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Brunner and Suddarth's Canadian Textbook of Medical-Surgical Nursing [3 ed.]
 9781451193336, 2014043943

Table of contents :
BRUNNER & SUDDARTH’S: Canadian Textbook of Medical-Surgical Nursing, Third Edition
Half Title Page
Title Page
Contributors New to the Third Canadian Edition
Contributors to the Second Canadian Edition
Contributors to the 12th U.S. Edition
Preface and
About the Third Canadian Edition
NANDA, NIC, NOC: Links, Languages, and Concept Maps
Basic Concepts in Nursing
CHAPTER 1 Health Care Delivery and Nursing Practice
CHAPTER 2 Community-Based Nursing Practice
CHAPTER 3 Critical Thinking, Ethical Decision Making, and the Nursing Process
CHAPTER 4 Health Education and Health Promotion
CHAPTER 5 Adult Health and Nutritional Assessment
CHAPTER 6 Obesity
UNIT 2 Biophysical and Psychosocial Concepts in Nursing Practice
CHAPTER 7 Homeostasis, Stress, and Adaptation
CHAPTER 8 Individual and Family Considerations Related to Illness
CHAPTER 9 Perspectives in Transcultural Nursing
CHAPTER 10 Genetics and Genomics Perspectives in Nursing
CHAPTER 11 Chronic Illness
CHAPTER 12 Principles and Practices of Rehabilitation Including Disabilities
CHAPTER 13 Health Care of the Older Adult
UNIT 3 Concepts and Challenges in Patient Management
CHAPTER 14 Pain Management
CHAPTER 15 Fluid and Electrolytes: Balance and Disturbance
CHAPTER 16 Shock and Multiple Organ Dysfunction Syndrome
CHAPTER 17 Oncology: Nursing Management in Cancer Care
CHAPTER 18 Hospice Palliative Care at the End-of-Life
UNIT 4 Perioperative Concepts and Nursing Management
CHAPTER 19 Preoperative Nursing Management
CHAPTER 20 Intraoperative Nursing Management
CHAPTER 21 Postoperative Nursing Management
UNIT 5 Gas Exchange and Respiratory Function
CHAPTER 22 Assessment of Respiratory Function
CHAPTER 23 Management of Patients With Upper Respiratory Tract Disorders
CHAPTER 24 Management of Patients With Chest and Lower Respiratory Tract Disorders
CHAPTER 25 Management of Patients With Chronic Obstructive Pulmonary Disease
CHAPTER 26 Respiratory Care Modalities
UNIT 6 Cardiovascular, Circulatory, and Hematologic Function
CHAPTER 27 Assessment of Cardiovascular Function
CHAPTER 28 Management of Patient With Dysrhythmias and Conduction Problems
CHAPTER 29 Management of Patients With Coronary Vascular Disorders
CHAPTER 30 Management of Patients With Structural, Infections, and Inflammatory Cardiac Disorders
CHAPTER 31 Management of Patients With Complications From Heart Disease
CHAPTER 32 Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation
CHAPTER 33 Assessment and Management of Patients With Hypertension
CHAPTER 34 Assessment and Management of Patients With Hematologic Disorders
UNIT 7 Digestive and Gastrointestinal Function
CHAPTER 35 Assessment of Digestive and Gastrointestinal Function
CHAPTER 36 Management of Patients With Oral and Esophageal Disorders
CHAPTER 37 Gastrointestinal Intubation and Special Nutritional Modalities
CHAPTER 38 Management of Patients With Gastric and Duodenal Disorders
CHAPTER 39 Management of Patients With Intestinal and Rectal Disorders
UNIT 8 Metabolic and Endocrine Function
CHAPTER 40 Assessment and Management of Patients With Hepatic Disorders
CHAPTER 41 Assessment and Management of Patients With Biliary Disorders
CHAPTER 42 Assessment and Management of Patients With Diabetes Mellitus
CHAPTER 43 Assessment and Management of Patients With Endocrine Disorders
UNIT 9 Urinary Tract Function
CHAPTER 44 Assessment of Renal and Urinary Tract Function
CHAPTER 45 Management of Patients With Renal Disorders
CHAPTER 46 Management of Patients With Urinary Disorders
UNIT 10 Reproductive Function
CHAPTER 47 Assessment and Management of Female Physiologic Processes
CHAPTER 48 Management of Patients With Female Reproductive Disorders
CHAPTER 49 Assessment and Management of Patients With Breast Disorders
CHAPTER 50 Assessment and Management of Concerns Related to Male Reproductive Processes
UNIT 11 Immunologic Function
CHAPTER 51 Assessment of Immune Function
CHAPTER 52 Management of Patients With Immunodeficiency
CHAPTER 53 Management of Patients With HIV Illness and AIDS
CHAPTER 54 Assessment and Management of Patients With Allergic Disorders
CHAPTER 55 Assessment and Management of Patients With Rheumatic Disorders
UNIT 12 Integumentary Function
CHAPTER 56 Assessment of Integumentary Function
CHAPTER 57 Management of Patients With Dermatologic Conditions
CHAPTER 58 Management of Patients With Burn Injury
UNIT 13 Sensorineural Function
CHAPTER 59 Assessment and Management of Patients With Eye and Vision Disorders
CHAPTER 60 Assessment and Management of Patients With Hearing and Balance Disorders
UNIT 14 Neurologic Function
CHAPTER 61 Assessment of Neurologic Function
CHAPTER 62 Management of Patients With Neurologic Dysfunction
CHAPTER 63 Management of Patients With Cerebrovascular Disorders
CHAPTER 64 Management of Patients With Neurologic Trauma
CHAPTER 65 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies
CHAPTER 66 Management of Patients With Oncologic or Degenerative Neurologic Disorders
UNIT 15 Musculoskeletal Function
CHAPTER 67 Assessment of Musculoskeletal Function
CHAPTER 68 Musculoskeletal Care Modalities
CHAPTER 69 Management of Patients With Musculoskeletal Disorders
CHAPTER 70 Management of Patients With Musculoskeletal Trauma
UNIT 16 Other Acute Problems
CHAPTER 71 Management of Patients With Infectious Diseases
CHAPTER 72 Emergency Nursing
CHAPTER 73 Emergency Preparedness and Disaster Nursing

Citation preview


Canadian Textbook of Medical-Surgical Nursing THIRD EDITION Pauline Paul, PhD, RN Associate Professor Faculty of Nursing, University of Alberta Edmonton, Alberta Rene A. Day, PhD, RN Professor Emerita Faculty of Nursing, University of Alberta Edmonton, Alberta Bev Williams, PhD, RN Professor Faculty of Nursing, University of Alberta Edmonton, Alberta

Authors of Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 12th Edition Suzanne C. Smeltzer, EdD, RN, FAAN Professor and Director, Center for Nursing Research Villanova University College of Nursing Villanova, Pennsylvania Brenda G. Bare, RN, MSN Formerly, Associate Administrator/Chief Nurse Executive Inova Mount Vernon Hospital Alexandria, Virginia Janice L. Hinkle, PhD, RN, CNRN Formerly, Senior Research Fellow, Acute Stroke Programme Oxford Brookes University and John Radcliffe Hospital Oxford, United Kingdom Kerry H. Cheever, PhD, RN Professor and Chairperson St. Luke’s School of Nursing at Moravian College Assistant Vice President St. Luke’s Hospital & Health Network Bethlehem, Pennsylvania

Executive Editor: Sherry Dickinson Supervising Product Development Editor: Annette Ferran Editorial Assistant: Dan Reilly Marketing Manager: Dean Karampelas Production Project Manager: David Saltzberg Design Coordinator: Joan Wendt Art Coordinator: Jen Clements Manufacturing Coordinator: Karin Duffield Prepress Vendor: Aptara, Inc. Third Canadian edition. Copyright © 2016 Wolters Kluwer. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2007, 2004, 2000 by Lippincott Williams & Wilkins. Copyright © 1996 by Lippincott-Raven Publishers. Copyright © 1992, 1988, 1984, 1975, 1970, 1964 by J. B. Lippincott Company. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at (products and services). 9 8 7 6 5 4 3 2 1 Printed in China Library of Congress Cataloging-in-Publication Data Brunner & Suddarth’s textbook of Canadian medical-surgical nursing Brunner & Suddarth’s Canadian textbook of medical-surgical nursing / [edited by] Pauline Paul, Rene A. Day, Bev Williams.—Third Canadian edition. p. ; cm. Canadian textbook of medical-surgical nursing Preceded by Brunner & Suddarth's textbook of Canadian medical-surgical nursing / [edited by] Rene A. Day ... [et al.]. 2nd Canadian ed. 2010. Includes bibliographical references and index. ISBN 978-1-4511-9333-6 (alk. paper) I. Paul, Pauline, 1958- , editor. II. Day, Rene A., editor. III. Williams, Bev, 1951- , editor. IV. Title. V. Title: Canadian textbook of medical-surgical nursing. [DNLM: 1. Nursing Care. 2. Perioperative Nursing. WY 150] RT41 610.730971—dc23 2014043943 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.

Preface and Acknowledgements

As we complete the second decade of the 21st century, nursing continues to be influenced by the expansion of science and technology and by social, cultural, economic, and environmental changes throughout the world. At the same time, today’s nurses are faced with the many challenges that result from the acute shortage of nurses throughout health care settings. This worldwide nursing shortage has resulted in the need for nurses to have increasingly high levels of nursing knowledge and skills in meeting the acute care, long-term care, and health promotion needs of individuals and groups. Nurses must be particularly skilled in critical thinking and clinical decision making as well as in consulting and collaborating with other members of the interprofessional health care team. Along with the challenges that today’s nurses confront, there are many opportunities for them to provide skilled, compassionate nursing care in a variety of health care settings, for patients in various stages of illness, and for patients across the age continuum. At the same time, there are significant opportunities for fostering health promotion activities for individuals and groups; this is an integral part of providing nursing care.

About the Third Canadian Edition This third Canadian edition builds on the 12th U.S. edition of Brunner & Suddarth’s Textbook of MedicalSurgical Nursing and is designed to assist nursing students in preparing for their roles and responsibilities within the complex health care system. A goal of the textbook is to provide balanced attention to both the art and science of adult medical-surgical nursing. The focus of the textbook is on physiologic, pathophysiologic, psychosocial, and spiritual concepts as they relate to nursing care. Emphasis is placed on integrating a variety of concepts from other disciplines such as nutrition, pharmacology, and gerontology. Throughout the textbook, particular attention has been placed on addressing the nursing care and health care needs of older adults and people with disabilities, both of which are important priorities in the education of tomorrow’s health care professionals. In addition, content relative to nursing research findings and evidence-based practice has been expanded to provide opportunities for the nurse to refine clinical decision-making skills.

Canadian contributors have reviewed each chapter and have changed the following as needed: drug names, names of tests and procedures, spelling, laboratory values to the international system of units, and all measurements to their metric equivalents. Whenever possible, the contributors have added Canadian citations, references, and research studies and have provided Canadian statistics related to disease entities. This third Canadian edition includes new and updated material that reflects the differences in Canadian nursing practice in terms of the health care system, community health, ethics, culture, epidemiology, pain management, gerontology, infection control, nursing and medical management, pharmacology, diagnostic tests and investigations, as well as support groups and Web resources specific to Canada. In this new edition a full chapter has been added on the topic of obesity, which is increasingly prevalent in Canadians. Many of the chapters have been significantly updated to reflect the latest evidence.

NANDA, NIC, NOC: Links, Languages, and Concept Maps Although Brunner & Suddarth’s Textbook of MedicalSurgical Nursing has long used nursing diagnoses developed by the North American Nursing Diagnosis Association (NANDA), this edition presents the links between the NANDA diagnoses and the Nursing Intervention Classification (NIC) and Nursing Outcomes Classification (NOC). Each unit begins with a case study and a chart presenting examples. Concept maps, which provide a visual representation of the NANDA, NIC, and NOC chart for each case study, are presented in each chapter. This material is included to introduce students and nurses to the NIC and NOC language and classifications and bring them to life in the clinical realm. Faculty and students alike may use some of the issues presented in the case studies as a springboard for developing their own concept maps.

Organization Brunner & Suddarth’s Canadian Textbook of Medical-Surgical Nursing, 3rd edition, is organized into 16 units. Units 1 through 4 cover core concepts related to medical-surgical nursing practice. Units 5 through 16 discuss adult health xi


Preface and Acknowledgements

conditions that are treated medically or surgically. Each unit covering adult health conditions is structured in the following way to facilitate understanding: • The first chapter in the unit covers assessment and includes a review of normal anatomy and physiology of the body system being discussed. • The subsequent chapters in the unit cover management of specific disorders. Pathophysiology, clinical manifestations, assessment and diagnostic findings, medical management, and nursing management are presented. Special Nursing Process sections, provided for selected conditions, clarify and expand on the nurse’s role in caring for patients with these conditions.

Features Nurses assume many different roles when caring for patients. Many of the features in this textbook have been developed to help nurses fulfill these varied roles.

Acknowledgements We gratefully acknowledge our Canadian contributors who took on the challenge of continuing to “Canadianize” and update this edition of Brunner & Suddarth’s Canadian Textbook of Medical-Surgical Nursing. At the Faculty of Nursing, University of Alberta, we thank: • Our students who are using the textbook and who have provided us with helpful suggestions • Our colleagues who have supported us through the process of bringing 73 chapters to production • L. Wayne Day, our project manager, for his outstanding Internet searching skills. At Wolters Kluwer, we thank Annette Ferran, Supervising Product Development Editor, Nursing Education for her patience and commitment to this project. Thanks also to Corey Wolfe, Barry Wight, and Dan Renaud for their ongoing support. Pauline Paul, PhD, RN Rene A. Day, PhD, RN Bev Williams, PhD, RN


UNIT 1 Basic Concepts in Nursing . . . . . . . . . . 2 1 Health Care Delivery and Nursing Practice 4 2 Community-Based Nursing Practice 13 3 Critical Thinking, Ethical Decision Making, and the Nursing Process 21 4 Health Education and Health Promotion 38 5 Adult Health and Nutritional Assessment 53 6 Obesity 7 7

UNIT 2 Biophysical and Psychosocial Concepts in Nursing Practice . . . . . . . . . . . . . . . 96

7 Homeostasis, Stress, and Adaptation 98 8 Individual and Family Considerations Related to Illness 117 9 Perspectives in Transcultural Nursing 130 10 Genetics and Genomics Perspectives in Nursing 142 11 Chronic Illness 166 12 Principles and Practices of Rehabilitation Including Disabilities 180 13 Health Care of the Older Adult 216

19 Preoperative Nursing Management 444 20 Intraoperative Nursing Management 464 21 Postoperative Nursing Management 483

UNIT 5 Gas Exchange and Respiratory Function . . . . . . . . . . . . . . . . . . . . . . 506

22 Assessment of Respiratory Function 508 23 Management of Patients With Upper Respiratory Tract Disorders 539 24 Management of Patients With Chest and Lower Respiratory Tract Disorders 574 25 Management of Patients With Chronic Obstructive Pulmonary Disease 632 26 Respiratory Care Modalities 667

UNIT 6 Cardiovascular, Circulatory, and Hematologic Function . . . . . . . . . . . 714

UNIT 3 Concepts and Challenges in Patient Management. . . . . . . . . . . . . . . . . . . 244

14 Pain Management 246 15 Fluid and Electrolytes: Balance and Disturbance 282 16 Shock and Multiple Organ Dysfunction Syndrome 334 17 Oncology: Nursing Management in Cancer Care 359 18 Hospice Palliative Care at the End-of-Life

UNIT 4 Perioperative Concepts and Nursing Management. . . . . . . . . . . . . . . . . . . 442


27 Assessment of Cardiovascular Function 716 28 Management of Patient With Dysrhythmias and Conduction Problems 754 29 Management of Patients With Coronary Vascular Disorders 790 30 Management of Patients With Structural, Infections, and Inflammatory Cardiac Disorders 840 31 Management of Patients With Complications From Heart Disease 867 32 Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation 896




33 Assessment and Management of Patients With Hypertension 938 34 Assessment and Management of Patients With Hematologic Disorders 961

UNIT 7 Digestive and Gastrointestinal Function . . . . . . . . . . . . . . . . . . . . . 1038

35 Assessment of Digestive and Gastrointestinal Function 1040 36 Management of Patients With Oral and Esophageal Disorders 1060 37 Gastrointestinal Intubation and Special Nutritional Modalities 1086 38 Management of Patients With Gastric and Duodenal Disorders 1114 39 Management of Patients With Intestinal and Rectal Disorders 1139

UNIT 8 Metabolic and Endocrine Function. . . . 1188

40 Assessment and Management of Patients With Hepatic Disorders 1190 41 Assessment and Management of Patients With Biliary Disorders 1243 42 Assessment and Management of Patients With Diabetes Mellitus 1271 43 Assessment and Management of Patients With Endocrine Disorders 1334

UNIT 9 Urinary Tract Function . . . . . . . . . . 1380

44 Assessment of Renal and Urinary Tract Function 1382 45 Management of Patients With Renal Disorders 1402 46 Management of Patients With Urinary Disorders 1450

UNIT 10 Reproductive Function . . . . . . . . . . 1488

47 Assessment and Management of Female Physiologic Processes 1490 48 Management of Patients With Female Reproductive Disorders 1531 49 Assessment and Management of Patients With Breast Disorders 1566

50 Assessment and Management of Concerns Related to Male Reproductive Processes 1600

UNIT 11 Immunologic Function . . . . . . . . . . 1634

51 Assessment of Immune Function 1636 52 Management of Patients With Immunodeficiency 1655 53 Management of Patients With HIV Illness and AIDS 1667 54 Assessment and Management of Patients With Allergic Disorders 1706 55 Assessment and Management of Patients With Rheumatic Disorders 1734

UNIT 12 Integumentary Function . . . . . . . . . 1762

56 Assessment of Integumentary Function 1764 57 Management of Patients With Dermatologic Conditions 1782 58 Management of Patients With Burn Injury 1838

UNIT 13 Sensorineural Function . . . . . . . . . . 1888

59 Assessment and Management of Patients With Eye and Vision Disorders 1890 60 Assessment and Management of Patients With Hearing and Balance Disorders 1938

UNIT 14 Neurologic Function . . . . . . . . . . . . 1970

61 Assessment of Neurologic Function 1972 62 Management of Patients With Neurologic Dysfunction 2003 63 Management of Patients With Cerebrovascular Disorders 2044 64 Management of Patients With Neurologic Trauma 2071 65 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 2104


66 Management of Patients With Oncologic or Degenerative Neurologic Disorders 2132

UNIT 15 Musculoskeletal Function . . . . . . . . 2166

67 Assessment of Musculoskeletal Function 2168 68 Musculoskeletal Care Modalities 2185 69 Management of Patients With Musculoskeletal Disorders 2215 70 Management of Patients With Musculoskeletal Trauma 2244


UNIT 16 Other Acute Problems . . . . . . . . . . 2284

71 Management of Patients With Infectious Diseases 2286 72 Emergency Nursing 2321 73 Emergency Preparedness and Disaster Nursing 2360

Appendix A: Understanding Clinical Pathways online Appendix B: Diagnostic Studies and Interpretation online Index 2383


Canadian Textbook of Medical-Surgical Nursing



Basic Concepts in Nursing

Case Study Applying Concepts From NANDA-I, NIC, and NOC The Community With an Identified Health Problem A nurse working in an urgent care clinic that serves an economically depressed urban area notes a high incidence of older patients with dehydration and heatstroke in the summer months. The nurse verifies the observations by accessing data about hospital admissions for dehydration and heatstroke. The nurse determines that many of the admitted patients live in the area served by the clinic and that many of the patients live alone and have chronic illnesses. The nurse sees the need for a plan that includes a community response to this situation. The plan includes arranging an education program about the prevention of dehydration; a community support buddy system in which neighbours or volunteers call or visit homebound older adults during critical periods in the summer; and economic support to air condition the senior citizens’ centre. Visit to view a concept map that illustrates the relationships that exist among the nursing diagnoses, interventions, and outcomes for the patient’s clinical conditions.

A community with an identified health problem receives the nursing diagnoses Ineffective Therapeutic Regimen Management

requires nursing interventions

supports the need for

Community Health Development

supports the need for


outcomes should show improvement in improves

Community Competence


Program Development and


Ineffective Community Coping

may also demonstrate Readiness for Enhanced Community Coping

supports the need for

improves and

may require intensive

Surveillance: Community

will help assess


will help assess

supports the need for

may enhance community

Environmental Risk Protection

Community Health Status

Nursing Classifications and Languages NANDA-I Nursing Diagnoses

Deficient Community Health Presence of one or more health problems or factors that deter wellness or increase the risk of health problems experienced by an aggregate.

NIC Nursing Interventions

NOC Nursing Outcomes

Return to functional baseline status, stabilization of, or improvement in:

Community Health Development— Assisting members of a community to identify a community’s health concerns, mobilize resources, and implement solutions Program Development—Planning, implementing, and evaluating a coordinated set of activities designed to enhance wellness or to prevent, reduce, or eliminate one or more health problems for a group or community

Ineffective Community Coping— Pattern of community activities (for adaptation and problem solving) that is unsatisfactory for meeting the demands or needs of the community

Surveillance: Community— Purposeful and ongoing acquisition, interpretation, and synthesis of data for decision making in the community

Community Competence— Capacity of a community to collectively problem solve to achieve community goals

Readiness for Enhanced Community Coping—Pattern of community activities for adaptation and problem solving that is sufficient for meeting the demands or needs of the community but can be improved for management of current and future problems/stressors and can be strengthened.

Environmental Risk Protection— Preventing and detecting disease and injury in populations at risk from environmental hazards

Community Health Status—The general state of well-being of a community or population

From Bulechek, G. M., Butcher, H. K., Dochterman, J. M., et al. (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Elsevier; Herdman, T. H. (Ed.) (2012). NANDA International nursing diagnosis: Definitions & classifications, 2012–2014. Oxford, UK: Wiley-Blackwell; Johnson, M., Bulechek, G., McCloskey Dochterman, J., et al. (2012). NOC and NIC linkages to NANDA-I (3rd ed.). St. Louis, MO: Mosby; Moorhead, S., Johnson, M., Mass, M. L., et al. (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Elsevier; North American Nursing Diagnosis Association - International. (2011). Nursing diagnoses, 2012–2014 Edition: Definitions & classification NANDA-I NURSING DIAGNOSIS. West Sussex, UK: John Wiley & Sons.



1 Health Care Delivery and Nursing Practice Adapted by Pauline Paul

Learning Objectives On completion of this chapter, the learner will be able to: 1. Define health, wellness, and health promotion. 2. Recognize and define the principles of the Canada Health Act. 3. Identify common nursing care delivery models. 4. Define primary health care. 5. List the principles of primary health care. 6. Describe factors contributing to changes in the health care system and their impact on health care and the nursing profession. 7. Describe the care giver, leadership, and research roles of nurses. 8. Discuss advanced nursing practice roles.



Organized nursing in Canada began in the 17th century with the settlement by France of the parts of North America that were then known as Acadia and New France. The provision of nursing care was one of the first services offered to settlers and Aboriginal people alike. For example, only 27 years after the foundation of Quebec City, the Augustinian Sisters founded the Hôtel-Dieu de Québec, the first hospital of New France. After the British North America Act of 1867, Roman Catholic nursing sisters continued to play an instrumental role in the development of nursing and health care in every region of the country. For example, during the late 1800s and early 1900s, the Grey Nuns of Montreal spearheaded the creation of an impressive network of hospitals across the Canadian Prairies. Although religious orders no longer play a predominant role in health care delivery in the 21st century, their legacy is alive and well through new generations of nurses and through the institutions they created and once managed. The nurses of today continue to be essential to the delivery and organization of health care services (Paul & Ross-Kerr, 2011).

THE HEALTH CARE SYSTEM AND THE NURSING PROFESSION Although the delivery of nursing care has been affected by changes occurring in the health care system, the definition of nursing has continued to distinguish nursing care and identify the major aspects of nursing care.

Nursing Defined Since the time of Florence Nightingale, who wrote in 1859 that the goal of nursing was “to put the patient in the best condition for nature to act upon him,” nursing leaders have described nursing as both an art and a science. However, the definition of nursing has evolved over time. The International Council of Nurses (ICN) states: Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of the ill, disabled and dying people. Advocacy, promotion of safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles. (ICN, 2010)

Health Care Delivery and Nursing Practice


In Canada, there are three regulated nursing professions: registered nurses (includes also nurse practitioners); practical nurses, who use the designation “licensed practical nurse” in some provinces and the designation “registered practical nurse” in other provinces; and registered psychiatric nurses, who are unique to Western Canada. Registered nurses are by far the largest group, as they constitute approximately 75% of the regulated nursing workforce (Canadian Institute for Health Information [CIHI], 2012). Because the regulation of health care professionals is under provincial jurisdiction, the provincial nursing associations—or colleges, as they are most often called— regulate individual nurses. In some provinces, registration of all nurses is under one college, while in other provinces each group of nurses has its own regulating college. The cases of Ontario and Alberta are used to provide examples of these two types of systems. In Ontario, registered nurses and registered practical nurses are both regulated by the College of Nurses of Ontario. In Alberta, registered nurses, licensed practical nurses, and registered psychiatric nurses each have their own regulating college, the College and Association of Registered Nurses of Alberta, College of Licensed Practical Nurses of Alberta, and College of Registered Psychiatric Nurses of Alberta, respectively. Provincial regulatory bodies set standards of practice and expect ethical practice from their members. An example of a code of ethics is the CNA’s Code of Ethics for Registered Nurses (Canadian Nurses Association [CNA], 2008a), which is used by most registered nurse regulatory bodies in Canada.

