychological tests more than oral opioid treatment (Sjogren et al, 2000).

4. Collaborate with health care team on an ongoing basis (including client and family) to determine optimal pain control profile. Identify the most effective interventions and the medication administration routes most acceptable to the family and client.
Success in pain control is partially dependent on the acceptability of the suggested intervention. Acceptability promotes compliance. Dosages vary among routes and will need to be adjusted accordingly to avoid breakthrough or transitional pain (Bohnet, 1995).

5. If administering medication using highly technological methods, assess home for necessary resources (e.g., electricity), and ensure that there will be responsible caregivers available to assist client with administration.
Some routes of medication administration require special conditions and procedures to be safe and accurate (McCaffery, Pasero, 1999).

6. Assess knowledge base of client and family for highly technological medication administration including the use of PCA pump.
Teach as necessary. Appropriate instruction in the home increases the accuracy and safety of medication administration (McCaffery, Pasero, 1999).

7. Support the client and family in the use of opioid analgesics.
Well-intentioned friends and family may create added stress by expressing judgment or fears regarding the use of opioid analgesics (McCaffery, Pasero, 1999).

Client/Family Teaching

NOTE: To avoid the negative connotations associated with the words drugs and narcotics, use the words pain medicine when teaching clients.

1. Provide written materials regarding pain control, such as the Agency for Health Care Policy and Research pamphlet, Managing Cancer Pain: Patient Guide.

2. Discuss the various discomforts encompassed by the word pain and ask clients to give examples of pain they have experienced. Explain the pain assessment process and the purpose of the pain rating scale that will be used. Teach clients to use the pain rating scale to rate the intensity of current or past pain. Ask them to set a pain relief goal by selecting a pain rating on the scale; if pain goes above this level, they should take action that decreases pain or notify a member of the health care team. (See Appendix E for information on teaching clients to use the pain rating scale.)

3. Discuss the total plan for drug and nondrug treatment, including the medication plan for ATC administration and supplemental doses, the maintenance of a pain diary, and the use of supplies and equipment.

4. Reinforce the importance of taking pain medications to keep pain under control.

5. Reinforce that taking opioids for pain relief is not an addiction.

6. Explain to clients with chronic neuropathic pain the process of taking adjuvant analgesics (e.g., tricyclic antidepressants); a low dose is used initially and is increased gradually. Emphasize that pain relief is delayed and the drugs must be taken daily. Reassure the client that although the medicine is an antidepressant, it is used for analgesia and not depression. Comparable teaching should take place when an anticonvulsant is prescribed for analgesia.

7. Emphasize to clients with chronic nonmalignant pain the importance of participating in therapeutic regimens other than medication (e.g., physical therapy, group therapy).

8. Emphasize to clients the importance of pacing themselves and taking rest breaks before they are needed.

9. Demonstrate the use of appropriate nonpharmacological approaches for controlling pain.

Urinary Retention – Nursing Interventions and Rationales

Urinary Retention Definition : Incomplete emptying of the bladder

Nursing Interventions and Rationales

1. Obtain focused urinary history emphasizing character and duration of lower urinary symptoms, remembering that the presence of obstructive or irritative voiding symptoms is not diagnostic of urinary retention. Query the patient about episodes of acute urinary retention (complete inability to void) or chronic rentention (documented elevated postvoid residual volumes).
A focused nursing history provides clues to the likely etiology of retention and its management (Gray, 2000a).

2. Question the client concerning specific risk factors for urinary retention including:

  • Disorders affecting the sacral spinal cord such as spinal cord injuries of vertebral levels T12 to L2, disk problems, cauda equina syndrome, tabes dorsalis
  • Acute neurological injury causing sudden loss of mobility such as spinal shock
  • Metabolic disorders such as diabetes mellitus, chronic alcoholism, and related conditions associated with polyuria and peripheral polyneuropathies
  • Heavy metal poisoning (lead, mercury) causing peripheral polyneuropathies
  • Advanced stage AIDS
  • Medications, including antispasmodics/parasympatholytics, alpha-adrenergics, antidepressants, sedatives, narcotics, psychotropic medications, illicit drugs
  • Recent surgery requiring general or spinal anesthesia
  • Bowel elimination patterns, history of fecal impaction, encopresis

Urinary retention is related to multiple factors affecting either detrusor contraction strength or urethral (bladder outlet) resistance of flow (Gray, 2000a; Kruse, Bray, deGroat, 1995; Pertek, Haberer, 1995; Anders, Goebel, 1998; Ginsberg et al, 1998).