The Patient/Client: Consumer of Nursing and Health Care The central figure in health care services is, of course, the patient. The term patient, which is derived from a Latin verb meaning “to suffer,” has traditionally been used to describe a person who is a recipient of care. For some, this term has a connotation of dependence. For this reason, many nurses prefer to use the term client, which is derived from a Latin verb meaning “to lean,” connoting alliance and interdependence. However, for many, the term client has a mercantile connotation, which makes its use even more negative than the term patient. The term patient is used throughout this book, with the understanding that either term is acceptable.

Glossary British North American Act of 1867: legislation that lead to the creation of the Canadian Confederation, and made health care a matter of provincial jurisdiction Canada Health Act: a federal health legislation enacted in 1984 that includes five principles that must be respected across the country continuous quality improvement (CQI): the ongoing examination of processes used to provide care, with

the aim of improving quality by assessing and improving those processes that might improve patient care outcomes and patient satisfaction regulated health profession: a health profession whose members are regulated by a professional college which has the legislated mandate to protect the public



Basic Concepts in Nursing

The patient who seeks care for a health concern or concerns (increasing numbers of people have multiple health concerns) is also an individual person, a member of a family, and a member of the community. Patients’ needs vary depending on their health issues, associated circumstances, and past experiences. Among the nurse’s important functions in health care delivery are identifying the patient’s immediate needs and working in concert with the patient to address them.

The Patient’s Basic Needs Certain needs are basic to all people. Some of these needs are more important than others. Once an essential need is met, people often experience a need on a higher level of priority.

Maslow’s Hierarchy Maslow ranked human needs as follows: physiologic needs; safety and security; sense of belonging and affection; esteem and self-respect; and self-actualization, which includes self-fulfillment, desire to know and understand, and aesthetic needs. Lower-level needs always remain, but a person’s ability to pursue higher-level needs indicates movement toward psychological health and well-being. Such a hierarchy of needs is a useful framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions.

Health Care in Transition Changes occurring in health care delivery and nursing are the result of societal, economic, technologic, scientific, and political forces that have evolved throughout the 20th and 21st centuries. Among the most significant changes are shifts in population demographics, particularly the increase in the aging population and the cultural diversity of the population; changing patterns of diseases; increased technology; increased consumer expectations; higher costs of health care and changes in health care financing; and other health care reform efforts. These changes have led to institutional restructuring, staff reduction and cross-training, increased outpatient care services, decreased lengths of hospital stay, and increased health care in community and home settings. Such changes have dramatically influenced where nurses practice. These changes have influenced society’s view of health and illness and affected the focus of nursing and health care. As the proportion of the population reaching age 65 years has increased, and with the shift from acute illnesses to chronic illnesses, the traditional disease management and care focus of the health care professions has expanded. There is increasing concern about emerging infectious diseases, trauma, obesity, diabetes, and bioterrorism. Thus, health care must focus more on disease prevention, health promotion, and management of chronic conditions and disability than in previous times. This shift in focus coincides with a nationwide emphasis on cost control and resource management directed toward

providing safe, cost-efficient, and cost-effective health care services to the population as a whole.

Organization and Financing of Health Care Services in Canada The passage of the British North American Act of 1867 made health care in Canada a matter of provincial jurisdiction, and the Constitutional Act of 1982 reconfirmed this division of power. In practice, it means that because provincial governments have this constitutional authority, it takes considerable efforts to obtain the provincial and federal consensus necessary to establish policies that have a national scope. However, because Canadians see health care and the provision of health care services as a key priority, the federal government has played an increasing role in fostering the development of national policies through cost-sharing initiatives. In 1955, the provincial and federal governments agreed to establish hospital insurance, which led to the Hospital Insurance and Diagnostic Act of 1957. In 1964, the Royal Commission on Health Services recommended that it would be important to also add the provision of medical services to the national program. This recommendation led to the passage of the Medical Care Act of 1968. Although all provincial governments entered into these partnerships, the development in the following decades of provincial variations, such as the introduction of extra-billing and users fees, concerned federal authorities and brought about the Canada Health Act of 1984 (Ross-Kerr, 2011).

The Canada Health Act The Canada Health Act stipulates that health care insurance plans must be publicly administered, universal, comprehensive, accessible, and portable. Providing an exhaustive definition of these principles is beyond the scope of this chapter, but in brief, the plan must be operated and administered on a nonprofit basis by a public authority responsible to the provincial government; 100% of the insured individuals in a province are entitled to the services that are provided under this plan; the plan must insure all services offered by hospitals and physicians and, where permitted, by other health care professionals; these services must be reasonably accessible; and when moving from one province to another, or when temporarily absent from their province (but within Canada), residents must continue to be covered (Health Canada, 2002). Current issues related to the financing of health care services are further addressed in the section of this chapter on economic pressures.

Models of Nursing Care Delivery Several organizational methods or models that vary greatly from one facility to another and from one set of patient circumstances to another may be used to carry out nursing care. These methods and models have changed over the years and have included functional nursing, team nursing, primary nursing, and patient-focused or patient-centred


care. A review of these models is beyond the scope of this chapter. Of note, health care agencies may use elements of a variety of models in the actual delivery of care, and there is much variation across Canada.

HEALTH, WELLNESS, AND HEALTH PROMOTION Health How health is perceived depends on how health is defined. The World Health Organization (WHO) defines health in the preamble to its constitution as a “state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity” (WHO, 2006, p. 1). Although this definition of health does not allow for any variation in degrees of wellness or illness, the concept of a health–illness continuum allows for a greater range in describing a person’s health status. By viewing health and illness on a continuum, it is possible to consider a person as being neither completely healthy nor completely ill. Instead, a person’s state of health is ever-changing and has the potential to range from high-level wellness to extremely poor health and imminent death. Use of the health–illness continuum makes it possible to regard a person as simultaneously possessing degrees of both health and illness. On the health–illness continuum, even people with a chronic illness or disability may attain a high level of wellness if they are successful in meeting their health potential within the limits of their chronic illness or disability.

Wellness Wellness and health are related terms that nurses often use interchangeably. However, for some, wellness is a broader concept that is like a journey taken by people in their quest for well-being. Miller (2008) believes that wellness is a broad concept that includes four components: achieving balance through all phases of health; recognizing that body, mind, and spirit are connected; recognizing personal responsibility; and building relationships with self, others, and the environment. With this in mind, it becomes evident that the goal of health care providers is to promote positive changes that are directed toward health and wellbeing. The fact that the sense of wellness has a subjective aspect emphasizes the importance of recognizing and responding to patient individuality and diversity in health care and nursing.

Health Promotion In Canada, the 1974 report A New Perspective on the Health of Canadians, a Working Document, also known as the Lalonde report, brought to the forefront the concept of health promotion. Prior to its publication, health education had been the main focus of policy makers (O’Neill, Pederson, Dupéré, et al., 2007). The Lalonde report suggested that medical care was not the most important determinant of health and changes in lifestyle and

Health Care Delivery and Nursing Practice


environment played the greatest role in improving the health of populations. The WHO and Canada played a central role in creating a new vision of health promotion that recognizes that social factors are paramount to the health of populations. In 1986, Canada hosted the first international conference on health promotion, at which was promulgated the Ottawa Charter for Health Promotion. In this charter, health promotion is defined as follows: [T]he process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental, social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is therefore seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to well-being. (WHO, 1986, p. 1)

Jackson and Riley (2007) have provided a review of the development of health promotion in Canada from 1986 to 2006. According to the Public Health Agency of Canada (PHAC), the “new” health promotion recognizes that a series of factors, known as determinants of health, have a profound impact on the health of individuals and populations. These factors are income and social status, social support networks, employment and working conditions, education, physical environment, social environment, biology and genetic endowment, personal health practices and coping skills, healthy child development, health services, gender, and culture (PHAC, 2011). The Population Health Approach endorsed by the PHAC is concerned with addressing the determinants of health for the population as a whole (PHAC, 2012).

Primary Health Care The primary health care (PHC) model, first introduced by the Alma-Ata Declaration of 1978, is important in the Canadian context, especially because there is a renewed interest by governments, who see it as a way to sustain our publicly funded health care system (Reutter & Ogilvie, 2011). It is also congruent with the Principles of the Canada Health Act. Primary health care is defined as follows: Essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford. It forms an integral part both of the country’s health system of which it is the nucleus and of the overall social and economic development of the community. (WHO, 1978)

Primary health care is based on five principles that are seen as essential if a nation wishes to improve the health of its population: services must be accessible to the population, this population must be involved in the planning and operation of services, intersectoral and interdisciplinary collaboration are essential because determinants of health cannot be addressed by one type of provider alone and by only the health care sector, technologies must be adapted to the given context, and a focus on health



Basic Concepts in Nursing

promotion and prevention of illness and injury must be present (Reutter & Ogilvie, 2011).

INFLUENCES ON HEALTH CARE DELIVERY The health care delivery system is constantly adapting as the population shifts its health care needs and expectations change. The shifting demographics of the population, the increase in chronic illnesses and disability, the greater emphasis on health care costs, and technologic advances have resulted in changing emphases in health care delivery and in nursing.

Population Demographics Changes in the population in general are affecting the need for and the delivery of health care. The 2011 Canadian census indicated that there were 33,476,688 people in the country (Statistics Canada, 2012b). Population growth is attributed in part to improved public health services and improved nutrition. Not only is the population increasing, but also its composition is changing. The decline in birth rate and the increase in lifespan due to improved health care have resulted in fewer school-age children and more senior citizens, many of whom are women. Much of the population resides in highly congested urban areas, with a steady migration of members of ethnic minorities to the inner cities and a migration of members of the middle class to suburban areas. The number of people who are homeless, including entire families, has increased significantly. The population has become more culturally diverse as increasing numbers of people from different national backgrounds enter the country. Because of population changes, the health care needs of people of specific ages, of women, and of diverse groups of people in specific geographic locations is altering the effectiveness of traditional means of providing health care. As a result, far-reaching changes in the overall health care delivery system are necessary.

Aging Population The older population in the Canada has increased significantly and will continue to grow in future years. According to the 2011 census, 4,945,060 people, representing 14.8% of the Canadian population, were aged 65 years or older. Among these, there were 5,825 centenarians (Statistics Canada, 2012a). Many older Canadians live with multiple chronic conditions. As the Canadian population continues to age, it will become increasingly imperative to provide services that make it easier for older people to remain in their homes and continue to have fulfilling lives. See Chapter 13 for more details about the health care of the older adult.

Cultural Diversity An appreciation for the diverse characteristics and needs of people from varied ethnic and cultural backgrounds is important in health care and nursing.

The term “Aboriginal Peoples” includes First Nations, Inuit, and Métis populations in Canada (Royal Commission on Aboriginal Peoples, 1996). Is usually written as Aboriginal Peoples (First Nations, Inuit, and Métis). There are over 605 Aboriginal Communities in Canada and each one is unique in terms of history, language, cultural beliefs, and ceremonies (Commission on the Future of Health Care in Canada, 2002). About 4% of the Canadian population have identified themselves as Aboriginal and of these 60% are First Nations, 4% are Inuit, and 33% are Métis (Romanow). The Truth and Reconciliation Commission of Canada held meetings (2010 to 2014) across Canada to hear firsthand from some of the 150,000 Aboriginal men and women who as children were taken from their families and forced to attend Indian Residential Schools. Many of the children were physically, emotionally, and sexually abused (Woods, 2013). Smith, Varcoe, and Edwards (2005) have written about the intergenerational impact of the residential schools and the implications for health policy. In 2013, new information was released about federal research projects conducted on aboriginal children in residential schools, which included severely limited diets for the children between 1942 and 1952 (Editorial, 2013), and giving antibiotics inappropriately, which resulted in deafness. More than 200 ethnic origins were identified in the 2011 national household survey, and visible minorities now constitute 19.1% of the Canadian population (Statistics Canada, 2013). As the cultural composition of the population changes, it is increasingly important to address cultural considerations in the delivery of health care. Patients from diverse sociocultural groups not only bring various health care beliefs, values, and practices to the health care setting, but also have a variety of risk factors for some disease conditions and unique reactions to treatment (Newbold, 2009). These factors significantly affect a person’s responses to health care issues or illnesses, to caregivers, and to the care itself. Unless these factors are assessed for, understood, and respected by health care providers, the care delivered may be ineffective, and health care outcomes may be negatively affected. Culture is defined as learned patterns of behaviour, beliefs, and values that are shared by a particular group of people. Included among the many characteristics that distinguish cultural groups are the manner of dress, language spoken, values, rules or norms of behaviour, genderspecific practices, economics, politics, law and social control, artifacts, technology, dietary practices, and health beliefs and practices. Health promotion, illness prevention, causes of sickness, treatment, coping, caring, dying, and death are part of every culture. Every person has a unique belief and value system that has been shaped at least in part by his or her cultural environment. This belief and value system guides the person’s thinking, decisions, and actions. It provides direction for interpreting and responding to illness and disability and to health care. To promote an effective nurse–patient relationship and positive outcomes of care, nursing care must be culturally safe and competent, appropriate, and sensitive to cultural differences. All attempts should be made to help patients retain their unique cultural characteristics. Providing special foods that have significance and arranging for religious observances may enable patients to maintain a


feeling of wholeness at a time when they may feel isolated from family and community. Knowing the cultural and social significance that particular situations have for each patient helps the nurse avoid imposing a personal value system when the patient has a different point of view. In most cases, cooperation with the plan of care occurs when communication among the nurse, the patient, and the patient’s family is directed toward understanding the situation or the concern and respecting each other’s goals.

Changing Patterns of Disease During the past 50 years, the health issues of Canadians have changed significantly. Although many infectious diseases have been controlled or eradicated, others, such as tuberculosis, acquired immunodeficiency syndrome (AIDS), and sexually transmitted infections, are on the rise. An increasing number of infectious agents are becoming resistant to antibiotic therapy as a result of widespread and inappropriate use of antibiotics. Obesity has become a major health concern, and the multiple comorbidities that accompany it, such as hypertension, heart disease, diabetes, and cancer, add significantly to its associated mortality (See Chapter 6). Conditions that were once easily treated have become more complex and life-threatening. The prevalence of chronic illnesses and disability is increasing because of the lengthening lifespan of Canadians and the advances in care and treatment options for conditions such as cancer, human immunodeficiency virus (HIV) infection, and cystic fibrosis. In addition, improvements in care for trauma and other serious acute health problems have meant that many people with these conditions live decades longer than in the past. Because the majority of health issues seen today are chronic in nature, many people are learning to maximize their health within the constraints of chronic illness and disability. As chronic conditions increase, health care broadens from a focus on cure and eradication of disease to include the prevention or rapid treatment of exacerbations of chronic conditions. Nursing, which has always encouraged patients to take control of their health and wellness, has a prominent role in the current focus on management of chronic illness and disability.

Advances in Technology and Genetics Advances in technology and genetics have occurred more rapidly during the past several decades compared with other time periods. Sophisticated techniques and devices have revolutionized surgery and diagnostic testing, making it possible to perform many procedures and tests on an outpatient basis. Increased knowledge and understanding of genetics have resulted in expanded screening, diagnostic testing, and treatments for a variety of conditions. The sophisticated communication systems that connect most parts of the world, with the capability of rapid storage, retrieval, and dissemination of information, have stimu-

Health Care Delivery and Nursing Practice


lated brisk change as well as swift obsolescence in health care delivery strategies. Advances in genetics and technology have also resulted in many ethical issues for the health care system, health care providers, patients, families, and society.

Demand for Quality Health Care Nurses in acute care settings work with other health care team members to maintain quality care while facing pressures to discharge patients and decrease staffing costs. Nurses in hospitals now care for patients who are hospitalized for relatively few days. Nurses in the community care for patients who need high-technology acute care services as well as long-term care in the home. The importance of effective discharge planning and quality improvement cannot be overstated. Acute care nurses must also work with community-based nurses and others in community settings to ensure continuity of care. The general public has become increasingly interested in and knowledgeable about health care and health promotion through television, newspapers, magazines, the Internet, and other communications media. The public has also become very health conscious and subscribes to the belief that health and quality health care constitute a basic right, rather than a privilege for a chosen few.

Quality Improvement and Evidence-Based Practice The general public has become increasingly interested in and knowledgeable about health care and health promotion. This awareness has been stimulated by television, newspapers, magazines, and other communications media as well as by political debate. The public desires care that is both personalized and delivered in a timely manner. Over the last three decades, new systems of quality assurance (QA) and delivery have gradually emerged. Three of them—continuous quality improvement (CQI) and evidence-based practice, clinical pathways and care mapping, and case management—are discussed in more detail.

Continuous Quality Improvement and Evidence-Based Practice Seeking to ensure the quality of patient care, Canadian hospitals have adopted, over time, various methods aimed at improving quality. The adoption of these methods has also been linked with the aim of meeting accreditation standards. Since 1958, the Canadian Council on Health Services Accreditation, formerly known as the Canadian Council on Hospital Accreditation, has the mandate to provide accreditation programs. In the 1970s and the 1980s, the presence of a QA program was one of its standards of accreditation. Although well intentioned, QA programs were found to have limitations including, for example, their costeffectiveness and their department-specific focus, which limited opportunities for interdisciplinary involvement to



Basic Concepts in Nursing

solve problems needing the involvement of more than a single discipline. In light of this, in the early 1990s, attention shifted from achieving predetermined standards to using processes of CQI (Cummings & Wong, 2011). CQI emphasizes the importance of improving the care processes used by organizations, that improvement must be continuous, customers must be the focus, leaders must be committed, staff education is essential to ensure a motivated workforce, and that cultural transformation is a long-term proposition. In contrast with QA, which was department and disciplinary focused, CQI is systemwide and interdisciplinary. The principles of quality improvement are recognized in the current accreditation standards of the Canadian Council on Hospital Services Accreditation (Cummings & Wong, 2011). If care is to be of the best possible quality and continuously improve, it follows that practice must be based on evidence. In other words, health professionals must incorporate the latest research findings in their practice. However, it is increasingly recognized that health professionals face challenges in locating and using research findings. This is why research on knowledge utilization and knowledge transfer is such a growing field of research.

Clinical Pathways and Care Mapping First developed in the United States, the use of clinical pathways, or care mapping, is increasingly common in Canada. Clinical pathways are tools for tracking a patient’s progress toward achieving positive outcomes within specified time frames. Clinical pathways based on current literature and clinical expertise have been developed for patients with certain diagnosis-related groups (DRGs) (e.g., heart failure, ischemic stroke, fractured hip), for high-risk patients (e.g., those receiving chemotherapy), and for patients with certain common health problems (e.g., diabetes, chronic pain). The pathways indicate key events, such as diagnostic tests, treatments, activities, medications, consultation, and education, that must occur within specified times for patients to achieve the desired and timely outcomes. A case manager often facilitates and coordinates interventions to ensure that the patient progresses through the key events and achieves the desired outcomes. Nurses who provide direct care have an important role in the development and use of clinical pathways through their participation in researching the literature and then developing, piloting, implementing, and revising clinical pathways. In addition, nurses monitor outcome achievement and document and analyze variances. Examples of clinical pathways can be found on . Other EBP tools used for planning patient care are care mapping, clinical guidelines, and algorithms. These tools are used to move patients toward predetermined outcome markers. Algorithms are used more often in acute situations to determine a particular treatment based on patient information or response. Care maps and clinical guidelines help facilitate coordination of care and education throughout hospitalization and after discharge. Because care mapping and guidelines are used for conditions in which a patient’s progress often defies prediction, specific time frames for achieving outcomes are excluded. A patient with a highly complex condition or

multiple underlying illnesses may benefit more from care mapping or guidelines than from clinical pathways, because the use of outcome milestones (rather than specific time frames) is more realistic. Through case management and the use of clinical pathways or care mapping, patients and the care they receive are continually assessed from preadmission to discharge— and in many cases after discharge to home care and community settings. Continuity of care, effective utilization of services, and cost containment are the major benefits for society and for the health care system.

Case Management Case management is a system of coordinating health care services to ensure cost-effectiveness, accountability, and quality care. The premise of case management is that the responsibility for meeting patient needs rests with one person or team whose goals are to provide the patient and family with access to required services, to ensure coordination of these services, and to evaluate how effectively these services are delivered. Since the 1980s, case management has become prominent in American hospitals. In Canada, case management is primarily used for care delivered in the community, such as home care services. Nurses or other members of the health care team (e.g., occupational therapists and social workers) serve as case managers. Case managers may carry out a variety of roles, depending on the way in which services are organized in a health region. They may be responsible for the care of individual clients or groups of clients and may also have responsibility at the level of program, organizations, or service-delivery systems. A case manager may serve as clinical expert, facilitator, coordinator, liaison, supporter, educator, researcher, negotiator, monitor, advocate, and manager (Smith, Smith, Newhook, et al., 2006).

ROLES OF THE NURSE The professional nurse in hospital/institutional, communitybased or public health, and home care settings has three major roles: the caregiver role, which includes teaching and collaborating; the leadership role; and the research role. Although each role carries specific responsibilities, these roles relate to one another and are found in all nursing positions. These roles are designed to meet the immediate and future health care and nursing needs of the population.

Caregiver Role The caregiver role involves those actions taken by nurses to meet the health care and nursing needs of individual patients, their families, and significant others. This role is a dominant one for nurses in primary, secondary, and tertiary health care settings and in home care and community nursing. It is achieved through use of critical thinking, clinical judgment, and the nursing process, all of which are key tools for nursing practice. Nurses help patients meet their needs by using direct intervention, by teaching patients and family members to perform care, and by


Health Care Delivery and Nursing Practice


coordinating and collaborating with other disciplines to provide needed services.


Leadership Role

Professional nursing is adapting to meet changing health needs and expectations. One such adaptation is through advanced nursing practice, which has developed to better respond to the needs of the population (Donnely, 2007; Schober & Affara, 2006). As stated by the CNA (2008b, p. ii):

The leadership role is often viewed as a role assumed by nurses who have titles that suggest leadership and who are the leaders of large groups of nurses or related health care professionals. However, demonstrating leadership skills is required within all nursing positions. For example, when advocating for patients, staff nurses must be able to convince others and to do this they must possess attributes of leadership (Grossman & Valiga, 2013). Nursing leadership involves four components: decision making, relating, influencing, and facilitating. Each of these components promotes change and the ultimate outcome of goal achievement. Basic to the entire process is effective communication, which determines the success of the process and achievement of goals. The components of the leadership process are appropriate during all phases of the nursing process and in all settings.

Research Role The primary task of nursing research is to contribute to the scientific base of nursing practice. Studies are needed to determine the effectiveness of nursing interventions and nursing care. The science of nursing grows through research, leading to the generation of scientifically based rationale for nursing practice and patient care. This process is the basis of EBP, with a resultant increase in the quality of patient care. The research role is considered to be a responsibility of all nurses in clinical practice. Nurses are constantly alert for nursing problems and important issues related to patient care that can serve as a basis for the identification of researchable questions. Nurses with a background in research methods can use their research knowledge and skills to initiate and implement timely, relevant studies. Nurses directly involved in patient care are often in the best position to identify potential research questions, and their clinical insights are invaluable. Nurses also have a responsibility to become actively involved in ongoing research studies. This may involve facilitating the data collection process, or it may include actual collection of data. Explaining the study to patients and their families and to other health care professionals is often of invaluable assistance to the researcher who is conducting the study. Above all, nurses must use research findings in their nursing practice; the use, validation, replication, dissemination, and evaluation of research findings further the science of nursing. As stated previously, EBP requires the critique of the best evidence available in research-based studies and validating their saliency to nursing practice. Nurses need to continually be aware of studies that are directly related to their own area of clinical practice and critically analyze those studies to determine the applicability of their implications for specific patient populations. Relevant conclusions and implications can be used to improve patient care.

Advanced nursing practice is an umbrella term describing an advanced level of clinical nursing practice that maximizes the use of graduate educational preparation, in-depth nursing knowledge and expertise in meeting the health needs of individuals, families, groups, communities and populations. It involves analyzing and synthesizing knowledge: understanding, interpreting and applying nursing theory and research; and developing and advancing nursing knowledge and the profession as a whole.

Advanced practice nurses usually have a graduate degree in nursing. Two advanced nursing practice roles exist in Canada: the clinical nurse specialist (CNS) and the nurse practitioner (NP). The CNS has been present in Canada since the 1960s (CNA, 2009). A clinical nurse specialist is “a registered nurse who holds a master’s or doctoral degree in nursing with expertise in a clinical nursing specialty: uses in-depth knowledge and skills, advanced judgment and clinical experience in a nursing specialty to assist in providing solutions for complex health care issues” (CNA, 2008b, p. 40). A nurse practitioner is “a registered nurse with additional educational preparation and experience who possesses and demonstrates the competencies to autonomously diagnose, order and interpret diagnostic tests, prescribe pharmaceuticals, and perform specific procedures within the legislated scope of practice” (CNA, 2008b, p. 41). Nurse practitioners are not as common in Canada as they are in the United States. The role initially emerged in the late 1960s, but had almost disappeared by the 1980s. After renewed interest from employers and governments in the 1990s, legislation regulating NP practice has been enacted (Pringle, 2007). The number of NPs are on the rise in Canada, increasing from 1,334 NPs in 2007 to 2,777 NPs by 2011 (CIHI, 2012). In general, initial care, ambulatory health care, and anticipatory guidance are all becoming increasingly important in nursing practice. Advanced practice roles enable nurses to function interdependently with other health care professionals and to establish a more collegial relationship with physicians. As changes in health care continue, the role of advanced practice nurses, especially in primary care settings, is expected to increase in terms of scope, responsibility, and recognition.

Interprofessional Collaboration This chapter has explored the changing roles of nursing. Many references have been made to the significance of nurses as members of the health care team. As team members, nurses develop and maintain solid working relationships with other health care professionals in order to obtain the best possible outcomes for patients. As interprofessional collaboration is becoming increasingly



Basic Concepts in Nursing

critical, the Canadian Interprofessional Health Collaborative (CIHC) has developed a competency framework to assist educators in fostering the development of new practitioners who will be well prepared for this type of collaboration (CIHC, 2010).

Critical Thinking Exercises 1 Your clinical assignment is in a long-term care facility. Identify a patient care issue (e.g., nutritional status) that could be improved. Describe the mechanism that is available within a clinical facility to address such quality improvement issues. 2 You are planning the discharge of an older patient who has several chronic medical conditions. A case manager has been assigned to this patient. How would you explain the role of the case manager to the patient and her husband? 3

You are assigned to care for a hospitalized patient who is obese, with a history of diabetes, and a new diagnosis of stable angina. There is a clinical nurse specialist (CNS) assigned to provide consistent, quality care for this patient from hospital admission to discharge. Identify the evidence that supports the effectiveness of CNSs in supervising care of patients and promoting positive patient outcomes. What is the strength of the evidence? How might this specific patient’s care be affected?

REFERENCES AND SELECTED READINGS BOOKS **Double asterisks indicate classic reference. Cummings, G. G., & Wong, C. A. (2011). Quality of care: Quality assurance and improvement to culture of patient safety. In J. C. Ross-Kerr & M. J. Wood (Eds.), Canadian nursing issues and perspectives (5th ed., pp. 210–227). Toronto, ON: Elsevier Mosby. Grossman, S. C., & Valiga, T. M. (2013). The new leadership challenge creating the future of nursing (4th ed.). Philadelphia, PA: F. A. Davis Company. **Lalonde, M. (1974). A new perspective on the health of Canadians, a working document. Ottawa, ON: Department of National Health and Welfare. Miller, C. A. (2008). Nurse’s toolbook for promoting wellness. New York: McGraw-Hill Medical. O’Neill, M., Pederson, A., Dupéré, S., et al. (2007). Introduction: An evolution in perspectives. In M. O’Neill, A. Pederson, S. Dupéré, et al. (Eds.), Health promotion in Canada: Critical perspectives (2nd ed., pp. 1–15). Toronto, ON: Canadian Scholar’s Press Inc. Paul, P., & Ross-Kerr, J. C. (2011). Nursing in Canada, 1600 to the present: A brief account. In J. C. Ross-Kerr & M. J. Wood (Eds.), Canadian nursing issues and perspectives (5th ed., pp. 17–41). Toronto, ON: Elsevier Mosby. Reutter, L., & Ogilvie, L. (2011). Primary health care: Challenges and opportunities for the nursing profession. In J. C. Ross-Kerr & M. J. Wood (Eds.), Canadian nursing issues and perspectives (5th ed., pp. 185–207). Toronto, ON: Elsevier Mosby. Ross-Kerr, J. C. (2011). The Canadian health care system. In J. C. RossKerr & M. J. Wood (Eds.), Canadian nursing issues and perspectives (5th ed., pp. 3–17). Toronto, ON: Elsevier Mosby. Schober, M., & Affara, F. (2006). Advanced nursing practice. Oxford, UK: Blackwell Publishing and International Council of Nursing.

Smith, D. L., Smith, J. E., Newhook, C., et al. (2006). Continuity of care, service integration, and case management. In J. M. Hibberd & D. L. Smith (Eds.), Nursing leadership and management in Canada (3rd ed., pp. 81–112). Toronto, ON: Elsevier Canada. **World Health Organization. (1978). Primary health care: Report of the international conference on primary health care: Alma-Ata. USSR. Geneva: Author. **World Health Organization. (1986). Ottawa charter for health promotion. Geneva: Author. World Health Organization. (2006). Constitution of the World Health Organization (45th ed.). New York: Author.

JOURNALS AND ELECTRONIC DOCUMENTS Canadian Institute for Health Information. (2012). Regulated nurses: Canadian trends, 2007 to 2011. Ottawa, ON: Author. Retrieved from Canadian Interprofessional Health Collaborative (2010). A national interprofessional competency framework. Ottawa, ON: Queens’ Printer. Retrieved from Canadian Nurses Association. (2008a). Code of ethics for registered nurses. Ottawa, ON: Author. Canadian Nurses Association. (2008b). Advanced nursing practice: A national framework. Ottawa, ON: Author. Retrieved from Canadian Nurses Association. (2009). Position statement: Clinical nurse specialist. Ottawa, ON: Author. Retrieved from en/advocacy/policy-support-tools/cna-position-statements/. Commission on the Future of Health Care in Canada. (2002). Building on values: The future of health care in Canada. Saskatoon, SK: Author. Donnely, G. (2007). Clinical expertise in advanced practice nursing: A Canadian perspective. Nursing Education Today, 23(3), 168–173. Editorials (2013, July 24). The healing power of truth. The Edmonton Journal, p. A16. **Health Canada. (2002). Canada Health Act Overview. Ottawa, ON: Author. Retrieved from International Council of Nurses. (2010). The ICN definition of nursing. Retrieved July 4, 2013, from icn-definition-of-nursing/. Jackson, S. F., & Riley, B. L. (2007). Health promotion in Canada: 1986 to 2006. Promotion and Education, 14(4), 214–218. Newbold, K. B. (2009). The short term health of Canada’s new immigrant arrivals: Evidence from LSIC. Ethnicity & Health 14(3), 315–336. Pringle, D. (2007). Nurse practitioner role: Nursing needs it. Canadian Journal of Nursing Leadership, 20(2), 1–5. Public Health Agency of Canada. (2007). WHO Collaborating Centre on non communicable disease policy. Ottawa, ON: Author. Retrieved from Public Health Agency of Canada. (2011). What determines health? Ottawa, ON: Author. Retrieved from ph-sp/determinants/index-eng.php. Public Health Agency of Canada. (2012). What is the Population Health Approach? Ottawa, ON: Author. Retrieved from http://www.phac-aspc. **Royal Commission on Aboriginal Peoples (1996). Royal commission report on Aboriginal peoples. Retrieved from http://www.aadnc-aandc. Smith, D., Varcoe, C., & Edwards, N. (2005). Turning around the intergenerational impact of residential schools on Aboriginal people: Implications for health policy and practice. Canadian Journal of Nursing Research, 37(4), 38–60. Statistics Canada. (2012a). The Canadian population in 2011: Age and Sex. 2011 census. Ottawa, ON: Author. Retrieved July 5, 2013, from http://–311-x/98-311x2011001-eng.cfm. Statistics Canada. (2012b). The Canadian population in 2011: Population counts and growth. Population and dwelling counts 2011 census. Ottawa, ON: Author. Retrieved July 5, 2013, from census-recensement/index-eng.cfm?HPA Statistics Canada. (2013). 2011 National Household Survey: Immigration, place of birth, citizenship, ethnic origin, visible minorities, language and religion. Ottawa, ON: Author. Retrieved from http://www. Woods, M. (2013, June 11). We can’t lose another generation. The Edmonton Journal, p. A12.


2 Community-Based Nursing Practice Adapted by Joanne K. Olson

Learning Objectives On completion of this chapter, the learner will be able to: 1. Discuss the changes in the health care system that have increased the need for medical-surgical nurses to practice in community-based settings. 2. Compare the differences and similarities between community-based and hospital nursing. 3. Describe the discharge planning process in relation to home care preparation. 4. Explain methods for identifying community resources and making referrals. 5. Discuss how to prepare for a home visit and how to conduct the visit. 6. Identify personal safety precautions a home care nurse takes when making home visits. 7. Describe the various types of nursing functions provided in ambulatory care facilities, in occupational health and school nursing programs, to people who are homeless, and to those with alcohol or drug addictions.




Basic Concepts in Nursing

The changes that have occurred in the health care system and society in the past two decades have increased the need for care in ambulatory settings and in the home. These changes have created a demand for highly skilled and wellprepared nurses to provide community-based care. The delivery of community health care occurs within the Canadian health care system, also known as Medicare. This system reflects the values that define Canadian culture: social justice, equity, and community. Guided by the Canada Health Act, passed in 1984, the system is based on the fundamental principle that all members of Canadian society, including the most vulnerable, are entitled to health care. Within the Canadian health care system, there has been a trend toward more health care being delivered within communities. This shift is partly due to ongoing implementation of a long-held Canadian belief that health promotion services are a critical component of the country’s health care system. The more recent factors contributing to this trend include advancements in scientific knowledge and technology leading to improved diagnostics and treatment, and thus earlier hospital discharge (Kozier, Erb, Berman, et al., 2010). As more health care delivery shifts into the community, more nurses are working in a variety of public health and community-based settings. These settings include public health departments, ambulatory health clinics, long-term care facilities, prenatal and well-baby clinics, hospice agencies, industrial settings (as occupational health nurses), shelters for people who are homeless, and clinics, nursing centres, home care agencies, urgent care centres, same-day surgical centres, short-stay correctional facilities, and patients’ homes. Nurses in these settings often deliver care without direct on-site supervision or the support of other health care personnel. They must be self-directed, flexible, adaptable, and tolerant of various lifestyles and living conditions. Expertise in independent decision making, critical thinking, assessment, and health education as well as competence in basic nursing care are essential to function effectively in the community-based setting (Stanhope, Lancaster, Jessup-Falcioni, et al., 2011).

COMMUNITY-BASED CARE Community-based nursing is a philosophy of care of individuals and families. The care is provided in a community as the individual or family move among various kinds of service providers outside of hospitals (Stanhope et al., 2011). Although the phrase “community-based nursing” is often interchanged with “community health nursing,” a distinction

FIGURE 2-1. Community-based nursing takes many forms and focuses.

Here, the school nurse performs screening for scoliosis.

should be made. The phrase “community health nursing” has generally been equated to “public health nursing.” Public health nursing is a specialty focused on total populations, although care may be given to individuals. Communitybased nursing is broader and may incorporate community health–public health nursing; it is focused on individuals and families rather than total populations. Community-based nursing also includes home care nursing, school health nursing, and a host of other nursing services provided to individuals and groups in the community (Fig. 2-1). Nurses in community-based practice provide preventive care at three levels: primary, secondary, and tertiary. Primary prevention focuses on health promotion and prevention of illness or disease, including interventions such as teaching about healthy lifestyles. Secondary prevention centers on health maintenance and is aimed at early detection and prompt intervention to prevent or minimize loss of function and independence, including interventions such as health screening and health risk appraisal. Tertiary prevention focuses on minimizing deterioration and improving quality of life, including rehabilitation to assist patients in achieving their maximum potential by working through their physical or psychological challenges. Home care nurses often focus on tertiary preventive nursing care, although primary and secondary prevention are also addressed.

Glossary community-based nursing: nursing care of individuals and families that is designed to 1) promote and maintain health and 2) prevent disease. It is provided as patient’s transition through the health care system to health-related services outside of the hospital setting primary prevention: health care delivery focused on health promotion and prevention of illness or disease

secondary prevention: health care delivery centred on health maintenance and aimed at early detection of disease, with prompt intervention to prevent or minimize loss of function and independence tertiary prevention: health care delivery focused on minimizing deterioration associated with disease and improving quality of life through rehabilitation measures


Nurses in community settings must be culturally competent and practice cultural safety, as culture plays a role in the delivery of care and there are many opportunities for culturally diverse interactions (Betancourt & Green, 2010; Canadian Association of Schools of Nursing, 2013; Harrowing, Mill, & Spiers, 2010; Starr & Wallace, 2009). Cross-cultural health encounters are especially common in Canada because of the diverse ethnic and Aboriginal peoples (First Nations, Inuit, and Métis) populations in the country (Kozier et al., 2010). Increasingly, health care providers in Canada are from diverse cultural backgrounds as well (Higginbottom, 2011). Community-based nursing practice focuses on promoting and maintaining the health of individuals and groups, preventing and minimizing the progression of disease, and improving quality of life (Stanhope et al., 2011). Although nursing interventions used by public health nurses may involve individuals, families, or small groups, the central focus remains promotion of health and prevention of disease in the entire community. The actions of community health nurses may include provision of direct care to patients and families as well as political advocacy to secure resources for aggregate populations (e.g., the aging population). The community health nurse may function as an epidemiologist, a case manager for a group of patients, a coordinator of services provided to an aggregate of patients, an occupational health nurse, a school nurse, a visiting nurse, or a parish nurse. (In parish nursing, the members of the religious community—the parish—are the recipients of care.) The commonality of these various roles is that the nurse maintains a focus on community needs as well as on the needs of the patient. Community-based care is generally focused on the individual or family; although efforts may be undertaken to improve the health of the whole community, the individual or family unit is the main focus. The primary concepts of community-based nursing care are self-care and preventive care within the context of culture and community. Two other important concepts are continuity of care and collaboration. Some community-based nursing fields have become specialties in their own right, such as school health nursing and home care nursing.

Community-Based Nursing Practice


provide palliative care in patients’ homes and within hospice centres, thus promoting comfort, peace, and dignity to patients who are dying. Clinic nurses may conduct home visits as part of patient follow-up. Public health, parish, and school nurses may make visits to provide anticipatory guidance to high-risk families and follow-up care to patients with communicable diseases. Many home care patients are acutely ill, and many have chronic health problems and disabilities, requiring nurses to provide more education and monitoring to the patients and families. Holistic care is provided in the home through the collaboration of an interdisciplinary team that includes professional nurses; home care aides; social workers; physical, speech, and occupational therapists; pharmacists; and physicians. An interdisciplinary approach is used to provide health and social services with oversight of the total health care plan by a case manager, clinical nurse specialist, or nurse practitioner. Basic home care services are provided to Canadians through programs operated by territorial or provincial governments. The basic services covered may vary from province to province or territory. Private payment or insurance coverage is therefore sometimes required to cover costs not publicly funded. Older adults are the most frequent users of home care services. To be eligible for service, the patient must be ill, homebound, and in need of skilled nursing services. Health care visits may be intermittent or periodic, and case management via telephone or via Internet may be used to promote communication with home care consumers. The nurse instructs the patient and family about skills and self-care strategies and about health maintenance and promotion activities (e.g., nutritional counselling, exercise programs, stress management). Nursing care includes skilled assessment of the patient’s physical, psychological, social, and environmental status (Fig. 2-2). Nursing interventions may include intravenous (IV) therapy and injections, parenteral nutrition, venipuncture, catheter insertion, pressure ulcer treatment, wound care, ostomy care, and patient and family teaching. Complex technical equipment, such as dialysis machines and ventilators, is often part of home health care (Stanhope et al., 2011).

HOME CARE Home care nursing is a unique aspect of community-based nursing. Home care visits are made by nurses who work for home care agencies, public health agencies, and visiting nurse associations; by nurses who are employed by hospitals; and by parish nurses who voluntarily work with the members of their religious communities to promote health. Such visits may also be part of the responsibilities of school nurses, clinic nurses, or occupational health nurses. Home health care agencies are continuing to employ more nurses. Because of the high acuity levels of patients, nurses with acute care and critical care experience are in demand in this field. The type of nursing services provided to patients in their homes varies from agency to agency. Nurses from home care or hospice agencies make home visits to provide skilled nursing care, follow-up care, and teaching to promote health and prevent complications. Hospice nursing has become a specialty area of nursing practice in which nurses

FIGURE 2-2. Assessment is an important part of any home health visit.



Basic Concepts in Nursing

Nurses have a role in evaluating the safety and effectiveness of technology in the home setting. In addition, “telehealth” is an emerging trend in home health care; this facilitates exchange of information via telephone lines between patients and nurses regarding health information such as blood glucose readings, vital signs, and cardiac parameters (Stanhope et al., 2011). Use of a broad spectrum of computer and Internet resources, such as Web cams, also facilitates exchange of information.

Nursing in the Home Setting The home care nurse is a guest in the patient’s home and must have permission to visit and give care. The nurse has minimal control over the lifestyle, living situation, and health practices of the patients he or she visits. This lack of full decision-making authority can create a conflict for the nurse and may lead to issues in the nurse–patient relationship. To work successfully with patients in any setting, the nurse must be nonjudgmental and convey respect for patients’ beliefs, even if they differ sharply from the nurse’s. This can be difficult when a patient’s lifestyle involves activities that a nurse considers harmful or unacceptable, such as smoking, use of alcohol, drug abuse, or overeating. The cleanliness of a patient’s home may not meet the standards of a hospital. Although the nurse can provide teaching points about maintaining clean surroundings, the patient and family decide whether they will implement the nurse’s suggestions. The nurse must accept their decisions and deliver the care required regardless of the conditions of the setting. The kind of equipment, supplies, and resources usually available in acute care settings are often unavailable in a patient’s home. The nurse has to learn to improvise when providing care, such as when changing a dressing or catheterizing a patient in a regular bed that is not adjustable and lacks a bedside table. At times, the nurse works closely with the patient and others to achieve a unique solution for each patient and family situation. Infection control is as important in the home as it is in the hospital, but it can be more challenging and requires creative approaches. As in any situation, it is important to cleanse one’s hands before and after giving direct patient care, even in a home that does not have running water. A waterless, alcoholbased hand cleanser is a useful product for hand decontamination. If aseptic technique is required, the nurse needs to have a plan for implementing this technique before going to the home. This applies also to Routine Practices and Additional Precautions (Health Canada, 1999) and disposal of bodily secretions and excretions. If injections are given, the nurse uses a closed container to dispose of syringes. Injectable and other medications must be kept out of the reach of children during visits and must be stored in a safe place if they are to remain in the house. Friends, neighbours, or family members may ask the nurse about the patient’s condition. A patient has a right to confidentiality, and information should be shared only with the patient’s permission. If the nurse carries the patient’s health record into the house, it must be put in a secure place to prevent it from being picked up by others or misplaced.

Discharge Planning for Home Care Discharge planning is an important part of making the transition from the acute care setting to the home care setting. Discharge planning begins with the patient’s admission to the hospital and must consider the possible need for follow-up home care. Several different personnel (e.g., social workers, home care nurses, and case managers) or agencies may be involved in the planning process. The development of a comprehensive discharge plan requires collaboration with professionals at both the referring agency and the home care agency, as well as the community agencies that provide specific resources upon discharge. The process involves identifying the patient’s needs and developing a thorough plan to meet them. It is essential to have open lines of communication with family members to ensure their understanding and cooperation.

COMMUNITY RESOURCES AND REFERRALS As case managers, community-based nurses may make referrals to other team members, such as home health aides and social workers. These nurses work collaboratively with the health team and the referring agency or person. Continuous coordinated care among all health care providers involved in a patient’s care is essential to avoid duplication of effort by the various personnel caring for the patient. A community health nurse is knowledgeable about community resources available to patients as well as services provided by local agencies, eligibility requirements, and any possible charges for the services. Most communities have directories of health and social service agencies that the nurse can consult. These directories are continually updated as resources change. If a community does not have a resource booklet, an agency may develop one for its staff. It should include the commonly used community resources that patients need as well as the costs of the services and eligibility requirements. The telephone book and Internet are often useful in helping patients identify the location and accessibility of grocery and drug stores, banks, health care facilities, ambulances, physicians, dentists, pharmacists, social service agencies, and senior citizens’ programs. In addition, a patient’s place of worship or parish may be an important resource for services. The community health nurse is responsible for informing the patient and family about the community resources available to meet their needs. During initial and subsequent home visits, the nurse helps the patient and family identify these community services and encourages them to contact the appropriate agencies. When appropriate, nurses may make the initial contact.

HOME VISITS Most agencies have a policy manual that states their philosophy and procedures and defines the services they provide. Becoming familiar with these policies is an essential


step before initiating a home visit. It is also important to know the agency’s policies and the provincial/territorial law regarding what actions to take if the nurse finds a patient who has died, encounters an abusive situation in the family, determines that a patient cannot safely remain at home, or observes a situation that possibly indicates malicious harm to the community at large. Before making a home visit, the nurse reviews the patient’s referral form and other pertinent data concerning the patient. It may be necessary to contact the referring agency if the purpose for the referral is unclear or if important information is missing. The first step is to call the patient to obtain permission to visit, schedule a time for the visit, and verify the address. This initial phone conversation provides an opportunity to introduce oneself, identify the agency, and explain the reason for the visit. If a patient does not have a telephone, the nurse should see if the people who made the referral have a number where a phone message can be left for the patient. If an unannounced visit to a patient’s home must be made, the nurse should ask permission to come in before entering the house. Explaining the purpose of the referral at the outset and setting up the times for future visits before leaving are also recommended. Most agencies provide nurses with bags that contain standard supplies and equipment needed during home visits. It is important to keep the bag properly stocked and to bring any additional items that might be needed for the visit.

Personal Safety Precautions Community nurses pay particular attention to personal safety, because their practice settings are often in unknown environments. Based on the principle of due diligence, agencies are required to inform employees of at-risk working environments. Agencies have policies and procedures concerning the promotion of safety for clinical staff, and training is provided to facilitate personal safety. Environments are proactively assessed for safety by the individual nurse and agency. Whenever a nurse makes a home visit, the agency should know the nurse’s schedule and the locations of the visits. The nurse needs to learn about the neighbourhood and obtain directions to the destination. A plan of action should always be established in case of emergencies. If a dangerous situation is encountered during the visit, the nurse should return to the agency and contact his or her supervisor or law enforcement officials, or both. Suggested precautions to take when making a home visit are presented in Chart 2-1.

Initial Home Visit The first visit sets the tone for subsequent visits and is a crucial step in establishing the nurse–patient relationship. The situations encountered can vary depending on numerous factors. Patients may be in pain and unable to care for themselves. Families may be overwhelmed and doubt their ability to care for their loved one. They may not understand why the patient was sent home from the hospital before being totally rehabilitated. They may not comprehend what home care is or why they cannot have 24-hour

Community-Based Nursing Practice



Safety Precautions in Home Care • Learn, or preprogram a cellular phone with the telephone numbers of the agency, police, and emergency services.

• Let the agency know your daily schedule and the tele• • • • • •

• • • • • • •

phone numbers of your patients so that you can be located if you do not return when expected. Know where the patient lives before leaving to make the visit and carry a map or GPS for quick referral. Keep your car in good working order and have sufficient gas in the tank. Park the car near the patient’s home and lock it during the visit. Do not drive an expensive car or wear expensive jewellery when making visits. Know the regular bus schedule and know the routes when using public transportation or walking to the patient’s house. Carry agency identification and have enough change to make telephone calls in case you get lost or have problems. Most agencies provide cellular phones for their nurses so that the agency can contact the nurse, and so that the nurse can contact the agency in case of an emergency or unexpected situation. When making visits in high-crime areas, visit with another person rather than alone. Schedule visits only during daylight hours. Never enter a patient’s home uninvited. If you do not feel safe entering a patient’s home, leave the area. Become familiar with the layout of the house, including exits from the house. If a patient or family member is intoxicated, hostile, or obnoxious, reschedule the visit and leave. If a family member is having a serious argument or abusing the patient or anyone else in the household, reschedule the visit, contact your supervisor, and report the abuse to the appropriate authorities.

nursing services. It is critical that the nurse try to convey an understanding of what the patient and family are experiencing and how the illness is affecting their lives. During the initial home visit, which usually lasts up to an hour, the patient is evaluated and a plan of care is established to be followed or modified on subsequent visits. The nurse informs the patient of the agency’s practices, policies, and hours of operation. The initial assessment includes evaluating the individual patient, the home environment, the patient’s self-care abilities or the family’s ability to provide care, and the patient’s need for additional resources. Identification of possible hazards, such as cluttered walk areas, potential fire risks, air or water pollution, or inadequate sanitation facilities, is also part of the initial assessment. Documentation considerations for home visits follow fairly specific regulations. The patient’s needs and the nursing care given are documented accurately. The medical diagnosis and specific detailed information on the functional limitations of the patient are usually part of the documentation. The goals and the actions appropriate for attaining them need to be identified. Expected outcomes of the nursing interventions are stated in terms of patient behaviours and are to be realistic and measurable. They



Basic Concepts in Nursing

reflect the nursing diagnosis or the patient’s conditions and specify those actions that address the patient’s issues. Some agencies provide home care nurses with handheld computers for documenting the condition of the patient, and results of the visit (Stolee, Steeves, Glenny, et al., 2010; Tapper, Quinn, Kerry, et al., 2012).

Determining the Need for Future Visits


Assessing the Need for Home Visits Current Health Status • How well is the patient progressing? • How serious are the present signs and symptoms? • Has the patient shown signs of progressing as expected? Or does it seem that recovery will be delayed?