3. Perform a focused physical assessment or review the results of a recent physical including perineal skin integrity; neurological examination, inspection, percussion, and palpation of the lower abdomen for obvious bladder distension; neurological examination including perineal skin sensation and the bulbocavernosus reflex; and vaginal vault examination in women/digital rectal examination in men.
The physical assessment provides clues to the likely etiology of urinary retention and its management.

4. Determine the urinary residual volume by catheterizing the patient immediately after urination, or by obtaining a bladder ultrasound following micturition.
Catheterization provides the most accurate method to determine urinary residual volume, but the procedure is invasive, carries a risk of infection, and may be uncomfortable for the patient. A bladder ultrasound is not as accurate as catheterization; nonetheless it is adequate for clinical judgments and is noninvasive (Bent, Nahhas, Mclennan, 1997; Lewis, 1995).

5. Complete a bladder log, including patterns of urine elimination, patterns of urine loss (if present), nocturia, and volume and type of fluids consumed for a period of 3 to 7 days.
The bladder log provides an objective verification of urine elimination patterns and allows comparison between fluids consumed and urinary output in a 24-hour period (Nygaard, Holcomb, 2000).

6. Consult with the physician concerning eliminating or altering medications suspected of producing or exacerbating urinary retention.
Medication side effects may cause or greatly exacerbate urinary retention in susceptible individuals (Gray, 2000a, 2000b).

7. Assess the severity of retention and its impact on quality of life using a symptom score such as the AUA Prostate
Symptom Score (BPH Guideline Panel, 1994). A symptom allows rating of the severity of obstructive and irritative symptoms, providing baseline assessment and evaluation of the efficacy of management.

8. Teach the patient with mild to moderate obstructive symptoms to double void by urinating, resting in the rest room for 3 to 5 minutes, then making a second effort to urinate.
Double voiding promotes more efficient bladder evacuation by allowing the detrusor to contract initially, then rest and contract again (Gray, 2000b).

9. Teach the patient with urinary retention and infrequent voiding to urinate by the clock.
Timed or scheduled voiding may reduce urinary retention by preventing bladder overdistension (Gray, 2000b).

10. Advise the male patient with urinary retention related to benign prostatic hyperplasia (BPH) to avoid risk factors associated with acute urinary retention by doing the following:

  • Avoiding over-the-counter cold remedies containing a decongestant (alpha-adrenergic agonist)
  • Avoiding over-the-counter dietary medications (which frequently contain alpha-adrenergic agonists)
  • Discussing voiding problems with a health care provider before beginning any new prescription medications
  • After prolonged exposure to cool weather, warming the body before attempting to urinate
  • Avoiding overfilling the bladder by adhering to regular urination patterns and refraining from excessive intake of alcohol

These manageable factors predispose the patient to acute urinary retention by overdistending the bladder and compromising detrusor contraction strength, or by increasing outlet resistance (Gray, 2000b).

11. Teach the elderly male client with BPH to self-administer finasteride or an alpha-adrenergic blocking agent such as doxazosin, terazosin, or tamsulosin as directed. Provide careful instruction concerning the dosage, administration schedule, and side effects of these drugs, including possible adverse effects when multiple doses are inadvertently missed.
Finasterid is a 5-alpha reductase inhibitor that reduces the risk of acute urinary retention when taken by men with BPH for a prolonged period (McConnell et al, 1998). The magnitude of obstruction associated with BPH is also reduced by routine administration of alpha-adrenergic blocking agents including tamsulosin, terazosin, or doxazosin. However, these agents must be taken regularly to reduce the risk of side effects, including postural hypotension (Narayan, Tewari, 1998; Lepor et al, 1997, 1998).