Home Environment

While conducting an assessment of the patient’s situation, the nurse evaluates the need for future visits and the frequency with which those visits may need to be made. To make these judgments, the nurse may find it helpful to consider the questions listed in Chart 2-2. With each subsequent visit, these same factors are evaluated to determine the continuing health needs of the patient. As progress is made and the patient, with or without the help of significant others, becomes more capable of self-care and more independent, the need for home visits may decline.

• Are worrisome safety factors apparent? • Are family or friends available to provide care? Or is the

Ending the Visit

• What level of nursing care does the patient require? • Does the care require basic skills or more complex inter-

As the visit comes to a close, it is important to summarize the main points of the visit for the patient and family and to identify expectations for future visits or patient achievements. The following points should be considered at the end of each visit: • What are the main points the patient or family should remember from the visit? • What positive attributes have been noted about the patient and the family that will give them a sense of accomplishment? • What were the main points of the teaching plan or the treatments needed to ensure that the patient and family understand what they must do? A written set of instructions should be left with the patient or family; provided they can read and see (alternative formats include video or audio recordings). Printed material should be in the patient’s primary language and in large print when indicated. • Whom should the patient or family call in case someone needs to be contacted immediately? Are current emergency telephone numbers readily available? Is telephone service available, or can an emergency cell phone service be provided? • What signs of complications should be reported immediately? • What is the date and time of the next visit? Will a different nurse make the visit? How frequently and for how long will visits be made (if determinable at this time)?

OTHER COMMUNITY-BASED HEALTH CARE SETTINGS Ambulatory Settings Ambulatory health care is provided for patients in community- or hospital-based settings. The types of agencies that provide ambulatory health care are medical clinics, ambulatory care units, urgent care centres, cardiac rehabilitation

patient alone?

Level of Self-Care Ability • • • •

Is the patient capable of self-care? What is the patient’s level of independence? Is the patient ambulatory? Or bedridden? Does the patient have sufficient energy? Or is he or she frail and easily fatigued? • Does the patient need and use assistive devices?

Level of Nursing Care Needed ventions?

Prognosis • What is the expectation for recovery in this particular instance?

• What are the chances that complications may develop if nursing care is not provided?

Educational Needs • How well has the patient or family grasped the teaching points made?

• Is there a need for further follow-up and retraining? • What level of proficiency does the patient or family show in carrying out the necessary care?

Mental Status • How alert is the patient? • Are there signs of confusion or thinking difficulties? • Does the patient tend to be forgetful or have a limited attention span?

Level of Adherence • Is the patient following the instructions provided? • Does the patient seem capable of following the instructions?

• Are the family members helpful, or are they unwilling or unable to assist in caring for the patient as expected?

programs, mental health centres, student health centres, community outreach programs, and nursing centres. Neighbourhood health centres provide services to patients who live in a geographically defined area. The centres may operate in freestanding buildings, storefronts, or mobile units. Agencies may provide ambulatory health care in addition to other services, such as offering an adult day care or health program. The kinds of services offered and the patients served depend on the agency’s mission. Nursing responsibilities in ambulatory health care settings include providing direct patient care, conducting patient intake screenings, treating patients with acute or chronic illnesses or emergency conditions, referring patients to other agencies for additional services, teaching


patients self-care activities, and offering health education programs that promote health maintenance. Nurses also work as clinic managers, direct the operation of clinics, and supervise other health team members. Nurse practitioners, educated in primary care, often practice in ambulatory care settings with a focus on gerontology, pediatrics, family or adult health, or women’s health. Nurses can play an important part in facilitating the function of the ambulatory care facility.

Occupational Health Programs In Canada, health and safety standards in the workplace are legislated by provincial and territorial governments. The legislated standards are directed at creating safer and healthier work conditions. It is in an employer’s interest to provide as safe a working environment as possible, because the result is reduced costs associated with employee absenteeism, hospitalization, and disability. Occupational health nurses may work in solo units in industrial settings, or they may serve as consultants on a limited or part-time basis. They may be members of an interdisciplinary team composed of a variety of personnel such as nurses, physicians, exercise physiologists, health educators, counsellors, dietitians, safety engineers, and industrial hygienists. Occupational health nurses may: • Provide direct care to employees who become ill or injured • Conduct health education programs for company staff members • Set up health programs aimed at establishing specific health behaviours, such as eating properly and getting enough exercise • Monitor employees’ hearing, vision, blood pressure, or blood glucose • Track exposure to radiation, infectious diseases, and toxic substances, reporting results to government agencies as necessary Occupational health nurses must be knowledgeable about government regulations pertaining to occupational health and safety and be familiar with other pertinent legislations.

School Health Programs School health programs provide services to students and may also serve the school’s community. School-age children and adolescents with health conditions are at major risk for underachieving or failing in school. The leading health conditions of elementary school children are injuries, infections (including influenza and pneumonia), malnutrition, dental disease, and cancer. The leading health concerns of high school students are alcohol and drug abuse, injuries, homicide, pregnancy, eating disorders, sexually transmitted infections (STIs), sports injuries, dental disease, and mental and emotional issues. Contemporary school health issues that are being examined include school violence, which may affect students’ and teachers’ physical and emotional health, and the increasing numbers of children and adolescents who are overweight or obese. Ideally, school health programs have an interdisciplinary health team consisting of physicians, nurses, dentists, social workers, counsellors, school administrators,

Community-Based Nursing Practice


parents, and students. The school may serve as the site for a family health clinic that offers primary health and mental health services to children and adolescents as well as to all family members in the community. Nurse practitioners perform physical examinations and diagnose and treat students and families for acute and chronic illnesses within the scope of their practice. These clinics are costeffective and benefit students from low-income families who lack access to traditional health care. School nurses play a number of roles, including care provider, health educator, consultant, and counsellor. They collaborate with students, parents, administrators, and other health and social service professionals regarding student health issues. School nurses perform health screenings, provide basic care for minor injuries and concerns, administer medications, monitor the immunization status of students and families, identify children with health concerns, provide teaching related to health maintenance and safety, and monitor the weight of children in order to facilitate prevention and treatment of obesity. They need to be knowledgeable about provincial/territorial and local regulations affecting school-age children, such as ordinances for excluding students from school because of communicable diseases or parasites such as lice or scabies. School nurses are also health education consultants for teachers. In addition to providing information on health practices, teaching health classes, and participating in the development of the health education curriculum, school nurses educate teachers and classes when a student has a special issue, a disability, or a disease such as hemophilia, asthma, or human immunodeficiency virus (HIV) infection.

Care for People Who Are Homeless While exact figures are unknown, it is estimated that 157,000 people are homeless each year in Canada (Trypuc & Robinson, 2009). The homeless population includes increasing numbers of women with children (often victims of abuse) and older adults. People who are homeless are a heterogeneous group, including members of dysfunctional families, the unemployed, and those who cannot find affordable housing. A significant number of persons who are homeless are chronically mentally ill and/or abuse alcohol or other drugs (Trypuc & Robinson, 2009). People who are homeless often have difficulty gaining access to health care. Because of numerous obstacles, they seek health care late in the course of a disease and deteriorate more quickly than other patients. Many of the health problems they experience are related in large part to their living situations. Street life exposes people who are homeless to the extremes of hot and cold environments and a culture of drugs, alcohol, and violence, all of which compound their health risks. Persons who are homeless have high rates of trauma, tuberculosis, upper respiratory tract infections, poor nutrition and anemia, lice, scabies, peripheral vascular problems, STIs, dental issues, arthritis, hypothermia, skin disorders, and foot problems. Common chronic health conditions of people who are homeless include diabetes, hypertension, heart disease, AIDS, and mental illness. These health conditions are made more difficult by living on the



Basic Concepts in Nursing

street and by being discharged to a transitory, homeless situation in which follow-up is unlikely (Pennington, Coast, & Kroh, 2010). Shelters are frequently overcrowded and unventilated, promoting the spread of communicable diseases such as tuberculosis. Community health nurses who work with people who are homeless need to be nonjudgmental, patient, and understanding. They must be skilled in dealing with people who have a wide variety of health problems and needs and recognize that individualized treatment strategies are required in highly unpredictable environments (Loewenson & Hunt, 2011). Nursing interventions are aimed at assessing health care needs of people who live on the streets and in shelters, providing nursing care, and attempting to obtain other appropriate health care services for all people. Cities such as Edmonton, Alberta are committed to locating/ building appropriate housing and are making significant progress in reducing the number of people who are homeless. The Homeward Trust Edmonton found housing for 773 previously homeless individuals, of whom 76% were noted to be “chronically homeless.” Since 2008, there has been a decrease of 30% in the number of people who are homeless in Edmonton (Homeward Trust Edmonton 2012 Annual Report). At this time, Alberta is the only province with a definite plan to end homelessness in 10 years. In 2007, Cathy Crowe (a street nurse in Toronto for 15 years) and a group of 10 activists who were homeless co-wrote a book: Dying for a Home: Homeless Activists Speak Out. The message is a call for nurses to advocate for the right to housing as a necessary prerequisite to health.

Critical Thinking Exercises 1 Recall a difficult discharge planning situation in which you have been involved. Evaluate the effectiveness of the processes used to accomplish the goals. What changes could have been made that would have improved the processes and the outcomes? 2

An older adult man with diabetes is being referred for home care after discharge from the hospital, and he will need glucose monitoring and teaching. He has no family at home; his wife died 3 years ago, and his only daughter lives several hundred kilometers away. During the nurse’s initial visit to the man’s home, the nurse learns that he has difficulty seeing and therefore cannot read. What is the evidence for conducting a safety assessment of the home environment for older adult patients and for patients with visual limitations? Evaluate the strength of the evidence. What assessment criteria would you use to determine the needs of the patient’s home care situation?

REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles.

BOOKS Crowe, C. (2007). Dying for a home: Homeless activists speak out. Toronto, ON: Between the Lines.

Homeward Trust Edmonton. (2012). Homeward Trust Edmonton 2012 Annual Report. Retrieved from files/2013-06-19-17-15HT%20Annual%20Report%202012%20WEB.pdf Kozier, B., Erb, G., Berman, A., et al. (2010). Fundamentals of Canadian nursing: Concepts, process, and practice (2nd ed.). Toronto, ON: Prentice Hall. Stanhope, M., Lancaster, J., Jessup-Falcioni, H., et al. (2011). Community health nursing in Canada. (2nd ed.). Toronto, ON: Elsevier Canada. Trypuc, B., & Robinson, J. (2009). Homeless in Canada: A funder’s primer in understanding the tragedy on Canada’s streets. King City, ON: Charity Intelligence.

JOURNALS Betancourt, J. R., & Green, A. R. (2010). Commentary: Linking cultural competence training to improved health outcomes: Perspectives from the field. Academic Medicine, 85, 583–585. Canadian Association of Schools of Nursing. (2013). Educating nurses to address socio-cultural, historical, and contextual determinants of health among Aboriginal peoples. Retrieved from newvisual/attachments/856/Media/2013WAHHRIKnowledgeProduct FINALforweb.pdf. *Harrowing, J., Mill, J., & Spiers, J. (2010). Critical ethnography, cultural safety, & international nursing research. Journal of Qualitative Methods, 9 (3), 240–251. *Higginbottom, G. (2011). The transitioning experiences of internationally-educated nurses into a Canadian health care system: A focused ethnography. BMC Nursing, 10, 14. Higginbottom, G., Caine, V., Salway, J., et al. (2013). Providing culturally safe and competent health care. A self-directed workbook and digital resource. Edmonton, AB: University of Alberta, Faculty of Nursing. Retrieved from Loewenson, K., & Hunt, R. (2011). Transforming attitudes of nursing students: Evaluating a service-learning experience. Journal of Nursing Education, 50(6), 345–349. Mahara, M., Duncan, S., & Whyte, N., et al. (2011). It takes a community to raise a nurse: Educating for culturally safe practice with Aboriginal peoples. International Journal of Nursing Education Scholarship, 8(1), 1–12. Pennington, K., Coast, M. J., & Kroh, M. (2010). Health care for the homeless: A partnership between a city and a school of nursing. Journal of Nursing Education, 49 (12), 700–703. Romonow, R. (2002). Building on values: The future of health care in Canada – Final Report. Royal Commission on Aboriginal Peoples (1996). Royal commission report on Aboriginal peoples. Retrieved from http://www.aadnc-aandc. *Starr, S. & Wallace, D. (2009). Self-reported cultural competence of public health nurses in a Southeastern U.S. public health department. Public Health Nursing, 26 (1), 48–57. Stolee, P., Steeves, B., Glenny, C., et al. (2010). The use of electronic health information systems in home care. Home Health Care, 28(3), 167–181. Tapper, L., Quinn, H., Kerry, J., et al. (2012). Introducing handheld computers into home care. Canadian Nurse, 108(1), 28–32.

RESOURCES AND WEB SITES Aboriginal Nurses Association of Canada (A.N.A.C.); http://www.anac. Canadian Association for Parish Nursing Ministry (CAPNM); http:// Canadian Nurses Association; Canadian Occupational Health Nurses Association (COHNA); http:// Canadian Public Health Association; Community Health Nurses Association of Canada (CHNAC); http:// Health Canada; National Aboriginal Health Organization (NAHO); National Advisory Committee on Immunization; http://www.phac-aspc. Public Health Agency of Canada; Victorian Order of Nurses;


3 Critical Thinking, Ethical Decision Making, and the Nursing Process Adapted by Pauline Paul

Learning Objectives On completion of this chapter, the learner will be able to: 1. Define the characteristics of critical thinking and critical thinkers. 2. Describe the critical thinking process. 3. Define ethics and nursing ethics. 4. Identify several ethical dilemmas common to the medical-surgical area of nursing practice. 5. Specify strategies that can be helpful to nurses in ethical decision making. 6. Describe the components of the nursing process. 7. Develop a plan of nursing care for a patient using strategies of critical thinking.




Basic Concepts in Nursing

In today’s health care arena, nurses face increasingly complex issues and situations resulting from advanced technology, greater acuity of patients in both hospital and community settings, an aging population, and complex disease processes, as well as ethical issues and cultural factors. The decision-making part of the problem-solving activities of nurses has become increasingly multifaceted and requires critical thinking.

CRITICAL THINKING Critical thinking is a multidimensional skill, a cognitive or mental process or set of procedures. It involves reasoning and purposeful, systematic, reflective, rational, outcome-directed thinking based on a body of knowledge, as well as examination and analysis of all available information and ideas. Critical thinking leads to the formulation of conclusions and alternatives that are most appropriate for the situation (Heffner & Rudy, 2008). Although many definitions of critical thinking have been offered in various disciplines, some consistent themes within those definitions are (1) a strong formal and informal foundation of knowledge; (2) willingness to pursue or ask questions; and (3) ability to develop solutions that are new, even those that do not fit the standard or current state of knowledge or attitudes. Willingness and openness to various viewpoints are inherent in critical thinking, and it is also important to reflect on the current situation (Chan, 2013). Critical thinking includes metacognition, the examination of one’s own reasoning or thought processes, to help refine thinking skills. Independent judgments and decisions

evolve from a sound knowledge base and the ability to synthesize information within the context in which it is presented. Nursing practice in today’s society requires the use of high-level critical thinking skills. Critical thinking enhances clinical decision making, helping to identify patient needs and the best nursing actions that will assist patients in meeting those needs. As previously stated, critical thinking is a conscious, outcome-oriented activity. It is not erratic but rather is systematic and organized. Critical thinkers are inquisitive truth seekers who are open to the alternative solutions that might surface. Alfaro-LeFevre (2013) identified critical thinkers as people who ideally are active thinkers, fair minded, open minded, persistent, empathic, independent in thought, good communicators, honest, organized and systematic, proactive, flexible, realistic, humble, cognizant of the rules of logic, curious and insightful, and creative and committed to excellence. The skills involved in critical thinking are developed over time through effort, practice, and experience.

Critical Thinking in Nursing Practice Critical thinking enhances clinical decision making, helping to identify patient needs and to determine the best nursing actions that will assist the patient in meeting those needs. Nurses must use critical thinking skills in all practice settings—acute care, ambulatory care, extended care, and the home and community. Regardless of the

Glossary assessment: the systematic collection of data to determine the patient’s health status and any actual or potential health problems collaborative problems: specific pathophysiologic manifestations that nurses monitor to detect onset or changes in status critical thinking: a process of insightful thinking that utilizes multiple dimensions of one’s cognition to develop conclusions, solutions, and alternatives that are appropriate for the given situation deontologic or formalist theory: an ethical theory maintaining that ethical standards or principles exist independently of the ends or consequences ethics: the formal, systematic study of moral beliefs evaluation: determination of the patient’s responses to the nursing interventions and the extent to which the outcomes have been achieved implementation: actualization or carrying out of the plan of care through nursing interventions moral dilemma: situation in which a clear conflict exists between two or more moral principles or competing moral claims moral distress: conflict that arises within oneself when a person is aware of the correct course of action but institutional constraints stand in the way of pursuing the correct action

moral problem: competing moral claim or principle; one claim or principle is clearly dominant moral uncertainty: conflict that arises within a person when he or she cannot accurately define what the moral situation is or what moral principles apply but has a strong feeling that something is not right morality: the adherence to informal personal values nursing diagnoses: actual or potential health problems that can be managed by independent nursing interventions nursing process: a deliberate problem-solving approach for meeting people’s health care and nursing needs; common components are assessment, diagnosis, planning, implementation, and evaluation planning: development of goals and outcomes, as well as a plan of care designed to assist the patient in resolving the diagnosed problems and achieving the identified goals and desired outcomes teleologic theory or consequentialism: the theoretical basis of ethics, which focuses on the ends or consequences of actions, such as utilitarianism utilitarianism: a teleologic theory of ethics based on the concept of “the greatest good for the greatest number”


Critical Thinking, Ethical Decision Making, and the Nursing Process

setting, each patient situation is viewed as unique and dynamic. The unique factors that patients and nurses bring to the health care situation are considered, studied, analyzed, and interpreted. Interpretation of the information then allows nurses to focus on those factors that are most relevant and most significant to the clinical situation. Decisions about what to do and how to do it are then developed into a plan of action. Because developing the skill of critical thinking takes time and practice, critical thinking exercises are offered throughout this book as a means of honing one’s ability to think critically. Some of the exercises include questions that stimulate the reader to seek information about evidence-based practice relative to the clinical situation described. The questions listed in Chart 3-1 can serve as a guide in working through the exercises, although it is important to remember that each situation is unique and calls for an approach that fits the particular circumstances described. In addition, much emphasis is placed on nurses basing their clinical actions on research, using evidence-based practice. Critical thinking has been associated with the use of research findings (Profetto-McGrath, Hesketh, Lang, et al., 2003).

ETHICAL NURSING CARE In the complex modern world, we are surrounded by ethical issues in all facets of our lives. Consequently, there has been a heightened interest in the field of ethics in an attempt to gain a better understanding of how these issues influence us. Specifically, the focus on ethics in health care has intensified in response to controversial developments, including advances in technology and genetics, as well as diminished health care and financial resources. Today, sophisticated technology can prolong life well beyond the time when death would have occurred in the past. Expensive experimental procedures, medications, equipment, and devices are available for attempting to preserve life, even when such attempts are likely to fail. The development of technologic support has influenced the quality and delivery of nursing care at all stages of life and also has contributed to an increase in average life expectancy. For example, the prenatal period has been influenced by genetic screening, in vitro fertilization, the harvesting and freezing of embryos, and prenatal surgery. Premature infants who once would have died early in life now may survive because of advances in technology. Children and adults who would have died of organ failure are living longer because of organ transplantation. These advances in technology have been a mixed blessing. Questions have been raised about whether it is appropriate to use such technology, and if so, under what circumstances. Although many patients do achieve a better quality of life, others face extended suffering as a result of efforts to prolong life, usually at great expense. Ethical issues also surround those practices or policies that seem to allocate health care resources unjustly on the basis of age, race, gender, disability, or social mores. The ethical dilemmas nurses may encounter in the medical-surgical nursing arena are numerous and diverse and occur in all settings. An awareness of underlying



The Inquiring Mind: Critical Thinking in Action Throughout the critical thinking process, a continuous flow of questions evolves in the thinker’s mind. Although the questions will vary according to the particular clinical situation, certain general inquiries can serve as a basis for reaching conclusions and determining a course of action. When faced with a patient situation, it is often helpful to seek answers to some or all of the following questions in an attempt to determine those actions that are most appropriate: • What relevant assessment information do I need, and how do I interpret this information? What does this information tell me? What contextual factors must be considered when gathering this information? • To what problems does this information point? Have I identified the most important ones? Does the information point to any other problems that I should consider? • Have I gathered all the information I need (signs and symptoms, laboratory values, medication history, emotional factors, mental status)? Is anything missing? • Is there anything that needs to be reported immediately? Do I need to seek additional assistance? • Does this patient have any special risk factors? Which ones are most significant? What must I do to minimize these risks? • What possible complications must I anticipate? • What are the most important problems in this situation? Do the patient and the patient’s family recognize the same problems? • What are the desired outcomes for this patient? Which have the highest priority? Do the patient and I agree on these points? • What is going to be my first action in this situation? • How can I construct a plan of care to achieve the goals? • Are there any age-related factors involved, and will they require some special approach? Will I need to make some change in the plan of care to take these factors into account? • How do the family dynamics affect this situation, and will they have an effect on my actions or the plan of care? • Are there cultural factors that I must address and consider? • Am I dealing with an ethical issue here? If so, how am I going to resolve it? • Has any nursing research been conducted on this subject? What are the nursing implications of this research for care of this patient?

philosophical concepts helps nurses use reason to work through these dilemmas. Basic concepts related to moral philosophy, such as ethics and its terminology, theories, and approaches, are included in this chapter. Understanding the role of the professional nurse in ethical decision making helps nurses articulate their ethical positions and develop the skills needed to make ethical decisions.

Ethics Versus Morality The terms ethics and morality are used to describe beliefs about right and wrong and to suggest appropriate



Basic Concepts in Nursing

guidelines for action. In essence, ethics is the formal, systematic study of moral beliefs, whereas morality is the adherence to informal personal values. Because the distinction between ethics and morality is slight, the two terms are often used interchangeably.

Ethics Theories One classic theory in ethics is teleologic theory or consequentialism, which focuses on the ends or consequences of actions. The best-known form of this theory, utilitarianism, is based on the concept of “the greatest good for the greatest number.” The choice of action is clear under this theory, because the action that maximizes good over bad is the correct one. The theory poses difficulty when one must judge intrinsic values and determine whose good is the greatest. In addition, it is important to ask whether good consequences can justify any amoral actions that might be used to achieve them. Another theory in ethics is the deontologic or formalist theory, which argues that ethical standards or principles exist independently of the ends or consequences. In a given situation, one or more ethical principles may apply. Nurses have a duty to act based on the one relevant principle, or the most relevant of several ethical principles. Problems arise with this theory when personal and cultural biases influence the choice of the most primary ethical principle.

Approaches to Ethics There are three approaches to ethics: meta-ethics, applied ethics, and relational ethics. An example of meta-ethics (understanding the concepts and linguistic terminology used in ethics) in the health care environment is analysis of the concept of informed consent. Nurses are aware that patients must give consent before surgery, but sometimes a question arises as to whether a patient is truly informed. Delving more deeply into the concept of informed consent would be a meta-ethical inquiry. An example of applied ethics is when a specific discipline identifies ethical problems within that discipline’s practice. Various disciplines use the frameworks of general ethical theories and principles and apply them to specific problems within their domain. Common ethical principles that apply in nursing include autonomy, beneficence, confidentiality, double effect, fidelity, justice, nonmaleficence, paternalism, respect for people, sanctity of life, and veracity. Brief definitions of these important principles can be found in Chart 3-2. Nursing ethics may be considered a form of applied ethics because it addresses moral situations that are specific to the nursing profession and patient care. Some ethical problems that affect nursing may also apply to the broader area of bioethics and health care ethics. Nursing has its own professional code of ethics. Relational ethics is a third approach to discussing ethics. According to Bergum and Dossetor (2005), “the focus of relational ethics is on people (whole persons) and the quality of the commitment between them. These commitments are experienced in a relational or ethical space which

stimulates a fundamental shift in how to think about health ethics” (pp. 8–9). The focus becomes asking the ethical question rather than trying to solve the ethical problem. Another way to look at relational ethics is about “nurturing of another person, the nurturing of the self, and the nurturing of the relationship” (Bergum & Dossetor, p. 16).

Moral Situations Many situations exist in which ethical analysis is needed. Some are moral dilemmas, situations in which a clear conflict exists between two or more moral principles or competing moral claims, and nurses must choose the lesser of two evils. Other situations represent moral problems, in which there may be competing moral claims or principles, but one claim or principle is clearly dominant. Some situations result in moral uncertainty, when one cannot accurately define what the moral situation is or what moral principles apply but has a strong feeling that something is not right. Still other situations may result in moral distress, in which one is aware of the correct course of action but constraints stand in the way of pursuing the correct action. For example, a patient tells a nurse that if he is dying he wants all possible measures taken to save his life. However, the surgeon and family have made the decision not to tell the patient that he is terminally ill and not to resuscitate him if he stops breathing. From an ethical perspective, the patient should be told the truth about his diagnosis and should have the opportunity to make decisions about treatment. Ideally, this information should come from the physician, with the nurse present to assist the patient in understanding the terminology and to provide further support, if necessary. In this situation, a moral problem exists because of the competing moral claims of the family and physician, who wish to spare the patient distress, and the nurse, who wishes to be truthful with the patient. If the patient’s competency were questionable, a moral dilemma would exist because no dominant principle would be evident. The nurse could experience moral distress if the hospital threatened disciplinary action or job termination because the information is disclosed to the patient without the agreement of the physician or the family, or both. It is essential that nurses freely engage in dialogue concerning moral situations, even though such dialogue is difficult for everyone involved. Improved interdisciplinary communication is supported when all members of the health care team can voice their concerns and come to an understanding of the moral situation. The use of an ethics consultant or consultation team could be helpful to assist the health care team, patient, and family to identify the moral dilemma and possible approaches to the dilemma. Nurses should be familiar with agency policy supporting patient self-determination and resolution of ethical issues.

Types of Ethical Problems in Nursing As a profession, nursing is accountable to society. Collectively, Canadian nursing has formally defined its standards of accountability through the Code of Ethics for Registered


Critical Thinking, Ethical Decision Making, and the Nursing Process



Common Ethical Principles The following common ethical principles may be used to validate moral claims.

Autonomy This word is derived from the Greek words autos (“self”) and nomos (“rule” or “law”), and therefore refers to self-rule. In contemporary discourse it has broad meanings, including individual rights, privacy, and choice. Autonomy entails the ability to make a choice free from external constraints.

Beneficence Beneficence is the duty to do good and the active promotion of benevolent acts (e.g., goodness, kindness, charity). It may also include the injunction not to inflict harm (see nonmaleficence).

Confidentiality Confidentiality relates to the concept of privacy. Information obtained from an individual will not be disclosed to another unless it will benefit the person or there is a direct threat to the social good.

Double Effect This is a principle that may morally justify some actions that produce both good and evil effects. All four of the following criteria must be fulfilled: 1. The action itself is good or morally neutral. 2. The agent sincerely intends the good and not the evil effect (the evil effect may be foreseen but is not intended). 3. The good effect is not achieved by means of the evil effect. 4. There is proportionate or favourable balance of good over evil.

Fidelity Fidelity is promise keeping; the duty to be faithful to one’s commitments. It includes both explicit and implicit promises to another person.

Justice From a broad perspective, justice states that like cases should be treated alike. A more restricted version of justice is distributive justice, which refers to the distribution of social

Nurses (Canadian Nurses Association [CNA], 2008a). This code is structured around values and responsibilities that are providing safe, compassionate, competent, and ethical care; promoting health and well-being; promoting and respecting informed decision making; preserving dignity; promoting justice; and being accountable (CNA, 2008a). The code offers an ideal framework for nurses to use in ethical decision making. Ethical issues have always affected the role of the professional nurse. The accepted definition of professional nursing has inspired a new advocacy role for nurses. The International Council of Nurses (2008, p. 1) states: Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.

benefits and burdens based on various criteria that may include the following: Equality Individual need Individual effort Societal contribution Individual merit Legal entitlement Retributive justice is concerned with the distribution of punishment.

Nonmaleficence This is the duty not to inflict harm as well as to prevent and remove harm. Nonmaleficence may be included within the principle of beneficence, in which case nonmaleficence would be more binding.

Paternalism Paternalism is the intentional limitation of another’s autonomy, justified by an appeal to beneficence or the welfare or needs of another. Under this principle, the prevention of evil or harm takes precedence over any potential evil caused by interference with the individual’s autonomy or liberty.

Respect for Persons Respect for persons is frequently used synonymously with autonomy. However, it goes beyond accepting the notion or attitude that people have autonomous choices, to treating others in such a way that enables them to make choices.

Sanctity of Life This is the perspective that life is the highest good. Therefore, all forms of life, including mere biologic existence, should take precedence over external criteria for judging quality of life.

Veracity Veracity is the obligation to tell the truth and not to lie or deceive others.

This definition supports the claim that nurses must be actively involved in the decision-making process regarding ethical concerns surrounding health care and human responses. Efforts to enact this standard may cause conflict in health care settings in which the traditional roles of the nurse are delineated within a bureaucratic structure. If, however, nurses learn to present ethical conflicts within a logical, systematic framework, struggles over jurisdictional boundaries may decrease. Health care settings in which nurses are valued members of the team promote interdisciplinary communication and may enhance patient care. To practice effectively in these settings, nurses must be aware of ethical issues and assist patients in voicing their moral concerns. Nursing theories that incorporate the biopsychosocial– spiritual dimensions emphasize a holistic viewpoint, with humanism or caring at the core. As the nursing profession strives to delineate its own theory of ethics, caring is often cited as the moral foundation. For nurses to embrace this



Basic Concepts in Nursing

professional ethos, they must be aware not only of major ethical dilemmas, but also of those daily interactions with health care consumers that frequently give rise to less easily identifiable ethical challenges. Although technologic advances and diminished resources have been instrumental in raising numerous ethical questions and controversies, including life-and-death issues, nurses should not ignore the many routine situations that involve ethical considerations. Some of the most common issues faced by nurses today include confidentiality, use of restraints, trust, refusing care, and end-of-life concerns.

Confidentiality All nurses should be aware of the confidential nature of information obtained in daily practice. If information is not pertinent, they should question whether it is prudent to document it in a patient’s record. In the practice setting, discussion of patients with other members of the health care team is often necessary. However, these discussions should occur in a private area where it is unlikely that the conversation will be overheard. Another threat to confidentiality is the widespread use of computer-based technologies and people’s easy access to them. The growing demand for tele-health innovations and the increasing use of this new method can result in unchecked access to health information. In addition, personal and health information is often made available to numerous individuals and corporate stakeholders, which may increase the potential for misuse of health care information. Because of these possibilities of maleficence (see Chart 3-2), sensitivity to the principle of confidentiality is essential.

Restraints The use of restraints (including physical and pharmacologic measures) is another issue with ethical overtones. It is important to weigh carefully the risks of limiting a person’s autonomy and increasing the risk of injury by using restraints against the risks of not using restraints; they have been documented as resulting in physical harm and death (Mohr, 2010). Before restraints are used, other strategies, such as asking family members to sit with the patient, should be tried. Professional nursing associations such as the College and Association of Registered Nurses of Alberta (CARNA, 2009) consider that registered nurses should “exhaust all possible alternative intervention before deciding to use a restraint” (p. 3). In situations where restraints are used, nurses have the moral responsibility to perform ongoing assessments and advocate for their clients (CARNA, 2009).

Trust Issues Telling the truth (veracity) is one of the basic principles of our culture. Three ethical dilemmas in clinical practice that can directly conflict with this principle are the use of placebos (nonactive substances used for treatment), not revealing a diagnosis to a patient, and revealing a diagnosis to people other than the patient with the diagnosis. All involve the issue of trust, which is an essential element in the nurse–patient relationship (Carter, 2009).

Placebos may be used in experimental research, in which a patient is involved in the decision-making process and is aware that placebos are being used in the treatment regimen. However, the use of a placebo as a substitute for an active drug to show that a patient does not have actual symptoms of a disease is deceptive, and this practice may severely undermine the nurse–patient relationship. Informing a patient of his or her diagnosis when the family and physician have chosen to withhold information is a common ethical situation in nursing practice. The nursing staff may often use evasive comments with the patient as a means of maintaining professional relationships with other health practitioners. This area is indeed complex, because it challenges a nurse’s integrity. Strategies nurses could consider include the following: • Not lying to the patient • Providing all information related to nursing procedures and diagnoses • Communicating the patient’s requests for information to the family and physician. The family is often unaware of the patient’s repeated questions to the nurse. With a better understanding of the situation, the family members may change their perspective Although providing the information may be the morally appropriate behaviour, the manner in which the patient is told is important. Nurses must be compassionate and caring while informing patients; disclosure of information merely for the sake of patient autonomy does not convey respect for others.

Refusing to Provide Care Any nurse who feels compelled to refuse to provide care for a particular type of patient faces an ethical dilemma. The reasons given for refusal range from a conflict of personal values to fear of personal injury. However, there is an ethical obligation to care for all patients, and nurses must be accountable. In the section on “Being Accountable,” the Code of Ethics for Registered Nurses includes the following statement: If nursing care is requested that is in conflict with the nurse’s moral beliefs and values but in keeping with professional practice, the nurse provides safe, compassionate, competent and ethical care until alternative care arrangements are in place to meet the person’s needs or desires. If nurses can anticipate a conflict with their conscience, they have an obligation to notify their employers (CNA, 2008a, p. 19).

To avoid facing these ethical situations, a nurse can follow certain strategies. For example, when applying for a job, one should ask questions regarding the patient population. If the applicant is uncomfortable with a particular situation, then not accepting the position would be an option. Denial of care, or providing substandard nursing care to some members of our society, is not an acceptable nursing practice.

End-of-Life Issues Dilemmas that centre on death and dying are prevalent in medical-surgical nursing practice and frequently initiate ethical discussion (CNA, 2008a). The dilemmas are


Critical Thinking, Ethical Decision Making, and the Nursing Process

compounded by the fact that the idea of curing is paramount in health care. With advanced technology, it may be difficult to accept the fact that nothing more can be done or that technology may prolong life but at the expense of comfort and quality of life. Focusing on the caring as well as the curing role may assist nurses in dealing with these difficult ethical situations. End-of-life issues are discussed in detail in Chapter 18.

Preventive Ethics When a nurse is faced with two conflicting alternatives, it is his or her moral decision to choose the lesser of the two evils. Various preventive strategies are available to help nurses anticipate or avoid certain kinds of ethical dilemmas. Frequently, dilemmas occur when health care practitioners are unsure of the patient’s wishes because the patient is unconscious or too cognitively impaired to communicate directly. Encouraging patients to prepare advanced directives serves in the prevention of these dilemmas.

Advance Directives An advance directive is a legal document that specifies a person’s wishes prior to illness (and before hospitalization) and provides valuable information that may assist health care providers in decision making (Health Canada, 2006). This directive is used only if the person is unable to speak for him or herself, and it is revoked if the person regains the ability to make decisions. Whereas one tends to think that the advance directive contains information about treatments that are not to be initiated or maintained, it can also provide the direction that active, potentially lifesaving treatment is to occur. An advance directive usually includes the name of a substitute decision maker who has agreed to make decisions that respect the instructions contained within the document. Each province and two of the three territories have advance directive legislation with information on what to include and how to ensure that the directive is legally binding (Nunavut only provides for power of attorney for property and financial matters) (Health Canada, 2006). All advance directives in Canada are about future health care decisions. There are fines or other penalties in place if an advance directive is not followed. The provinces and territories have laws that regulate how individuals can arrange for another person to manage their financial affairs if they become physically unable to do so themselves (power of attorney). This type of power of attorney ends if the signer becomes mentally incompetent. Of more importance is the durable power of attorney, in which an individual identifies another person to make health care decisions on his or her behalf. In this type of directive, the person may have clarified his or her wishes concerning a variety of medical situations. The benefit of a durable power of attorney is that it continues even if the signer becomes mentally incompetent. Institutional ethics committees, which exist in many hospitals to assist practitioners with ethical dilemmas, also aid in preventive ethics. The purpose of these multidisciplinary committees varies among institutions. In


some hospitals, the committee exists solely for the purpose of developing policies; in others, it may have a strong educational or consultation focus. Because these committees usually comprise individuals with some advanced training in ethics, they are important resources to the health care team, patient, and family. Nurses with a particular interest or expertise in the area of ethics are valuable members of ethics committees and can serve as resources for staff nurses. The heightened interest in ethical decision making has resulted in many continuing education programs, ranging from seminars or workshops to full-semester courses offered by local colleges or professional organizations. In addition, nursing and medical journals contain articles on ethical issues, and numerous textbooks on clinical ethics or nursing ethics are available. These are valuable resources because they cover the ethical theory and dilemmas of practice in greater depth. The CNA also has publications available to assist nurses with ethical decision making.

Ethics Committees Institutional ethics committees exist in many hospitals to assist clinicians with ethical dilemmas. The purpose of these interdisciplinary committees varies among institutions. In some hospitals, the committees exist solely for the purpose of developing policies, whereas in others, they may have a strong educational or consultation focus. These committees usually are composed of people with some advanced training in ethics and are important resources for the health care team, patient, and family. Nurses with a particular interest or expertise in the area of ethics can serve as members of these committees, which are valuable resources for staff nurses.

Ethical Decision Making As noted in the preceding discussions, ethical dilemmas are common and diverse in nursing practice. Situations vary, and experience indicates that there are no clear solutions to these dilemmas. However, the fundamental philosophical principles are the same, and the process of moral reflection helps nurses justify their actions. The approach to ethical decision making can follow the steps of the nursing process. Chart 3-3 outlines the steps of an ethical analysis.

THE NURSING PROCESS Definition The nursing process is a deliberate problem-solving approach for meeting people’s health care and nursing needs. Although the steps of the nursing process have been stated in various ways by different writers, the common components cited are assessment, diagnosis, planning, implementation, and evaluation. The traditional steps are defined as follows: 1. Assessment: The systematic collection of data to determine the patient’s health status and any actual or

Basic Concepts in Nursing

The following are guidelines to assist nurses in ethical decision making. These guidelines reflect an active process in decision making, similar to the nursing process detailed in this chapter.

Assessment 1. Assess the ethical/moral situations of the problem. This step entails recognition of the ethical, legal, and professional dimensions involved. a. Does the situation entail substantive moral problems (conflicts among ethical principles or professional obligations)? b. Are there procedural conflicts? (e.g., who should make the decisions? Any conflicts among the patient, health care providers, family, and guardians?) c. Identify the significant people involved and those affected by the decision.

Planning 2. Collect information. a. Include the following information: the medical facts, treatment options, nursing diagnoses, legal data, and the values, beliefs, and religious components. b. Make a distinction between the factual information and the values/beliefs. c. Validate the patient’s capacity, or lack of capacity, to make decisions. d. Identify any other relevant information that should be elicited. e. Identify the ethical/moral issues and the competing claims.


Assessment data are gathered through the health history and the physical assessment. In addition, ongoing monitoring is crucial to remain aware of changing patient needs and the effectiveness of nursing care. Outcome(s) Documentation

n of nursing care Pla

hy s

n ical me assess



rative proble llabo ms


achieved or rev mes ised tco Ou rative activiti es llabo Co ected outcomes

alth histor y He


4. Decide and evaluate the decision. a. What is the best or morally correct action? b. Give the ethical reasons for your decision. c. What are the ethical reasons against your decision? d. How do you respond to the reasons against your decision?


E xp


Using the Nursing Process


3. List the alternatives. Compare alternatives with applicable ethical principles and professional code of ethics. Choose either of the frameworks below, or other frameworks, and compare outcomes. a. Utilitarian approach: Predict the consequences of the alternatives; assign a positive or negative value to each consequence; choose the consequence that predicts the highest positive value or “the greatest good for the greatest number.” b. Deontologic approach: Identify the relevant moral principles; compare alternatives with moral principles; appeal to the “higher-level” moral principle if there is a conflict.

Dividing the nursing process into distinct steps serves to emphasize the essential nursing actions that must be taken to address the patient’s nursing diagnoses and manage any collaborative problems or complications. However, dividing the process into separate steps is artificial: The process functions as an integrated whole, with the steps being interrelated, interdependent, and recurrent (Fig. 3-1). Chart 3-4 presents an overview of the nursing activities involved in applying the nursing process.


Steps of an Ethical Analysis

• Collaborative problems: “Certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed and nurse-prescribed interventions to minimize the complications of the events” (Carpenito-Moyet, 2012, p. 19). 3. Planning: Development of goals and outcomes, as well as a plan of care designed to assist the patient in resolving the diagnosed problems and achieving the identified goals and desired outcomes 4. Implementation: Actualization of the plan of care through nursing interventions. 5. Evaluation: Determination of the patient’s responses to the nursing interventions and the extent to which the outcomes have been achieved

g diagnose s


sin Nur

d als an priorities Go





potential health problems. (Analysis of data is included as part of the assessment. Analysis may also be identified as a separate step of the nursing process.) 2. Diagnosis: Identification of the following two types of patient problems: • Nursing diagnoses: Actual or potential health problems that can be managed by independent nursing interventions

IMPL EMENTATION EVALUATION FIGURE 3-1. The nursing process is depicted schematically in this cir-

cle. Starting from the innermost circle, nursing assessment, the process moves outward through the formulation of nursing diagnoses and collaborative problems; planning, with setting of goals and priorities in the nursing plan of care; implementation and documentation; and, finally, the ongoing process of evaluation and outcomes.


Critical Thinking, Ethical Decision Making, and the Nursing Process



Steps of the Nursing Process Assessment 1. 2. 3. 4. 5.

Conduct the health history. Perform the physical assessment. Interview the patient’s family or significant others. Study the health record. Organize, analyze, synthesize, and summarize the collected data.

Diagnosis NURSING DIAGNOSIS 1. Identify the patient’s nursing problems. 2. Identify the defining characteristics of the nursing problems. 3. Identify the etiology of the nursing problems. 4. State nursing diagnoses concisely and precisely. COLLABORATIVE PROBLEMS 1. Identify potential problems or complications that require collaborative interventions. 2. Identify health team members with whom collaboration is essential.

Planning 1. Assign priority to the nursing diagnoses. 2. Specify the goals. a. Develop immediate, intermediate, and long-term goals. b. State the goals in realistic and measurable terms. 3. Identify nursing interventions appropriate for goal attainment. 4. Establish expected outcomes. a. Make sure that the outcomes are realistic and measurable. b. Identify critical times for the attainment of outcomes.

Health History The health history is conducted to determine a person’s state of wellness or illness and is best accomplished as part of a planned interview. The interview is a personal dialogue between a patient and a nurse that is conducted to obtain information. The nurse’s approach to the patient largely determines the amount and quality of the information that is received. To achieve a relationship of mutual trust and respect, the nurse must have the ability to communicate a sincere interest in the patient. Examples of effective therapeutic communication techniques that can be used to achieve this goal are found in Table 3-1. The use of a health history guide may help in obtaining pertinent information and in directing the course of the interview. A variety of health history formats designed to guide the interview are available, but they must be adapted to the responses, problems, and needs of the person. See Chapter 5 for further information about the health history.

Physical Assessment A physical assessment may be carried out before, during, or after the health history, depending on a patient’s physical and emotional status and the immediate priorities of the situation. The purpose of the physical assessment is to identify those aspects of a patient’s physical, psychological, and emotional state that indicate a need for nursing care. It

5. Develop the written plan of nursing care. a. Include nursing diagnoses, goals, nursing interventions, expected outcomes, and critical times. b. Write all entries precisely, concisely, and systematically. c. Keep the plan current and flexible to meet the patient’s changing problems and needs. 6. Involve the patient, family or significant others, nursing team members, and other health team members in all aspects of planning.

Implementation 1. Put the plan of nursing care into action. 2. Coordinate the activities of the patient, family or significant others, nursing team members, and other health team members. 3. Record the patient’s responses to the nursing actions.

Evaluation 1. Collect data. 2. Compare the patient’s actual outcomes with the expected outcomes. Determine the extent to which the expected outcomes were achieved. 3. Include the patient, family or significant others, nursing team members, and other health care team members in the evaluation. 4. Identify alterations that need to be made in the nursing diagnoses, collaborative problems, goals, nursing interventions, and expected outcomes. 5. Continue all steps of the nursing process: assessment, diagnosis, planning, implementation, and evaluation.

requires the use of sight, hearing, touch, and smell, as well as appropriate interview skills and techniques. Physical examination techniques as well as techniques and strategies for assessing behaviours and role changes are presented in Chapters 5 and 8 and in each unit of this book.

Other Components of the Assessment Additional relevant information should be obtained from the patient’s family or significant others, from other members of the health team, and from the patient’s health record or chart. Depending on the patient’s immediate needs, this information may have been completed before the health history and the physical assessment were obtained. Whatever the sequence of events, it is important to use all available sources of pertinent data to complete the nursing assessment.

Recording the Data After the health history and physical assessment are completed, the information obtained is recorded in the patient’s permanent record. This record provides a means of communication among members of the health care team and facilitates coordinated planning and continuity of care. The record fulfills other functions as well: • It serves as the legal and business record for a health care agency and for the professional staff members who




Basic Concepts in Nursing

Therapeutic Communication Techniques



Therapeutic Value


Active process of receiving information and examining one’s reactions to the messages received Periods of no verbal communication among participants for therapeutic reasons

Nonverbally communicates nurse’s interest in patient


Repeating to the patient what the nurse believes is the main thought or idea expressed

Demonstrates that the nurse is listening and validates, reinforces, or calls attention to something important that has been said


Directing back to the patient his or her feelings, ideas, questions, or content

Validates the nurse’s understanding of what the patient is saying and signifies empathy, interest, and respect for the patient


Asking the patient to explain what he or she means or attempting to verbalize vague ideas or unclear thoughts of the patient to enhance the nurse’s understanding

Helps to clarify the patient’s feelings, ideas, and perceptions and to provide an explicit correlation between them and the patient’s actions


Questions or statements to help the patient develop or expand an idea

Allows the patient to discuss central issues and keeps communication goal directed

Broad openings

Encouraging the patient to select topics for discussion

Indicates acceptance by the nurse and the value of the patient’s initiative


Discharge of energy through the comic enjoyment of the imperfect

Promotes insight by bringing repressed material to consciousness, resolving paradoxes, tempering aggression, and revealing new options; a socially acceptable form of sublimation


Providing information

Helpful in health teaching or patient education about relevant aspects of patient’s well-being and self-care

Sharing perceptions

Asking the patient to verify the nurse’s understanding of what the patient is thinking or feeling

Conveys the nurse’s understanding to the patient and has the potential to clarify confusing communication

Theme identification

Underlying issues or problems experienced by the patient that emerge repeatedly during the course of the nurse–patient relationship

Allows the nurse to best promote the patient’s exploration and understanding of important problems


Presentation of alternative ideas for the patient’s consideration relative to problem solving

Increases the patient’s perceived options or choices


Gives patient time to think and gain insights, slows the pace of the interaction, and encourages the patient to initiate conversation, while conveying the nurse’s support, understanding, and acceptance

Adapted from Stuart, G. W., & Laraia, M. T. (2005). Principles and practice of psychiatric nursing (8th ed.). St Louis, MO: CV Mosby.

are responsible for the patient’s care. A variety of systems are used for documenting patient care, and each health care agency selects the system that best meets its needs. • It serves as a basis for evaluating the quality and appropriateness of care and for reviewing the effective use of patient care services. • It provides data that are useful in research, education, and short- and long-range planning.

lating nursing diagnoses acceptable for study. Approved nursing diagnoses are compiled and categorized by NANDA International in a taxonomy that is updated to maintain currency. The diagnostic labels identified by NANDA International (2012) have been generally accepted, but ongoing validation, refinement, and expansion based on clinical use and research are encouraged. They are not yet complete or mutually exclusive, and more research is needed to determine their validity and clinical applicability.


Choosing a Nursing Diagnosis

The assessment component of the nursing process serves as the basis for identifying nursing diagnoses and collaborative problems. Soon after the completion of the health history and the physical assessment, nurses organize, analyze, synthesize, and summarize the data collected and determine the patient’s need for nursing care.

Nursing Diagnosis Nursing diagnoses, the first taxonomy created in nursing, have fostered autonomy and accountability in nursing and have helped delineate the scope of practice. North American Nursing Diagnosis Association (NANDA) International is the official organization responsible for developing the taxonomy of nursing diagnoses and formu-

When choosing the nursing diagnoses for a particular patient, nurses must first identify the commonalities among the assessment data collected. These common features lead to the categorization of related data that reveal the existence of a problem and the need for nursing intervention. The identified problems are then defined as specific nursing diagnoses. Nursing diagnoses represent actual or potential health problems that can be managed by independent nursing actions. It is important to remember that nursing diagnoses are not medical diagnoses; they are not medical treatments prescribed by the physician, and they are not diagnostic studies. Rather, they are succinct statements in terms of specific patient problems that guide nurses in the development of the nursing plan of care.



Critical Thinking, Ethical Decision Making, and the Nursing Process

To give additional meaning to the nursing diagnosis, the characteristics and etiology of the problem are identified and included as part of the diagnosis. For example, the nursing diagnoses and their defining characteristics and etiology for a patient who has anemia may include the following: • Activity intolerance related to weakness and fatigue • Ineffective tissue perfusion related to inadequate blood volume • Imbalanced nutrition: Less than body requirements related to fatigue and inadequate intake of essential nutrients

Collaborative Problems In addition to nursing diagnoses and their related nursing interventions, nursing practice involves certain situations and interventions that do not fall within the definition of nursing diagnoses. These activities pertain to potential problems or complications that are medical in origin and require collaborative interventions with the physician and other members of the health care team. The term collaborative problem is used to identify these situations. Collaborative problems are certain physiologic complications that nurses monitor to detect changes in status or onset of complications. Nurses manage collaborative problems using physician-prescribed and nurse-prescribed interventions to minimize complications (CarpenitoMoyet, 2012). When treating collaborative problems, a primary nursing focus is monitoring patients for the onset of complications or changes in the status of existing complications. The complications are usually related to the disease process, treatments, medications, or diagnostic studies. The nurse recommends nursing interventions that are appropriate for managing the complications and implements the treatments prescribed by the physician. The algorithm in Figure 3-2 depicts the differences between nursing diagnoses and collaborative problems. After the nursing diagnoses and collaborative problems have been identified, they are recorded on the plan of nursing care.