12. Teach the client who is unable to void specific strategies to manage this potential medical emergency including:

  • Drinking a cup of hot tea or coffee
  • Attempting urination in complete privacy
  • Placing the feet solidly on the floor
  • If unable to void using these strategies, taking a warm sitz bath or shower and voiding (if possible) while still in the tub or the shower
  • If unable to void within 6 hours, or if bladder distension is producing significant pain, seeking urgent or emergency care

A warm cup of coffee or tea stimulates the bladder and may promote voiding. Attempting urination in complete privacy and placing the feet solidly on the floor help relax the pelvic muscles and may encourage voiding. Warm water also stimulates the bladder and may produce voiding, while the cooling experienced by leaving the tub or shower may again inhibit the bladder (Gray, 2000b).
13. Remove the indwelling urethral catheter at midnight in the hospitalized patient to reduce the risk of acute urinary retention.
Removal of indwelling catheters offers several advantages to morning removal, including a larger initial voided volume (Crowe et al, 1994) or early hospital discharge with no increased risk for readmission when compared with those undergoing morning removal (McDonald, Thompson, 1999).

14. Consult the physician about bladder stimulation in the patient with urinary retention caused by deficient detrusor contraction strength.
Electrical stimulation of the bladder neck has been reported to provide beneficial results among persons with urinary retention resulting from deficient detrusor contraction strength (Moore et al, 1993).

15. Teach the client with significant urinary retention to perform self-intermittent catheterization as directed.
Intermittent catheterization allows regular, complete bladder evacuation without serious complications (Horsley, Crane, Reynolds, 1982).

16. Advise the person managed by intermittent catheterization that bacteria are likely to colonize the urine but that this condition does not indicate a clinically significant urinary tract infection.
Bacteriuria frequently occurs in the patient managed by intermittent catheterization; only symptoms producing infections warrant treatment (Maynard, Diokno, 1984).

17. Insert an indwelling catheter for the individual with urinary retention who is not a suitable candidate for intermittent catheterization.
An indwelling catheter provides continuous drainage of urine; however, the risk of serious urinary complications with prolonged use are significant (Anson, Gray, 1993; Stickler, Zimakoff, 1994).

18. Advise the person managed by an indwelling catheter that bacteria in the urine is an almost universal finding after the catheter has remained in place for a period of weeks or months and that only symptomatic infections warrant treatment.
The indwelling catheter is associated with frequent bacterial colonization. Most bacteriuria does not produce significant infection and attempts to eradicate bacteriuria often produce subsequent morbidity because resistant bacteria are encouraged to reproduce while more easily managed strains are eradicated (Moore, Rayome, 1995; White, Ragland, 1995).

Geriatric

1. Aggressively assess the elderly client for urinary retention, particularly the client with dribbling urinary incontinence, urinary tract infection, or related conditions.
Elderly women (and men) may experience retention of urine of 1500 ml or more with few or no apparent symptoms; a urinary residual volume and related assessments are necessary to determine the presence of retention in this population (Williams, Wallhagen, Dowling, 1993)

2. Assess the elderly client for impaction when urinary retention is documented or suspected.
Impaction is a common and reversible factor associated with urine loss and retention among elderly persons (Urinary Incontinence Guideline Panel, 1996).

3. Assess the elderly male client for retention related to BPH or prostate cancer.
The incidence of urinary retention related to BPH and prostate cancer increase with aging (BPH Guideline Panel, 1994).

Client/Family Teaching

1. Teach techniques for intermittent catheterization including use of clean rather than sterile technique, washing using soap and water or a microwave technique, and reuse of the catheter.

2. Teach the person with an indwelling catheter to assess the tube for patency, maintain the drainage system below the level of the symphysis pubis, and to routinely cleanse the bedside bag.

3. Teach the person managed by an indwelling catheter or intermittent catheterization the symptoms of a significant urinary infection, including hematuria, acute onset incontinence, dysuria, flank pain, or fever.

Total Urinary Incontinence Nursing Interventions and Rationales

Total urinary Incontinence Definition : Continuous and unpredictable loss of urine.

 

Nursing Interventions and Rationales

1. Obtain a history of duration and severity of urine loss, previous method of management, and aggravating or alleviating features.
The symptom of continuous incontinence may be caused by extraurethral leakage or other types of incontinence that have been inadequately evaluated and/or managed. The patient history will provide clues to the etiology of the urinary leakage (Gray, Haas, 2000).

2. Perform a focused physical assessment, including inspection of the perineal skin, examination of the vaginal vault, reproduction of the sign of stress urinary incontinence (refer to care plan for Stress urinary Incontinence), and testing of bulbocavernosus reflex and perineal sensations.
The physical examination will provide evidence supporting the diagnosis of extraurethral or another type of incontinence (stress, urge, or reflex), providing the basis for further evaluation and/or treatment (Gray, Haas, 2000).

3. Complete a bladder log of urine elimination patterns and frequency and severity of urine loss.
The bladder log provides further information, allowing the nurse to differentiate extraurethral from other forms of urine loss and providing the basis for further evaluation and treatment (Gray, Haas, 2000).

4. Assist the patient to select and apply a urine containment devices or devices. Review types of containment products with the patient, including advantages and potential complications associated with each type of product.
Urine containment products include a variety of absorptive pads, incontinent briefs, underpads for bedding, absorptive inserts that fit into specially designed undergarments, and condom catheters. Careful selection of a containment product and education concerning its use maximizes its effectiveness in controlling urine loss for a particular individual (Shirran, Brazelli, 2000; McKibben, 1995).

5. Evaluate disposable vs. reusable products for urine containment, considering factors of setting (home care vs. acute care vs. long-term care), preferences of the patient and caregiver(s), and immediate vs. long-term costs.
The impact of routine use of urine containment devices is significant, regardless of the setting. Economic factors, as well as patient and caregiver preferences, have an impact on the success and ultimate cost of a reusable vs. disposable urine containment device (Shirran, Brazelli, 2000; Hu, Kaltreider, Igou, 1990; Cummings et al, 1995).

6. Cleanse the skin with an incontinence cleansing product system or plain water when changing urinary containment devices or pads. Use soap and water on the perineum no more than once daily or every other day as necessary.
Excessive cleansing of the perineal skin may exacerbate alterations in skin integrity, particularly among the elderly (Byers et al, 1995; Lindell, Olsson, 1990).

7. Apply a skin moisturizer following cleansing.
Moisturizers promote comfort and may reduce the risk of skin breakdown (Kemp, 1994).

8. Apply a protective barrier or ointment to the perineal skin when incontinence is severe, when double fecal and urinary incontinence exist, or when the risk of a pressure ulcer is considered significant.
A moisture barrier is indicated when the risk of altered skin integrity is complicated by coexisting factors of shear, fecal incontinence, or exposure to prolonged pressure (Fiers, Thayer, 2000; Kemp, 1994).

9. Consult the physician concerning use of an antifungal powder or ointment when perineal dermatitis is complicated by monilial infection. Teach the patient to use the product sparingly when applying to affected areas.
Antifungal powders or ointments provide effective relief from monilial rash; however, application of excessive amounts of the product retain moisture and diminish its effectiveness (Fiers, Thayer, 2000).

10. Consult the physician concerning placement of an indwelling catheter when severe urine loss is complicated by urinary retention, when careful fluid monitoring is indicated, when perineal dryness is required to promote the healing of a stage 3 or 4 pressure ulcer, during periods of critical illness, or in the terminally ill client when use of absorbent products produces pain or distress.
Although not routinely indicated, the indwelling catheter provides an effective, transient management technique for carefully selected patients (Urinary Incontinence Guideline Panel, 1996; Treatment of Pressure Ulcers Guideline Panel, 1994).

11. Refer the client with “intractable” or extraurethral incontinence to a continence service or specialist for further evaluation and management of urine loss.
The successful management of complex, severe urinary incontinence requires specialized evaluation and treatment from a health care provider with special expertise (Doughty, 1991; Gray; 1992).

Geriatric

1. Provide privacy and support when changing incontinent device of elderly client.
Elderly, hospitalized clients frequently express feelings of shame, guilt, and dependency when undergoing urinary containment device changes (Biggerson et al, 1993).

2. Employ meticulous infection control procedures when using an indwelling catheter.

Home Care Interventions

NOTE: The interventions identified are all applicable to the home care setting. Review the interventions for appropriateness to individual clients.

Client/Family Teaching

1. Teach the family to obtain, apply, and dispose of or clean and reuse urine containment devices.

2. Teach the family a routine perineal skin care regimen, including daily or every other day hygiene and cleansing with containment product changes.

3. Teach the client and family to recognize and manage perineal dermatitis, ammonia contact dermatitis, and monilial rash.

4. Teach the patient to maintain adequate fluid intake (30 ml/kg of body weight/day).

5. Teach the client and family to recognize and manage urinary infection.