Situation identified (health status, problem)

Can the nurse legally order the primary interventions to achieve a goal?



Nursing diagnosis

Are medical and nursing interventions needed to achieve the patient goal?

Prescribe and execute the interventions that are definitive for prevention, treatment, or health promotion



Discharged from nursing care

Collaborative problems

Monitor and evaluate condition

Prescribe and implement interventions that are in the domain of nursing

Implement the prescriptive orders

FIGURE 3-2. Differentiating nursing diagnoses and collaborative prob-

Planning Once the nursing diagnoses have been identified, the planning component of the nursing process begins. This phase involves the following steps: 1. Assigning priorities to the nursing diagnoses and collaborative problems 2. Specifying expected outcomes 3. Specifying the immediate, intermediate, and long-term goals of nursing action 4. Identifying specific nursing interventions appropriate for attaining the outcomes 5. Identifying interdependent interventions 6. Documenting the nursing diagnoses, collaborative problems, expected outcomes, nursing goals, and nursing interventions on the plan of nursing care 7. Communicating to appropriate personnel any assessment data that point to health care needs that can best be met by other members of the health care team

lems. (Redrawn from Carpenito-Moyet, L. J. (2012). Nursing diagnosis: Application to clinical practice (14th ed., p. 27). Philadelphia, PA: Lippincott Williams & Wilkins.)

Setting Priorities Assigning priorities to the nursing diagnoses and collaborative problems is a joint effort by the nurse and the patient or family members. Any disagreement about priorities is resolved in a way that is mutually acceptable. Consideration must be given to the urgency of the problems, with the most critical problems receiving the highest priority. The Maslow hierarchy of needs provides one framework for prioritizing problems, with importance being given first to physical needs; once those basic needs are met, higher-level needs can be addressed. See Chapter 1 for a further discussion of the Maslow hierarchy.



Basic Concepts in Nursing


Nursing-Sensitive Outcomes Classification (NOC) The NOC is a classification of patient outcomes sensitive to nursing interventions. Each outcome is a neutral statement about a variable patient condition, behaviour, or perception, coupled with a rating scale. The outcome statement and

scale can be used to identify baseline functioning, expected outcomes, and actual outcomes for individual patients. The following table is an example of a nursing-sensitive outcome.

Respiratory Status: Gas Exchange (0402) Domain—Physiologic Health (II) Class—Cardiopulmonary (E) Scale(s)—Severe deviation from normal range to No deviation from normal range (b) and Severe to None (n) Definition: Alveolar exchange of carbon dioxide and oxygen to maintain arterial blood gas concentrations. OUTCOME TARGET RATING

Maintain at ______

Respiratory Status: Gas Exchange Overall Rating Indicators 040208 Partial pressure of oxygen in arterial blood (PaO2) 040209 Partial pressure of carbon dioxide in arterial blood (PaCO2) 040210 Arterial pH 040211 Oxygen saturation 040212 End-tidal carbon dioxide 040213 Chest x-ray findings 040214 Ventilation–perfusion balance 040203 040204 040205 040206 040207 040216

Dyspnea at rest Dyspnea with mild exertion Restlessness Cyanosis Somnolence Impaired cognition

Increase to ______

Severe Deviation From Normal Range

Substantial Deviation From Normal Range

Moderate Deviation From Normal Range

Mild Deviation From Normal Range

No Deviation From Normal Range


















1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

4 4 4 4 4

5 5 5 5 5







1 1 1 1 1 1

2 2 2 2 2 2

3 3 3 3 3 3

4 4 4 4 4 4

5 5 5 5 5 5


With permission from Moorhead, S., Johnson, M., Maas, M. L., et al. (Eds.). (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Mosby-Elsevier.

Establishing Expected Outcomes Expected outcomes of the nursing interventions are expressed in terms of the patient’s behaviours and the time period in which the outcomes are to be achieved, as well as any special circumstances related to achieving the outcome (Smith-Temple & Johnson, 2013). These outcomes must be realistic and measurable. Resources for identifying appropriate expected outcomes include the NursingSensitive Outcomes Classification (NOC) (Chart 3-5) and standard outcome criteria established by health care agencies for people with specific health problems. These outcomes can be associated with nursing diagnoses and interventions and can be used when appropriate. However, the NOC may need to be adapted to establish realistic criteria for the specific patient involved. The expected outcomes that define the desired behaviour of the patient are used to measure the progress made

toward resolving the problem. The expected outcomes also serve as the basis for evaluating the effectiveness of the nursing interventions and for deciding whether additional nursing care is needed or whether the plan of care needs to be revised.

Establishing Goals After the priorities of the nursing diagnoses and expected outcomes have been established, goals (immediate, intermediate, and long term) and the nursing actions appropriate for attaining the goals are identified. The patient and family are included in establishing goals for the nursing actions. Immediate goals are those that can be attained within a short period. Intermediate and long-term goals require a longer time to be achieved and usually involve preventing complications and other health problems and promoting self-care and rehabilitation. For example, goals


Critical Thinking, Ethical Decision Making, and the Nursing Process

for a patient with a nursing diagnosis of impaired physical mobility related to pain and edema following total knee replacement may be stated as follows: • Immediate goal: Stands at bedside for 5 minutes 6 to 12 hours after surgery • Intermediate goal: Ambulates with walker or crutches in hospital and home • Long-term goal: Ambulates independently 1 to 2 miles each day

Determining Nursing Actions In planning appropriate nursing actions to achieve the desired goals and outcomes, the nurse, with input from the patient and significant others, identifies individualized interventions based on the patient’s circumstances and preferences that address each outcome. Interventions should identify the activities needed and who will implement them. Determination of interdisciplinary activities is made in collaboration with other health care providers as needed. The nurse identifies and plans patient teaching and demonstration as needed to assist the patient in learning certain self-care activities. Planned interventions should be ethical and appropriate to the patient’s culture, age, and gender. Standardized interventions, such as those found on institutional care plans or in the Nursing Interventions Classification (NIC) (Bulechek, Butcher, Dochterman, et al., 2013) can be used. Chart 3-6 describes the NIC system and provides an example of an NIC system intervention. It is important to individualize prewritten interventions to promote optimal effectiveness for each patient. Actions of nurses should be based on established standards.

Implementation The implementation phase of the nursing process involves carrying out the proposed plan of nursing care. The nurse assumes responsibility for the implementation and coordinates the activities of all those involved in implementation, including the patient and family, other members of the nursing team, and other members of the health care team, so that the schedule of activities facilitates the patient’s recovery. The plan of nursing care serves as the basis for implementation, as described below: • The immediate, intermediate, and long-term goals are used as a focus for the implementation of the designated nursing interventions. • While implementing nursing care, the nurse continually assesses the patient and his or her response to the nursing care. • Revisions are made in the plan of care as the patient’s condition, problems, and responses change and when reordering of priorities is required. Implementation includes direct or indirect execution of the planned interventions. It is focused on resolving the patient’s nursing diagnoses and collaborative problems and achieving expected outcomes, thus meeting the patient’s health needs. Examples of nursing interventions are assisting with hygiene care; promoting physical and psychological comfort; supporting respiratory and elimination functions; facilitating the ingestion of food, fluids, and nutrients; managing the patient’s immediate sur-



Nursing Interventions Classification (NIC) The NIC is a standardized classification of nursing treatments (interventions) that includes independent and collaborative interventions. Intervention labels are terms such as hemorrhage control, medication administration, or pain management. Listed under each intervention are multiple discrete nursing actions that together constitute a comprehensive approach to the treatment of a particular condition. Not all actions are applicable to every patient; nursing judgment will determine which actions to implement. The following is an example of a nursing intervention:

Ventilation Assistance DEFINITION Promotion of an optimal spontaneous breathing pattern that maximizes oxygen and carbon dioxide exchange in the lungs ACTIVITIES Maintain a patent airway. Position to alleviate dyspnea. Position to facilitate ventilation–perfusion matching (“good lung down”), as appropriate. Assist with frequent position changes, as appropriate. Position to minimize respiratory efforts (e.g., elevate the head of the bed and provide overbed table for patient to lean on). Monitor the effects of position change on oxygenation (e.g., arterial blood gases, SaO2, SvO2). Encourage slow deep breathing, turning, and coughing. Assist with incentive spirometer, as appropriate. Auscultate breath sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds. Monitor for respiratory muscle fatigue. Initiate and maintain supplemental oxygen, as prescribed. Administer appropriate pain medication to prevent hypoventilation. Ambulate three to four times per day, as appropriate. Monitor respiratory and oxygenation status. Administer medications (e.g., bronchodilators and inhalers) that promote airway patency and gas exchange. Teach pursed lips breathing techniques, as appropriate. Teach breathing techniques, as appropriate. Initiate a program of respiratory muscle strength and/or endurance training, as appropriate. Initiate resuscitation efforts, as appropriate. Used with permission from Bulechek, G. M., Butcher, H. K., Dochterman, J. M., et al. (Eds.). (2013). Nursing interventions classification (NIC) (5th ed.). St. Louis, MO: Mosby-Elsevier.

roundings; providing health teaching; promoting a therapeutic relationship; and carrying out a variety of therapeutic nursing activities. Judgment, critical thinking, and good decision-making skills are essential in the selection of appropriate evidence-based and ethical nursing interventions. All nursing interventions are patient focused and outcome directed and are implemented with compassion, confidence, and a willingness to accept and understand the patient’s responses. Although many nursing actions are independent, others are interdependent, such as carrying out prescribed treatments, administering medications and therapies, and



Basic Concepts in Nursing

collaborating with other health care team members to accomplish specific expected outcomes and to monitor and manage potential complications. Such interdependent functioning is just that—interdependent. Requests or orders from other health care team members should not be followed blindly but should be assessed critically and questioned when necessary. The implementation phase of the nursing process ends when the nursing interventions have been completed.

• Do priorities need to be reordered? • Have the patient’s nursing needs been met? • Should the nursing interventions be continued, revised, or discontinued? • Have new problems evolved for which nursing interventions have not been planned or implemented? • What factors influenced the achievement or lack of achievement of the objectives? • Should changes be made in the expected outcomes and outcome criteria?


Objective data that provide answers to these questions are collected from all available sources (e.g., patients, families, significant others, health care team members). These data are included in patients’ records and must be substantiated by direct patient observation before the outcomes are documented.

Evaluation, the final step of the nursing process, allows the nurse to determine the patient’s response to the nursing interventions and the extent to which the objectives have been achieved. The plan of nursing care is the basis for evaluation. The nursing diagnoses, collaborative problems, priorities, nursing interventions, and expected outcomes provide the specific guidelines that dictate the focus of the evaluation. Through evaluation, the nurse can answer the following questions: • Were the nursing diagnoses and collaborative problems accurate? • Did the patient achieve the expected outcomes within the critical time periods? • Have the patient’s nursing diagnoses been resolved? • Have the collaborative problems been resolved?

Plan of Nursing Care

Documentation of Outcomes and Revision of Plan Outcomes are documented concisely and objectively. Documentation should relate outcomes to the nursing diagnoses and collaborative problems, describe the patient’s responses to the interventions, indicate whether the outcomes were met, and include any additional pertinent data. An example of an individualized plan of nursing care is given in Chart 3-7.

Chart 3-7. Example of an Individualized Plan of Nursing Care

Mrs. T.C., a 52-year-old elementary school teacher, was admitted to the nursing unit from the emergency department. She had had a gnawing pain on her right side radiating to her back for 3 days. She now describes her pain as “excruciating after eating or drinking.” In the past 48 hours she has been vomiting about 2 to 3 hours after she eats. She has not had anything to eat or drink for the past 12 hours. Mrs. T.C. stated that she had not been successful in adhering to the weight reduction diet that had been prescribed by her physician and that she had rapidly lost, then regained, weight several times in the past year and a half. She stated, “My life is just too busy—I work late hours planning lessons and have to buy my meals out a lot.” She indicated that in addition to her work, she and her husband share the responsibility for raising their three young children. Admission physical examination revealed BP 132/84, P 104, R 22, T 37.8°C, height 1.7m, weight 92 kg, skin warm, no jaundice. She stated that her urine has been “a strange gold colour” and her stools were “greyish.” She was admitted with the diagnosis of acute cholecystitis. The physician’s orders on admission included monitor vital signs every 4 hours; IV of D5 Ringer’s lactate 125 mL per hour; 1,500-calorie, low-fat liquid diet and progress to low-fat soft diet if no pain in 16 hours; morphine sulfate 2 mg IV every 2 hours as needed; notify physician for sudden increase in frequency or intensity of pain; promethazine 12.5 mg IV every 4 hours as needed for nausea or vomiting.

Nursing Diagnoses • Acute pain related to distended cystic duct and inflamed or infected gallbladder

• Risk for deficient fluid volume related to vomiting and decreased intake

• Ineffective coping related to role and responsibilities at work and home

• Imbalanced nutrition: More than body requirements, re-

lated to knowledge deficit about sedentary lifestyle, poor food choices and eating pattern

Collaborative Problems • Risk for cystic duct necrosis or perforation • Obesity

Goals Immediate • Relief of pain • Prevent fluid volume deficit and electrolyte imbalance • Promote rest • Early detection of any complications Intermediate • Initiation of lifestyle alterations to decrease stress and facilitate rest

Long Term • Alteration of lifestyle to reduce emotional and environmental stressors

• Compliance with dietary regimen • Weight reduction


Plan of Nursing Care

Critical Thinking, Ethical Decision Making, and the Nursing Process

Chart 3-7. Example of an Individualized Plan of Nursing Care, Continued




1. Monitor BP, pulse, temperature, and respirations every 4 hours.

1. Vital signs within normal limits

2. Monitor pain status with accompanying abdominal assessment every 2 hours, or more frequently, as needed. a. Assess pain characteristics every 2 hours or as needed. b. Assess abdomen every 2 hours or with pain assessment. c. Use nonpharmacologic measures (pillows, repositioning, etc.) as desired and tolerated by patient for pain relief. d. Administer analgesic at regular intervals as needed, and assess response. 3. Monitor and support fluid and electrolyte status: a. Monitor weight. b. I&O c. Monitor skin turgor and temperature. d. Monitor serum electrolytes. e. Monitor colour and consistency of urine and stool output. f. Encourage low-fat liquid intake if pain-free. g. Administer promethazine as prescribed to control or relieve vomiting. 4. Promote atmosphere conducive to physical and mental rest: a. Encourage alternation of rest and activity. b. Encourage limitation of visitors and interactions that are stress producing.

2. Experiences pain relief; abdominal assessment within normal limits

1. BP range 110/62–128/78 with pain relief measures; temperature 36.6°– 37.1°C; pulse range 74–88; respirations 18–22 2. Verbalized decrease in pain from severe (8) to low (2) intensity within 10 minutes after morphine administered; no pain radiation to back Abdomen soft and nontender

5. Assist patient to alter lifestyle to decrease stress: a. Discuss relationship between emotional stress and physiologic function. b. Encourage patient to identify stressproducing stimuli. c. Encourage patient to identify adjustments necessary to reduce stress relative to the home and work setting. 6. Encourage patient to identify sedentary lifestyle, obesity, and repetitive weight loss and gain as physiologic and emotional stressors; request consultation with dietitian and reinforce instructions given. 7. Teach importance of maintaining lowfat liquid diet and progression toward long-term low-fat diet. Teach food and menu choices low in fat.

5. Describes stress, sedentary lifestyle, and obesity as precursors to alteration in physiologic functioning Identifies lifestyle factors that produce stress

3. Fluid balance maintained; electrolytes within normal limits

3. Weight 92.9 kg on admission and 90.2 kg after 2-day period Urinary output adequate in relation to oral and IV intake Skin warm and supple, good recoil Electrolytes in normal range Urine dark amber in colour, no sediment; stools soft, formed, light brown No vomiting reported

4. Alternates periods of rest and activity Limits visitors to family in the evenings Avoids stress-producing interactions

4. Rested in bed 2 hours in morning and 2 hours in afternoon; disconnected phone during rest periods. 8 hours uninterrupted sleep at night; husband and children visit 2 hours in evening; patient calm and relaxed after visits Accurately described relationship between stress, sedentary lifestyle, and obesity 5. Identified the following stressors: Demands of job Excessive involvement in children’s school and recreational activities

6. Identifies lifestyle adjustments necessary to reduce stress Discusses lifestyle adjustments with family 7. Identifies harmful effects of obesity and high-fat foods Makes plans for losing weight Makes plans for preplanned meals Identifies foods/menu choices low in fat

6. Identified need to stop taking work home with her Consulted with husband and children; will alternate with husband in attending children’s activities; all family members supportive 7. Accurately described effects of obesity and intake of high-fat foods on overall physical health and well-being Plans to attend Weight Watchers; has had success with this program in the past Identified that preparing low-fat lunches at home the night before work is a good preplanning option




Basic Concepts in Nursing


Hierarchy of Taxonomy in Nursing Practice: A Unified Structure of Nursing Language I. The functional domain is defined as the diagnoses, outcomes, and interventions that promote basic needs and includes the following eight classes: Activity/exercise: physical activity, including energy conservation and expenditure Comfort: a sense of emotional, physical, and spiritual wellbeing and relative freedom from distress Growth and development: physical, emotional, and social growth and developmental milestones Nutrition: processes related to taking in, assimilating, and using nutrients Self-care: ability to accomplish basic and instrumental activities of daily living Sexuality: maintenance or modification of sexual identity and patterns Sleep/rest: the quantity and quality of sleep, rest, and relaxation patterns Values/beliefs: ideas, goals, perceptions, and spiritual and other beliefs that influence choices or decisions II. The physiologic domain is defined as the diagnoses, outcomes, and interventions to promote optimal biophysical health and includes the following 10 classes: Cardiac function: cardiac mechanisms used to maintain tissue perfusion Elimination: processes related to secretion and excretion of body wastes Fluid and electrolyte: regulation of fluid/electrolytes and acid–base balance Neurocognition: mechanisms related to the nervous system and neurocognitive functioning, including memory, thinking, and judgment Pharmacologic function: effects (therapeutic or adverse) of medications or drugs and other pharmacologically active products Physical regulation: body temperature, endocrine, and immune system responses to regulate cellular processes

Reproduction: processes related to human procreation and birth Respiratory function: ventilation adequate to maintain arterial blood gases within normal limits Sensation/perception: intake and interpretation of information through the senses, including seeing, hearing, touching, tasting, and smelling Tissue integrity: skin and mucous membrane protection to support secretion, excretion, and healing III. The psychosocial domain is defined as the diagnoses, outcomes, and interventions to promote optimal mental and emotional health and social functioning and includes the following seven classes: Behaviour: actions that promote, maintain, or restore health Communication: receiving, interpreting, and expressing spoken, written, and nonverbal messages Coping: adjusting or adapting to stressful events Emotional: a mental state of feeling that may influence perception of the world Knowledge: understanding and skill in applying information to promote, maintain, and restore health Roles/relationships: maintenance and/or modification of expected social behaviours and emotional connectedness with others Self-perception: awareness of one’s body and personal identity IV. The environmental domain is defined as the diagnoses, outcomes, and interventions that promote and protect the environmental health and safety of individuals, systems, and communities and includes the following three classes: Health care system: social, political, and economic structures and processes for delivery of health care services Populations: aggregates of individuals or communities having characteristics in common Risk management: avoidance or control of identifiable health threats

From: Herdman, T. H. (Ed.) (2013). NANDA International Nursing Diagnoses: Definitions & Classification 2012–2014 , Oxford, UK: Wiley-Blackwell.

The plan of care is subject to change as a patient’s needs change, as the priorities of needs shift, as needs are resolved, and as additional information about a patient’s state of health is collected. As the nursing interventions are implemented, the patient’s responses are evaluated and documented, and the plan of care is revised accordingly. A well-developed, continuously updated plan of care is the greatest assurance that the patient’s nursing diagnoses and collaborative problems are addressed and his or her basic needs are met.

Framework for a Common Nursing Language: Combining NANDA, NIC, and NOC Various frameworks or taxonomies can be used for determining nursing diagnoses (e.g., NANDA-I), establishing outcomes (e.g., NOC), and designing interventions (e.g.,

NIC). Ultimately, a framework that uses a language common to all aspects of nursing, regardless of the classification system, is desirable. Although still controversial and in its infancy, significant efforts have been made toward accomplishing this goal of unifying the language of nursing. In 2001, a taxonomy of nursing practice was developed for the harmonization of NANDA-I, NIC, and NOC. This three-part combination links nursing diagnoses, accompanying interventions, and outcomes, organizing them in the same way. Such organization of concepts in a common language may facilitate the process of critical thinking, because interventions and outcomes are more accurately matched with appropriately developed nursing diagnoses ( Johnson, Moorhead, Bulechek, et al., 2012). The final taxonomic scheme identifies four clinical domains (functional, physiologic, psychosocial, and environmental), which contain numerous classes of diagnoses, outcomes, and interventions. Chart 3-8 presents the taxonomy of nursing practice.


Critical Thinking, Ethical Decision Making, and the Nursing Process

Critical Thinking Exercises 1 A 50-year-old, morbidly obese man is admitted to your unit with a severe asthma attack. He reports extreme shortness of breath and chest pain. What are the priorities for data collection for this patient’s current condition? How would these priorities change if the client is in no acute distress and not having chest pain? 2 You are at the bedside of a 93-year-old patient who has no advance directives. The patient has been comatose for 3 days and the physician has not prescribed any feedings. When you ask the physician about an enteral nutritional supplement (tube feeding), he responds, “No, I don’t think so.” What actions should be taken in this situation? What ethical and legal dilemmas exist? What other health professionals could be helpful in resolving any issues? 3

You are caring for a patient with another nursing student, and the student shares that he administered a wrong medication to the patient but is afraid to share this with the faculty and nurses. The patient was given an antihypertensive agent that was not due for another 12 hours. The patient appears to be “OK” at this time, and it is 2 hours after the medication was given. What actions should be taken? Should this information be communicated to your faculty supervisor? What is the care priority for the patient? What evidence supports or does not support disclosure of medication administration errors to patients? What steps would you take and in what order?

REFERENCES AND SELECTED READINGS BOOKS Alfaro-LeFevre, R. (2013). Critical thinking and clinical judgment: A practical approach to outcome focused thinking (5th ed.). Philadelphia, PA: Saunders. Bergum, V., & Dossetor, J. (2005). Relational ethics. The full measure of respect. Hagerstown, MD: University Publishing Group. Bulechek, G. M., Butcher, H. K., Dochterman, J. M., et al. (Eds.). (2013). Nursing interventions classification (NIC). (6th ed.). St. Louis, MO: Mosby-Elsevier. Carpenito-Moyet, L. J. (2012). Nursing diagnosis: Application to clinical practice (14th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Herdman, T. H. (Ed.). (2012). NANDA International Nursing Diagnoses: Definitions & Classification, 2012–2014. Oxford, UK: Wiley-Blackwell.


Johnson, M., Moorhead, S., Bulechek, G. M., et al. (2012). NOC and NIC linkages to NANDA-I and clinical conditions: Supporting critical reasoning and quality care (3rd ed.). Maryland Heights, MO: Elsevier Mosby. Moorhead, S., Johnson, M., Maas, M. L., et al. (Eds.). (2013). Nursing outcomes classification (NOC). Measurement of health outcomes (5th ed.). St. Louis, MO: Mosby-Elsevier. Smith-Temple, J., & Johnson, J. Y. (2013). Nurses’ guide to clinical procedures (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (2010). Canadian Bates’ guide to health assessment for nurses (1st ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stuart, G. W., & Laraia, M. T. (2005). Principles and practice of psychiatric nursing (8th ed.). St. Louis, MO: Mosby.

JOURNALS AND ELECTRONIC DOCUMENTS *Asterisks indicate nursing research articles. Canadian Nurses Association. (2008a). Code of ethics for registered nurses. Ottawa, ON: Author. Retrieved from http://buydownload. Canadian Nurses Association. (2008b). Providing nursing care at the end of life. Ottawa, ON: Author. Retrieved from sitecore%20modules/web/∼/media/cna/page%20content/pdf%20 en/2013/07/26/10/43/ps96_end_of_life_e.pdf#search=%22providing care at the end of life%22. Carter, M.A. (2009). Trust, power, and vulnerability: A discourse on Helping in Nursing. Nursing Clinics of North America, 44, 393–405. *Chan, Z. C. Y. (2013). A systematic review of critical thinking in nursing education. Nurse Education Today, 33, 236–240. College and Association of Registered Nurses of Alberta. (2009). Position statement on the use of restraints in client care settings. Edmonton, AB: Author. Retrieved from Uploads/Use_of_Restraints.pdf. Health Canada. (2006). Advance care planning: The Glossary project: Final report. Ottawa, ON: Author. Retrieved from hcs-sss/pubs/palliat/2006-proj-glos/index-eng.php. Heffner, S., & Rudy, S. (2008). Critical thinking: What does it mean in the care of elderly hospitalized patients? Critical Care Nursing Quarterly, 31(1), 73–78. International Council of Nurses. (2008). The ICN definition of nursing. Retrieved from Mohr, W. K. (2010). Restraints and the code of ethics: An uneasy fit. Archives of Psychiatric Nursing, 24(1), 3–14. *Profetto-McGrath, J., Hesketh, K. L., Lang, S., et al. (2003). A study of critical thinking and research utilization among nurses. Western Journal of Nursing Research, 25 (3), 322–337.

RESOURCES Canadian Nurses Association (CNA): International Council of Nurses (ICN): NANDA International:


4 Health Education and Health Promotion Adapted by Beverly Williams

Learning Objectives On completion of this chapter, the learner will be able to: 1. Describe the purposes and significance of health education. 2. Describe the concept of adherence to a therapeutic regimen. 3. Identify variables that affect learning readiness and adult learning abilities. 4. Describe the relationship of the teaching–learning process to the nursing process. 5. Develop a teaching plan for a patient. 6. Identify modifications indicated when teaching patients with disabilities. 7. Define the concepts of health, wellness, and health promotion. 8. Discuss major health promotion theories. 9. Describe the components of health promotion: self-responsibility, nutritional awareness, stress reduction and management, and physical fitness. 10. Specify the variables that affect health promotion activities for adolescents, young and middle-aged adults, and older adults. 11. Describe the role of the nurse in health promotion.



Effective health education lays a solid foundation for individual and community wellness. Teaching is an integral tool that all nurses use to assist patients and families in developing effective health behaviours and altering lifestyle patterns that predispose people to health risks. Health education is an influential factor directly related to positive patient care outcomes.

HEALTH EDUCATION TODAY Today’s health care environment mandates the use of an organized approach to health education so that patients can meet their specific health care needs. Significant factors for nurses to consider when planning patient education include the availability of health care outside the hospital setting, the use of diverse health care providers to accomplish care management goals, and the increased use of complementary and alternative strategies rather than traditional approaches to care. Careful consideration of these factors can provide patients with the comprehensive information that is essential for making informed decisions about health care. Demands from consumers for comprehensive information about their health issues throughout the life cycle accentuate the need for holistic health education to occur in every patient–nurse encounter. Teaching, as a function of nursing, is included in provincial standards of practice. For example, see the College and Association of Registered Nurses of Alberta (CARNA, 2013) and the Code of Ethics of the Canadian Nurses Association (CNA, 2008). Health education is an independent function of nursing practice and is a primary nursing responsibility. All nursing care is directed toward promoting, maintaining, and restoring health; preventing illness; and helping people adapt to the residual effects of illness. Many of these nursing activities are accomplished through health education or patient teaching. Nurses who serve as teachers are challenged to focus on the educational needs of communities and to provide specific patient and family education. Health education is important to nursing care because it affects the abilities of people and families to perform important self-care activities.

Health Education and Health Promotion


Every contact an individual nurse has with a patient, whether or not that person is ill or has a disability, should be considered an opportunity for health teaching. Although people have a right to decide whether or not to learn, nurses have the responsibility to present information that motivates people to recognize the need to learn. Therefore, nurses use opportunities in all health care settings to promote wellness. Educational environments may include homes, hospitals, community health centres, schools, places of business, service agencies, shelters, correctional facilities, and consumer action or support groups.

Purpose of Health Education This emphasis on health education stems in part from the public’s right to comprehensive health care, which includes up-to-date health information. It also reflects the emergence of an informed public that is asking more significant questions about health and health care. Because of the importance Canadian society places on health and the responsibility each person has to maintain and promote his or her own health, members of the health care team, specifically nurses, are obligated to make health education available. Without adequate knowledge and education in self-care skills, consumers cannot make informed decisions about their health. As the lifespan of the population increases, the number of people with chronic illnesses and disabilities also increases. People with chronic illness may need health care information to participate actively in and assume responsibility for self-care. Health education can help those with chronic illness adapt to their illness, prevent complications, carry out prescribed therapy, and solve issues when confronted with new situations. It can also help prevent crisis situations and reduce the potential for rehospitalization resulting from inadequate information about self-care. The goal of health education is to teach people to live life to their healthiest—that is, to strive toward achieving their maximum health potential. In addition to the public’s right to and desire for health education, patient education is also a strategy for promoting

Glossary adherence: the process of faithfully following guidelines or directions community: an interacting population of individuals living together within a larger society feedback: the return of information about the results of input given to a person or a system health education: a variety of learning experiences designed to promote behaviours that facilitate health health promotion: the art and science of assisting people to change their lifestyle toward a higher state of wellness learning: the act of gaining knowledge and skill learning readiness: the optimum time for learning to occur; usually corresponds to the learner’s perceived need and desire to obtain specific knowledge nutrition: the science that deals with food and nourishment in humans

physical fitness: the condition of being physically healthy as a result of appropriate exercise and nutrition reinforcement: the process of strengthening a given response or behaviour to increase the likelihood that the behaviour will continue self-responsibility: personal accountability for one’s actions or behaviours stress management: behaviours and techniques used to strengthen a person’s resources against stress teaching: the imparting of knowledge therapeutic regimen: a routine that promotes health and healing wellness: a condition of good physical and emotional health sustained by a healthy lifestyle



Basic Concepts in Nursing

self-care at home and in the community, reducing health care costs by preventing illness, effectively managing necessary therapies, avoiding expensive medical interventions, decreasing hospital lengths of stay, and facilitating earlier discharge. For health care agencies, offering community wellness programs is a public relations tool for increasing patient knowledge and satisfaction and for developing a positive image of the institution.

Adherence to the Therapeutic Regimen One of the goals of patient education is to encourage people to adhere to their therapeutic regimen. Adherence to treatment usually requires that a person make one or more lifestyle changes to carry out specific activities that promote and maintain health. Common examples of behaviours facilitating health include taking prescribed medications, maintaining a healthy diet, increasing daily activities and exercise, self-monitoring for signs and symptoms of illness, practicing specific hygiene measures, seeking recommended health evaluations and screening, and performing other therapeutic and preventive measures. Many people do not adhere to their prescribed regimens; rates of adherence are generally low, especially when the regimens are complex or of long duration (e.g., therapy for tuberculosis, multiple sclerosis, and human immunodeficiency virus [HIV] disease and hemodialysis). Nonadherence to prescribed therapy has been the subject of many studies (Belguzar, Kayser, & Selim (2007); Brown & Bussell, 2011; Law, Cheng, Dhalla, et al., 2012; Loke, Hinz, Wang, et al., 2012; Ho, Bryson, & Rumsfeld, 2009). For the most part, findings have been inconclusive, and no one predominant causative factor has been identified. Instead, a wide range of variables appears to influence the degree of adherence, including the following: • Demographic variables, such as age, gender, race, socioeconomic status, level of education, and health literacy • Illness variables, such as the severity of the illness and the relief of symptoms afforded by the therapy • Therapeutic regimen variables, such as the complexity of the regimen and uncomfortable side effects • Psychosocial variables, such as intelligence, motivation, availability of significant and supportive people (especially family members), attitudes toward health professionals, acceptance or denial of illness, substance abuse, and religious or cultural beliefs • Financial variables, especially the direct and indirect costs associated with a prescribed regimen Nurses’ success with health education is determined by ongoing assessment of the variables that affect patients’ ability to adopt specific behaviours, to obtain resources, and to maintain a healthy social environment (Edelman & Mandle, 2010). Teaching programs are more likely to succeed if the variables affecting patient adherence are identified and considered in the teaching plan. The problem of nonadherence to therapeutic regimens is a substantial one that must be addressed before patients

can achieve their maximum health potential. Surprisingly, patients’ need for knowledge has not been found to be a sufficient stimulus for acquiring knowledge and thereby enabling complete adherence to a health regimen. Teaching directed toward stimulating patient motivation results in varying degrees of adherence. The variables of choice, establishment of mutual goals, and quality of the patient–provider relationship directly influence the behavioural changes that can result from patient education. These factors are directly linked to motivation for learning. Using a learning contract or agreement can also be a motivator for learning. Such a contract is based on assessment of patient needs; health care data; and specific, measurable goals (Redman, 2007). A well-designed learning contract is realistic and positive; it includes measurable goals, with a specific time frame and reward system for goal achievement. The learning contract is recorded in writing and contains methods for ongoing evaluation. The value of the contract lies in its clarity, its specific description of what is to be accomplished, and its usefulness for evaluating behavioural change. In a typical learning contract, a series of goals is established, beginning with small, easily attainable objectives and progressing to more advanced goals. Frequent, positive reinforcement is provided as the person moves from one goal to the next. For example, incremental goals such as weight loss of 0.5 to 1 kg per week are more appropriate in a weight reduction program than a general goal such as a 14 kg weight loss.

Gerontologic Considerations Nonadherence to therapeutic regimens is a significant concern for older adults, leading to increased morbidity, mortality, and cost of treatment (Latif & McNicoll, 2009). Many admissions to nursing homes and hospitals are associated with nonadherence. Older adults frequently have one or more chronic illnesses that are managed with numerous medications, and complicated by periodic acute episodes. Older adults may also have other issues that affect adherence to therapeutic regimens, such as increased sensitivity to medications and their side effects, difficulty in adjusting to change and stress, financial constraints, forgetfulness, inadequate support systems, lifetime habits of self-treatment with over-the-counter medications, visual and hearing impairments, and mobility limitations. To promote adherence among older adults, all variables that may affect health behaviour should be assessed (Fig. 4-1). Nurses also consider that cognitive impairment may be manifested by the older person’s inability to draw inferences, apply information, or understand the major teaching points (Ebersole, Touhy, Hess, et al., 2008). The person’s strengths and limitations must be assessed to encourage use of existing strengths to compensate for limitations. Above all, health care professionals need to work together to provide continuous, coordinated care; otherwise, the efforts of one health care professional may be negated by those of another.


Health Education and Health Promotion


In general, there is no definitive theory about how learning occurs and how it is affected by teaching. However, learning can be affected by factors such as readiness to learn, the learning environment, and the teaching techniques used (Bastable, 2008).

Learning Readiness

FIGURE 4-1. Taking time to teach patients about their medication and treatment program promotes interest and cooperation. Older adults who are actively involved in learning about their medication and treatment program and the expected effects may be more likely to adhere to the therapeutic regimen.

THE NATURE OF TEACHING AND LEARNING Learning can be defined as acquiring knowledge, attitudes, or skills. Teaching is defined as helping another person learn. These definitions indicate that the teaching– learning process is an active one, requiring the involvement of both teacher and learner in the effort to reach the desired outcome, a change in behaviour. The teacher does not simply give knowledge to the learner but instead serves as a facilitator of learning.

One of the most significant factors influencing learning is a person’s learning readiness. For adults, readiness is based on culture, personal values, physical and emotional status, and past experiences in learning. The “teachable moment” occurs when the content and skills being taught are congruent with the task to be accomplished (Redman, 2007). Culture encompasses values, ideals, and behaviours, and the traditions within each culture provide the framework for solving the issues and concerns of daily living. Because people with different cultural backgrounds have different values and lifestyles, choices about health care vary. Culture is a major variable influencing readiness to learn because it affects how people learn and what information can be learned. Sometimes people do not accept health teaching because it conflicts with culturally mediated values. Before beginning health teaching, nurses conduct an individual cultural assessment instead of relying only on generalized assumptions about a particular culture. A patient’s social and cultural patterns are appropriately incorporated into the teaching–learning interaction. Chapter 9 (Chart 9-3) describes cultural assessment components to consider when formulating a teaching plan. Chart 4-1 summarizes a research study exploring sexual behaviour of Canadian Aboriginal young people (Devries, Free, Morison, et al., 2009).


Chart 4-1. Factors Associated With the Sexual Behaviour of Canadian Aboriginal Young People and Their Implications for Health Promotion Devries, K., Free, C., Morison, L., et al. (2009). Factors associated with the sexual behaviour of Canadian Aboriginal young people and their implications for health promotion. American Journal of Public Health, 99(5), 855–862. Purpose The purpose of this study was to examine factors that might be associated with having ever had sex, having more than one lifetime sexual partner, and condom nonuse in the last incidence of sexual intercourse among Canadian aboriginal young people. Design The study was a secondary analysis of a cross sectional survey (2003 British Columbia Adolescent Survey) conducted with young people in grades 7–12. Findings Of the 1,140 young aboriginal males 34% had had sex with 63% having had more than one sexual partner and 21% had

not used a condom during their last incidence of intercourse. Of the 1,336 young aboriginal women, 34% had had sex with 56% having had more than one sexual partner and 41% had not used a condom during their last incidence of intercourse. Several factors were strongly associated with sexual behaviour outcomes including frequent substance abuse, having been sexually abused, and having lived on a land reservation. Strong family connections were associated with more frequent condom use. Nursing Implications Young people on land reserves require particular attention. Encouraging changes in sexual behaviour of Aboriginal young people must move beyond the individual and incorporate interpersonal and structural dimensions of the family. Interventions to assist with reduction of substance use and sexual abuse while promoting feelings of individual worth and family connectedness should be considered.



Basic Concepts in Nursing

A person’s values include beliefs about behaviours that are desirable and undesirable. The nurse needs to know what value the patient places on health and health care. In clinical situations, patients express their values through their actions and the level of knowledge pursued (Andrews & Boyle, 2012). When the nurse is unaware of the patient’s cultural values, misunderstanding, lack of cooperation, and negative health outcomes may occur (Leininger & McFarland, 2006). A person’s values and behaviours can be either an asset or a deterrent to readiness to learn. Therefore, patients are unlikely to accept health education unless their values and beliefs about health and illness are respected (Giger & Davidhizar, 2013). Physical readiness is of vital importance, because until the person is physically capable of learning, attempts at teaching and learning may be both futile and frustrating. For example, a person in acute pain is unable to focus attention away from the pain long enough to concentrate on learning. Likewise, a person who is short of breath concentrates on breathing rather than on learning. Emotional readiness also affects the motivation to learn. A person who has not accepted an existing illness or the threat of illness is not motivated to learn. A person who does not accept a therapeutic regimen, or who views it as conflicting with his or her present lifestyle, may consciously avoid learning about it. Until the person recognizes the need to learn and demonstrates an ability to learn, teaching efforts may be thwarted. However, it is not always wise to wait for the person to become emotionally ready to learn, because that time may never come unless the nurse makes an effort to stimulate the person’s motivation. Illness and the threat of illness are usually accompanied by anxiety and stress. Nurses who recognize such reactions can use simple explanations and instructions to alleviate these anxieties and provide further motivation to learn. Because learning involves behaviour change, it often produces mild anxiety, which can be a useful motivating factor. Emotional readiness can be promoted by creating a warm, accepting, positive atmosphere and by establishing realistic learning goals. When learners achieve success and a feeling of accomplishment, they are often motivated to participate in additional learning opportunities. Feedback about progress also motivates learning. Such feedback is presented in the form of positive reinforcement when the learner is successful, and in the form of constructive suggestions for improvement when the learner is unsuccessful. Experiential readiness refers to past experiences that influence a person’s ability to learn. Previous educational experiences and life experiences in general are significant determinants of a person’s approach to learning. People with little or no formal education may not be able to understand the instructional materials presented. People who have had difficulty learning in the past may be hesitant to try again. Many behaviours required for reaching maximum health potential require knowledge, physical skills, and positive attitudes. In their absence, learning may be very difficult and very slow. For example, a person who does not understand the basics of adequate nutrition may not be able to understand the restrictions of a specific diet. A person who does not view the desired learning as personally meaningful may reject teaching efforts. A per-

son who is not future oriented may be unable to appreciate many aspects of preventive health teaching. Experiential readiness is closely related to emotional readiness, because motivation tends to be stimulated by an appreciation for the need to learn and by those learning tasks that are familiar, interesting, and meaningful.

The Learning Environment Although learning can take place without teachers, most people who are attempting to learn new or altered health behaviours benefit from contact with a nurse. The interpersonal interaction between the person and the nurse who is attempting to meet the person’s learning needs may be formal or informal, depending on the method and techniques of teaching. Learning may be optimized by minimizing factors that interfere with the learning process. For example, the room temperature, lighting, noise levels, and other environmental conditions should be appropriate to the learning situation. In addition, the time selected for teaching should be suited to the needs of the individual person. Scheduling a teaching session at a time of day when a patient is fatigued, uncomfortable, or anxious about a pending diagnostic or therapeutic procedure, or when visitors are present, is not conducive to learning. However, if the family is to participate in providing care, the sessions should be scheduled when family members are present so that they can learn any necessary skills or techniques.

Teaching Techniques Teaching techniques and methods enhance learning if they are appropriate to the patient’s needs. Numerous techniques are available, including lectures, group teaching, and demonstrations, all of which can be enhanced with specially prepared teaching materials. The lecture or explanation method of teaching is commonly used but should be accompanied by discussion. Discussion is important because it affords learners opportunities to express their feelings and concerns, to ask questions, and to receive clarification. Group teaching is appropriate for some people because it allows them not only to receive needed information, but also to feel secure as members of a group. People with similar health issues or learning needs have the opportunity to identify with each other and gain moral support and encouragement. However, not everyone relates or learns well in groups or benefits from such experiences. Also, if group teaching is used, assessment and follow-up are necessary to ensure that each person has gained sufficient knowledge and skills. Demonstration and practice are essential ingredients of a teaching program, especially when teaching skills. It is best to demonstrate the skill and then give the learner ample opportunity for practice. When special equipment is involved, such as syringes, colostomy bags, dialysis equipment, dressings, or suction apparatus, it is important to teach with the same equipment that will be used in the home setting. Learning to perform a skill with one kind of equipment and then having to change to a different kind may lead to confusion, frustration, and mistakes.


Teaching aids used to enhance learning include books, pamphlets, pictures, films, slides, audio tapes, models, programmed instruction, other visual aids (e.g., charts), and computer-assisted learning modules. These are made available as needed for home, clinic, or hospital use, and they allow review and reinforcement of content and enhanced visual and auditory learning. Such teaching aids are invaluable when used appropriately and can save a significant amount of personnel time and related cost. However, all such aids should be reviewed before use to ensure that they meet the person’s learning needs, are up to date, and are free of advertisements that may confuse the patient. Human interaction and discussion cannot be replaced by teaching technologies but may be enhanced by them. Reinforcement and follow-up are important because learning takes time. Allowing ample time to learn and reinforcing what is learned are important teaching strategies; a single teaching session is rarely adequate. Followup sessions are required to promote the learner’s confidence in his or her abilities and to plan for additional teaching sessions. For hospitalized patients who may not be able to transfer what they have learned in the hospital to the

Health Education and Health Promotion

home setting, follow-up after discharge is essential to ensure that they have realized the full benefits of a teaching program.

Teaching Special Populations People With Disabilities When providing health information to people with disabilities, the individual needs of each person must be assessed and incorporated into the teaching plan. Teaching techniques and the imparting of information may need to be altered. The nurse needs to be aware of the health promotion needs when teaching specific groups of people with physical disabilities; emotional, psychiatric, or mental health disabilities; hearing, visual, or sensory impairments; learning disabilities; and developmental disabilities. It may be necessary to institute new or modified approaches to teach people with disabilities about their health. Table 4-1 outlines some of the teaching strategies to use when teaching people with disabilities.


Teaching People With Disabilities

Type of Disability

Teaching Strategy

Physical, Emotional, or Cognitive Disability

Adapt information to accommodate the person’s cognitive, perceptual, and behavioural disabilities. Give clear written and oral information. Highlight significant information for easy reference. Avoid medical terminology or “jargon.”

Hearing Impairment

Use slow, directed, deliberate speech. Use sign language or interpreter services if appropriate. Position yourself so that the person can see your mouth if speech reading. Use telecommunication devices (TTY or TDD) for the person with hearing impairment. Use written materials and visual aids, such as models and diagrams. Use captioned videos, films, and computer-generated materials. Teach on the side of the “good ear” if unilateral deafness is present.

Visual Impairment

Use optical devices such as magnifying lens. Use proper lighting and proper contrast of colours on materials and equipment. Use large-print materials. Use Braille materials if appropriate. Convert information to auditory and tactile formats. Obtain audiotapes and talking books. Explain noises associated with procedures, equipment, and treatments. Arrange materials in clockwise pattern.

Learning Disabilities Input disability

Output disability

Developmental disability


If visual perceptual disorder: • Explain information verbally, repeat, and reinforce frequently. • Use audiotapes. • Encourage learner to verbalize information received. If auditory perceptual disorder: • Speak slowly with as few words as possible, repeat, and reinforce frequently. • Use direct eye contact to focus person on task. • Use demonstration and return demonstration such as modelling, role playing, and hands-on experiences. • Use visual tools, written materials, and computers. Use all senses as appropriate. Use written, audiotape, and computer information. Review information and give time to interact and ask questions. Use hand gestures and motions. Base information and teaching on developmental stage, not chronologic age. Use nonverbal cues, gestures, signing, and symbols as needed. Use simple explanations and concrete examples with repetition. Encourage active participation. Demonstrate information and have the person perform return demonstrations.



Basic Concepts in Nursing

Older Adults Nurses caring for older people need to be aware of how the usual changes that occur with aging may affect learning abilities and how they can help older people age well. Above all, it is important to recognize that just because a person is older does not mean that he or she cannot learn. Older adults can learn and remember if information is paced appropriately, is relevant, and is followed by the appropriate feedback strategies that apply to all learners (Miller, 2009). Because changes associated with aging vary significantly among older people, the nurse conducts a thorough assessment of each person’s level of physiologic and psychological functioning before beginning teaching. More information on the physiologic effects of aging can be found in Chapter 13. Changes in cognition with age may include slowed mental functioning; decreased short-term memory, abstract thinking, and concentration; and slowed reaction time. These changes are often accentuated by the health concerns that cause the older person to seek health care in the first place. Effective teaching strategies include slowpaced presentation of small amounts of material at a time; frequent repetition of information; and the use of reinforcement techniques, such as audiovisual and written materials, and repeated practice sessions. Distracting stimuli should be minimized as much as possible in the teaching environment. Sensory changes associated with aging also affect teaching and learning. Teaching strategies to accommodate decreased visual acuity include large-print and easy-to-read materials printed on nonglare paper. Because colour discrimination is often impaired, the use of colour-coded or highlighted materials may not be effective. To maximize hearing, teachers speak distinctly with a normal or lowered pitch, facing the person so that speech reading can occur as needed. Visual cues often help reinforce verbal teaching. Family members should be involved in teaching sessions when possible and appropriate. They provide another source for reinforcement of material and can help the older person recall instructions later. Family members can also provide valuable assessment information about the person’s living situation and related learning needs. The chance of success is maximized when nurses, families, and other health care professionals work collaboratively to facilitate the older person’s learning. Successful learning should result in improved self-care management skills, enhanced self-esteem, confidence, and a willingness to learn in the future.

THE NURSING PROCESS IN PATIENT TEACHING The steps of the nursing process are used when constructing a teaching plan to meet people’s teaching and learning needs (Chart 4-2).

Assessment Assessment in the teaching–learning process is directed toward the systematic collection of data about the person

and family’s learning needs and readiness to learn. All internal and external variables that affect the patient’s readiness to learn are identified. A learning assessment guide may be used for this purpose. Some of the available guides are directed toward the collection of general health information (e.g., smoking cessation), whereas others are specific to medication regimens or disease processes (e.g., stroke risk assessments). Such guides facilitate assessment but must be adapted to the responses, issues, and needs of each person. The nurse organizes, analyzes, synthesizes, and summarizes the assessment data collected and determines the patient’s need for teaching.

Nursing Diagnosis The process of formulating nursing diagnoses makes educational goals and evaluations of progress more specific and meaningful. Teaching is an integral intervention implied by all nursing diagnoses, and for some diagnoses, education is the primary intervention. Examples of nursing diagnoses that help in planning for educational needs are ineffective therapeutic regimen management, impaired or ineffective home maintenance, health-seeking behaviours (specify), and decisional conflict (specify). The diagnosis “deficient knowledge” should be used cautiously, because knowledge deficit is not a human response but a factor relating to or causing the diagnosis. For example, “ineffective therapeutic regimen management related to a lack of information about wound care” is a more appropriate nursing diagnosis than “deficient knowledge” (Carpenito-Moyet, 2013; Herdman, 2012). A nursing diagnosis that relates specifically to a patient’s and family’s learning needs serves as a guide in the development of the teaching plan.

Planning Once the nursing diagnoses have been identified, the planning component of the teaching–learning process is established in accordance with the steps of the nursing process: 1. Assigning priorities to the diagnoses 2. Specifying the immediate, intermediate, and long-term goals of learning 3. Identifying specific teaching strategies appropriate for attaining goals 4. Specifying the expected outcomes 5. Documenting the diagnoses, goals, teaching strategies, and expected outcomes of the teaching plan The assignment of priorities to the diagnoses should be a collaborative effort by the nurse, the patient, and family members. Consideration is given to the urgency of the patient’s learning needs; the most critical needs should receive the highest priority. After the diagnostic priorities have been mutually established, it is important to identify the immediate and longterm goals and the teaching strategies appropriate for attaining the goals. Teaching is most effective when the objectives of both the patient and nurse are in agreement


Health Education and Health Promotion



A Guide to Patient Education Assessment 1. Assess the person’s readiness for health education. a. What are the person’s health beliefs and behaviours? b. What physical and psychosocial adaptations does the person need to make? c. Is the learner ready to learn? d. Is the person able to learn these behaviours? e. What additional information about the person is needed? f. Are there any variables (e.g., hearing or visual impairment, cognitive issues, literacy issues) that will affect the choice of teaching strategy or approach? g. What are the person’s expectations? h. What does the person want to learn? 2. Organize, analyze, synthesize, and summarize the collected data.

Nursing Diagnosis 1. Formulate the nursing diagnoses that relate to the person’s learning needs. 2. Identify the learning needs, their characteristics, and their etiology. 3. State nursing diagnoses concisely and precisely.

Planning and Goals 1. Assign priority to the nursing diagnoses that relate to the individual’s learning needs. 2. Specify the immediate, intermediate, and long-term learning goals established by teacher and learner together. 3. Identify teaching strategies appropriate for goal attainment. 4. Establish expected outcomes. 5. Develop the written teaching plan. a. Include diagnoses, goals, teaching strategies, and expected outcomes. b. Put the information to be taught in logical sequence. c. Write down the key points.

(Bastable, 2008). Learning begins with the establishment of goals that are appropriate to the situation and realistic in terms of the patient’s ability and desire to achieve them. Involving the patient and family in establishing goals and in planning teaching strategies promotes their cooperation in the implementation of the teaching plan. Outcomes of teaching strategies can be stated in terms of expected behaviours of patients, families, or both. Outcomes are to be realistic and measurable, and the critical time periods for attaining them are also identified. The desired outcomes and the critical time periods serve as a basis for evaluating the effectiveness of the teaching strategies. During the planning phase, the nurse considers the sequence in which the subject matter is presented. Critical information (e.g., survival skills for a patient with diabetes) and material that the person or family identifies to be of particular importance receives high priority. An outline is often helpful for arranging the subject matter and for ensuring that all necessary information is included. In addition, appropriate teaching aids to be used in imple-

d. Select appropriate teaching aids. e. Keep the plan current and flexible to meet the person’s changing learning needs. 6. Involve the learner, family or significant others, nursing team members, and other health care team members in all aspects of planning.

Implementation 1. Put the teaching plan into action. 2. Use language the person can understand. 3. Use appropriate teaching aids and provide Internet resources if appropriate. 4. Use the same equipment that the person will use after discharge. 5. Encourage the person to participate actively in learning. 6. Record the learner’s responses to the teaching actions. 7. Provide feedback.

Evaluation 1. Collect objective data. a. Observe the person. b. Ask questions to determine whether the person understands. c. Use rating scales, checklists, anecdotal notes, and written tests when appropriate. 2. Compare the person’s behavioural responses with the expected outcomes. Determine the extent to which the goals were achieved. 3. Include the person, family or significant others, nursing team members, and other health care team members in the evaluation. 4. Identify alterations that need to be made in the teaching plan. 5. Make referrals to appropriate sources or agencies for reinforcement of learning after discharge. 6. Continue all steps of the teaching process: assessment, diagnosis, planning, implementation, and evaluation.

menting teaching strategies are prepared or selected at this time. The entire planning phase concludes with the formulation of the teaching plan. This teaching plan communicates the following information to all members of the nursing team: • The nursing diagnoses that specifically relate to the patient’s learning needs and the priorities of these diagnoses • The goals of the teaching strategies • The teaching strategies that are appropriate for goal attainment • The expected outcomes, which identify the desired behavioural responses of the learner • The critical time period within which each outcome is expected to be met • The patient’s behavioural responses (which are documented on the teaching plan) The same rules that apply to writing and revising the plan of nursing care apply to the teaching plan.



Basic Concepts in Nursing

Implementation In the implementation phase of the teaching–learning process, the patient, the family, and other members of the nursing and health care team carry out the activities outlined in the teaching plan. The nurse coordinates these activities. Flexibility during the implementation phase of the teaching–learning process and ongoing assessment of patient responses to the teaching strategies support modification of the teaching plan as necessary. Creativity in promoting and sustaining the patient’s motivation to learn is essential. New learning needs that may arise after discharge from the hospital or after home care visits have ended should also be taken into account. The implementation phase ends when the teaching strategies have been completed and when the patient’s responses to the actions have been recorded. This serves as the basis for evaluating how well the defined goals and expected outcomes have been achieved.

Evaluation Evaluation of the teaching–learning process determines how effectively the patient has responded to teaching and to what extent the goals have been achieved. An evaluation is made to determine what was effective and what needs to be changed or reinforced. It cannot be assumed that patients have learned just because teaching has occurred; learning does not automatically follow teaching. An important part of the evaluation phase addresses the question, “What can be done to improve teaching and enhance learning?” Answers to this question direct the changes to be made in the teaching plan. A variety of measurement techniques can be used to identify changes in patient behaviour as evidence that learning has taken place. These techniques include directly observing the behaviour; using rating scales, checklists, or anecdotal notes to document the behaviour; and indirectly measuring results using oral questioning and written tests. All direct measurements are supplemented with indirect measurements whenever possible. Using more than one measuring technique enhances the reliability of the resulting data and decreases the potential for error from a measurement strategy. In many situations, measurement of actual behaviour is the most accurate and appropriate evaluation technique. Nurses often perform comparative analyses using patient admission data as the baseline. Selected data points observed when nursing care is given and self-care is initiated are compared with the patient’s baseline data. In other cases, indirect measurement may be used. Some examples of indirect measurement are patient satisfaction surveys, attitude surveys, and instruments that evaluate specific health status variables. Measurement is only the beginning of evaluation, which must be followed by data interpretation and value judgments about learning and teaching. These aspects of evaluation are conducted periodically throughout the teaching–learning program, at its conclusion, and at varying periods after the teaching has ended.

Evaluation of learning after teaching that occurs in any setting (e.g., clinics, offices, and hospitals) is essential, because the analysis of teaching outcomes must extend into aftercare. With shortened hospital lengths of stay and with short-stay and same-day surgical procedures, followup evaluation is especially important. Coordination of efforts and sharing of information between hospital-based and community-based nursing personnel facilitate postdischarge teaching and home care evaluation. Evaluation is not the final step in the teaching–learning process but is the beginning of a new patient assessment. The information gathered during evaluation is used to redirect teaching actions, with the goal of improving the patient’s responses and outcomes.

HEALTH PROMOTION Health teaching and health promotion are linked by a common goal—to encourage people to achieve as high a level of wellness as possible so that they can live maximally healthy lives and avoid preventable illnesses. The call for health promotion has become a cornerstone in health policy because of the need to control costs and reduce unnecessary sickness and death (Chart 4-3). Health goals for the nation were originally established in the Ottawa Charter for Health Promotion (1986) with the intent of achieving Health for All by the year 2000 and beyond. The priorities from this initiative were identified as building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services. The original goals continue to be relevant today. Every few years countries meet to reaffirm the original goals.

Definition Health promotion may be defined as those activities that assist people in developing resources that maintain or enhance well-being and improve their quality of life.


Leading Health Indicators to be Used to Measure the Health of the Nation 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Physical activity Diet Body mass index Tobacco use Substance abuse Responsible sexual behaviour Mental health Injury and violence Environmental quality Immunization Access to health care

From Health Quality Council of Canada. (2011). A Citizen’s Guide to Health Indicators. Health Quality Council of Canada, Toronto, ON.


These activities involve people’s efforts to remain healthy in the absence of symptoms and do not require the assistance of a health care team member. The purpose of health promotion is to focus on the person’s potential for wellness and to encourage appropriate alterations in personal habits, lifestyle, and environment in ways that reduce risks and enhance health and wellbeing. Health promotion is an active process; that is, it is not something that can be prescribed or dictated. It is up to each person to decide whether to make changes to promote a higher level of wellness. Only the individual can make these choices. Following the catastrophic public event of SARS, the Public Health Agency of Canada (PHAC) was created in 2003, with Dr. Butler-Jones as the first Chief Public Health Officer of Canada. The focus of the PHAC is on “five essential public health functions: health promotion, health protection, health surveillance, disease and injury prevention, and population health assessment” (Reutter & Kushner, 2010). The Federal Government’s “Health Canada”, also has a role in delivery of health promotion programs. Examples of two of these programs are “Federal Tobacco Control Strategy” and the “Canadian Diabetes Strategy” (Reutter & Kushner, 2012).

Health and Wellness The concept of health promotion has evolved because of a changing definition of health and an awareness that wellness exists at many levels of functioning. Health is viewed as a dynamic, ever-changing condition that enables people to function at an optimal potential at any given time. The ideal health status is one in which people are successful in achieving their full potential, regardless of any limitations they might have. Wellness, a reflection of health, involves a conscious and deliberate attempt to maximize one’s health. Wellness does not just happen; it requires planning and conscious commitment and is the result of adopting lifestyle behaviours for the purpose of attaining one’s highest potential for well-being. Wellness is not the same for every person. The person with a chronic illness or disability may still be able to achieve a desirable level of wellness. The key to wellness is to function at the highest potential within the limitations over which there is no control, such as a lifelong disability or genetic disorders (Chart 4-4). A significant amount of research has shown that people, by virtue of what they do or fail to do, influence their own

Health Education and Health Promotion

health. Today, many of the major causes of illness are chronic diseases that have been closely related to lifestyle behaviours (e.g., type 2 diabetes mellitus, heart disease, lung and colon cancer, chronic obstructive pulmonary diseases, hypertension, cirrhosis, traumatic injury, and HIV disease). To a large extent, a person’s health status may be reflective of his or her lifestyle.

Health Promotion Models Several health promotion models identify health-protecting behaviours and seek to explain what makes people engage in preventive behaviours. A health-protecting behaviour is defined as any behaviour performed by people, regardless of their actual or perceived health condition, for the purpose of promoting or maintaining their health, whether or not the behaviour produces the desired outcome (Keleher, MacDougall, & Murphy, 2011). One model, the Health Belief Model, was designed to foster understanding of why some healthy people choose actions to prevent illness while others do not. Another model, the resource model of preventive health behaviour, addresses the ways in which people use resources to promote health (Keleher, et al., 2011). Nurse educators can use this model to assess how demographic variables, health behaviours, and social and health resources influence health promotion. The Canadian health promotion initiative, Achieving Health for All, builds on the work of Lalonde (1977), in which four determinants of health—human biology, environment, lifestyle, and the health care delivery system— were identified. Determinants of health were defined as factors and conditions that have an influence on the health of individuals and communities. Since the 1970s, a total of 12 health determinants have been identified, and this number will continue to increase as population health research progresses. Determinants of health provide a framework for assessing and evaluating the population’s health. The Health Belief Model developed by Becker (1974) is based on the premise that four variables influence the selection and use of health promotion behaviours. Demographic and disease factors, the first variable, include patient characteristics such as age, gender, education, employment, severity of illness or disability, and length of illness. Barriers, the second variable, are defined as factors leading to unavailability or difficulty in gaining access to a specific health promotion alternative. Resources, the third variable, encompass such factors as


Chart 4-4. Genetics Aspects of Health Education and Promotion Nurses in all settings should be prepared to incorporate genetics into health education and promotion by: • Inquiring about patients’ and families’ desired health outcomes with regard to genetics-related conditions or risk factors


• Referring patients for genetics services when indicated • Identifying barriers to accessing genetics-related health services

• Offering appropriate genetics information and resources



Basic Concepts in Nursing

financial and social support. Perceptual factors, the fourth variable, consist of how the person views his or her health status, self-efficacy, and the perceived demands of the illness. Becker demonstrated that these four variables have a positive correlation with a person’s quality of life. The health promotion model described by Pender, Murdaugh and Parsons (2011) is based on social learning theory and emphasizes the importance of motivational factors in acquiring and sustaining health promotion behaviours. This model explores how cognitive-perceptual factors affect the person’s view of the importance of health. It also examines perceived control of health, self-efficacy, health status, and the benefits and barriers to healthpromoting behaviours. The Transtheoretical Model of Change, also known as the Stages of Change Model, is a framework that focuses on the motivation of a person to make decisions that promote healthy behaviour change (Miller, 2009; DiClemente, 2007). Table 4-2 shows the six stages of the model. Research indicates that people seeking assistance from professionals or self-help groups progress through these stages of change (Kim, 2007). Any of the models can serve as an organizing framework for clinical work and research that support the enhancement of health. Research and other literature that support health promotion concepts and frameworks increase the nurse’s understanding of the health promotion behaviours of families and communities (Betz, 2007; Chen, Shiao & Gau, 2007; Reutter & Kushner, 2010; Rowley, Dixon, & Palk, 2007; Seals, 2007).

Components of Health Promotion There are several components of health promotion as an active process: self-responsibility, nutritional awareness, stress reduction and management, and physical fitness.

TABLE 4-2 Stage

Stages in the Transtheoretical Model of Change Description

1. Precontemplative The person is not thinking about making a change. 2. Contemplative The person is only thinking about change in the near future. 3. Decision making The person constructs a plan to change behaviour. 4. Action The person takes steps to operationalize the plan of action. 5. Maintenance The person works to prevent relapse and to sustain the gains made from the actions taken. 6. Termination The person has the ability to resist relapse back to unhealthy behavior(s). Adapted from DiClemente, C. (2007). The transtheoretical model of intentional behavior change. Drugs & Alcohol Today, 7(1), 29–33 and Miller, C. A. (2009). Nursing wellness in older adults (5th ed.). Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins.

Self-Responsibility Taking responsibility for oneself is the key to successful health promotion. The concept of self-responsibility is based on the understanding that the individual controls his or her life. Each person alone must make the choices that determine how healthy his or her lifestyle is. As more people recognize that lifestyle and behaviour significantly affect health, they may assume responsibility for avoiding highrisk behaviours such as smoking, alcohol and drug abuse, overeating, driving while intoxicated, risky sexual practices, and other unhealthy habits. They may also assume responsibility for adopting routines that have been found to have a positive influence on health, such as engaging in regular exercise, wearing seat belts, and eating a healthy diet. A variety of techniques have been used to encourage people to accept responsibility for their health, ranging from extensive educational programs to reward systems. No one technique has been found to be superior to any other. Instead, self-responsibility for health promotion is individualized and depends on a person’s desires and inner motivations. Health promotion programs are important tools for encouraging people to assume responsibility for their health and to develop behaviours that improve health.

Nutritional Awareness Nutrition, as a component of health promotion, has become the focus of considerable attention and publicity with the growing epidemic of obesity in Canada. A vast array of books and magazine articles address the topics of special diets; natural foods; and the hazards associated with certain substances, such as sugar, salt, cholesterol, trans fats, carbohydrates, artificial colours, and food additives. It has been suggested that good nutrition is the single most significant factor in determining health status, longevity, and weight control. Nutritional awareness involves an understanding of the importance of a healthy diet that supplies all of the essential nutrients. Understanding the relationship between diet and disease is an important facet of a person’s selfcare. Many clinicians believe that a healthy diet is one that substitutes “natural” foods for processed and refined ones and reduces the intake of sugar, salt, fat, cholesterol, caffeine, alcohol, food additives, and preservatives. Chapter 5 contains further information about the assessment of a person’s nutritional status. It describes the physical signs indicating nutritional status, assessment of food intake (food record, 24-hour recall), the dietary guidelines presented in the Canada Food Guide, and calculation of ideal body weight.

Stress Management and Stress Reduction Stress management and stress reduction are important aspects of health promotion. Studies have shown the negative effects of stress on health and a cause-and-effect relationship between stress and infectious diseases, traumatic injuries (e.g., motor vehicle crashes), and some chronic illnesses. Stress has become inevitable in contemporary societies in which demands for productivity have become excessive. More and more emphasis is placed on encouraging


people to manage stress appropriately and to reduce the pressures that are counterproductive. Techniques such as relaxation training, exercise, and modification of stressful situations are often included in health promotion programs dealing with stress. Further information on stress management, including health risk appraisal and stress reduction methods such as biofeedback and the relaxation response, can be found in Chapter 6.

Physical Fitness Physical fitness is another important component of health promotion. Clinicians and researchers (Perry, Rosenfeld, Bennett, et al., 2007; Chao, Lian, Yu, et al., 2007) who have examined the relationship between health and physical fitness have found that a regular exercise program can promote health in the following ways: • Improve the function of the circulatory system and the lungs • Decrease cholesterol and low-density lipoprotein levels • Decrease body weight by increasing calorie expenditure • Delay degenerative changes such as osteoporosis • Improve flexibility and overall muscle strength and endurance An appropriate exercise program can have a positive effect on a person’s performance capacity, appearance, and level of stress and fatigue, as well as his or her general state of physical, mental, and emotional health. An exercise program is designed specifically for a given person, with consideration given to age, physical condition, and any known cardiovascular or other risk factors. Exercise can be harmful if it is not started gradually and increased slowly in accordance with a person’s response.

HEALTH PROMOTION THROUGHOUT THE LIFESPAN Health promotion is a concept and a process that extends throughout the lifespan. The health of a child can be affected either positively or negatively by the health practices of the mother during the prenatal period. Therefore, health promotion starts before birth and extends through childhood, adolescence, adulthood, and old age. Health promotion includes health screening. The College of Family Physicians of Canada has developed recommendations for periodic health examinations for both adults (Iglar, Katyal, Matthew, et al., 2008) and children (Greig, Constantin, Carsley, et al., 2010) that identify when specific screening interventions are appropriate. Table 4-3 presents general population guidelines.

Adolescents Health screening has traditionally been an important aspect of adolescent health care. The goal has been to detect health problems at an early age so that they can be treated at this time. Today, health promotion goes beyond the mere screening for disabilities and includes extensive efforts to promote positive health practices at an early age. Because health

Health Education and Health Promotion


habits and practices are formed early in life, adolescents should be encouraged to develop positive health attitudes. For this reason, more and more programs are being offered to adolescents to help them develop good health habits. Although the negative results of practices such as smoking, risky sexual activities, alcohol and drug abuse, and poor nutrition are explained in these educational programs, emphasis is also placed on values training, self-esteem, and healthy lifestyle practices. The projects are designed to appeal to a particular age group, with emphasis on learning experiences that are fun, interesting, and relevant.

Young and Middle-Aged Adults Young and middle-aged adults represent an age group that not only expresses an interest in health and health promotion, but also responds enthusiastically to suggestions that show how lifestyle practices can improve health. Adults are frequently motivated to change their lifestyles in ways that are believed to enhance their health and wellness. Many adults who wish to improve their health turn to health promotion programs to help them make the desired changes in their lifestyles. Many have responded to programs that focus on topics such as general wellness, smoking cessation, exercise, physical conditioning, weight control, conflict resolution, and stress management. Because of the nationwide emphasis on health during the reproductive years, young adults actively seek programs that address prenatal health, parenting, family planning, and women’s health issues. Programs that provide health screening, such as those that screen for cancer, high cholesterol, hypertension, diabetes, abdominal aneurysm, and visual and hearing impairments, are quite popular with young and middle-aged adults. Programs that involve health promotion for people with specific chronic illnesses such as cancer, diabetes, heart disease, and pulmonary disease are also popular. Chronic disease and disability do not preclude health and wellness; rather, positive health attitudes and practices can promote optimal health for people who must live with the limitations imposed by their chronic illnesses and disabilities. Health promotion programs can be offered almost anywhere in the community. Common sites include local clinics, schools, colleges, recreation centres, churches, and even private homes. Health fairs are frequently held in civic centres and shopping malls. The outreach idea for health promotion programs has served to meet the needs of many adults who otherwise would not avail themselves of opportunities to strive toward a healthier lifestyle. The workplace has become a centre for health promotion activity for several reasons. Employers have become increasingly concerned about the rising costs of health care insurance to treat illnesses related to lifestyle behaviours, and they are also concerned about increased absenteeism and lost productivity. Some employers use health promotion specialists to develop and implement these programs, and others purchase packaged programs that have already been developed by health care agencies or private health promotion corporations. Programs offered at the workplace usually include employee health screening and counselling, physical fitness, nutritional awareness, work safety, and stress




Basic Concepts in Nursing

Routine Health Promotion Screening for Adults

Type of Screening

Suggested Time Frame

Routine health examination


Blood chemistry profile

Baseline at age 20, then as mutually determined by patient and clinician

Complete blood count

Baseline at age 20, then as mutually determined by patient and clinician

Lipid profile

Baseline at age 20, then as mutually determined by patient and clinician

Hemoccult screening (fecal occult blood)

Yearly after age 50. If positive, follow-up with colonoscopy


Baseline at age 40, then as mutually determined by patient and clinician

Blood pressure

Yearly, then as mutually determined by patient and clinician

Chest x-ray film

Baseline and as needed

Breast self-examination

Optional. However, it is important for both women and men to “be breast aware”—to know how their breasts look and feel, & what changes to look for (Canadian Breast Cancer Foundation, 2013).


Every 2 years for women 50 to 69 years and then as determined by patient and clinician. For women at increased risk due to family history of breast cancer, begin mammograms 10 years before date of onset in woman’s relative.

Clinical breast examination (CBE)

Yearly examination by a physician or nurse practitioner is questioned. “There is no direct scientific evidence that CBE reduces breast cancer death rates.” (Canadian Breast Cancer Foundation, 2013, p. 1). CBE and mammogram together slightly reduces breast cancer deaths but results in many false positives (Canadian Breast Cancer Foundation).

Gynecologic examination


Pap smear

Every 1 to 3 years for sexually active women to age 70 years

Bone density screening

Based on identification of primary and secondary risk factors (prior to onset of menopause, if indicated)

Nutritional screening

As mutually determined by patient and clinician. (Includes weight, waist measurement, body mass index [BMI], if meeting the requirements of Canada’s Food Guide, and amount of sodium, fats, fibre, calcium, vitamin D taken daily.)

Digital rectal examination

Yearly for men after age 50


Every 5 years after age 50 or as mutually determined by patient and clinician

Prostate examination


Prostate-specific antigen

Every 1 to 2 years after age 50

Testicular examination

Monthly self-examination

Skin examination

Yearly or as mutually determined by patient and clinician

Vision screening glaucoma

Every 2 to 3 years Baseline at age 40, then every 2 to 3 years until age 70, then yearly

Dental screening

Every 6 months

Hearing screening

As needed

Health risk appraisal

As needed

Adult Immunizations Hepatitis A & B (if not received as a child)

Series of three doses (now, 1 month later, then 5 months after the second date)—for lifetime

Influenza vaccine



Once at age 60 years (earlier if have respiratory conditions)

Diphtheria, Pertussis, Tetanus

Every 10 years

Note: Any of these screenings may be performed more frequently if deemed necessary by the patient or recommended by the health care provider.

management and stress reduction. In addition, efforts are made to promote a safe and healthy work environment. Many large businesses provide exercise facilities for their employees and offer their health promotion programs to retirees.

Gerontologic Considerations Health promotion is as important for older people as it is for others. Although 80% of people older than 65 years have one or more chronic illnesses and many are

limited in their activity, older adults as a group experience significant gains from health promotion. Older adults are very health conscious, and most view their health positively and are willing to adopt practices that will improve their health and well-being. Although their chronic illnesses and disabilities cannot be eliminated, these adults can benefit from activities that help them maintain independence and achieve an optimal level of health. Various health promotion programs have been developed to meet the needs of older Canadians. Both public and private organizations continue to be responsive to


Health Education and Health Promotion


nurse in assessing the student’s situation? What is the evidence base for offering information and health programs to help this young adult make appropriate health decisions and establish positive health behaviours? Identify the criteria used to evaluate the strength of the evidence for this practice. 2 After falling from a piece of machinery at a construction site, a 40-year-old man is recuperating at home after being in the hospital. A home care nurse visits three times a week to perform abdominal wound care. During a visit, the man reports that he misses his daily exercise routine and asks when he will be able to resume exercising. Determine the factors that influence his ability to engage in exercise. What factors support the overall relationship between fitness and health? Develop a plan to assist the man to maintain muscle tone and promote well-being. 3

FIGURE 4-2. Health promotion for the older adults includes physical

fitness. Here, a nurse teaches exercises at a seniors’ centre.

health promotion, and more programs that serve older adults are emerging. Many of these programs are offered by health care agencies, churches, community centres, senior citizen residences, and a variety of other organizations. The activities directed toward health promotion for the older adult are the same as those for other age groups: physical fitness and exercise, nutrition, safety, and stress management (Fig. 4-2).

A 74-year-old woman is volunteering at a local health fair being held at her granddaughter’s high school. When the nurse coordinator asks the woman if she would like to participate in the screening events and other informational activities, she replies, “No, thank you. I’m too old to think about health promotion. I just need to take care of the health problems that I already have.” What evidence supports the importance of health promotion strategies for the older adult? What information should you include in a discussion with this woman about promoting health in older adults? What type of information, available at various booths at the health fair, would be appropriate for this woman to obtain?


NURSING IMPLICATIONS By virtue of their expertise in health and health care and their long-established credibility with consumers, nurses play a vital role in health promotion. In many instances, they have initiated health promotion and health screening programs or have participated with other health care personnel in developing and providing wellness services in a variety of settings. As health care professionals, nurses have a responsibility to promote activities that foster well-being, self-actualization, and personal fulfillment. Every interaction with consumers of health care must be viewed as an opportunity to promote positive health attitudes and behaviours.

Critical Thinking Exercises 1 A female college student with a 2-year history of irritable bowel syndrome makes an appointment to speak with the nurse practitioner at the college health centre to discuss her increased use of antidiarrheal medication. The student states, “I’ve been very busy with my studies and several activities this semester, and I haven’t been eating right.” What health promotion components guide the

*Asterisks indicate nursing research articles. **Double asterisks indicate classic reference.

BOOKS Andrews, M. M., & Boyle, J. S. (2012). Transcultural concepts in nursing care (6th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Bastable, S. B. (2008). Nurse as educator: Principles of teaching and learning (3rd ed.). Sudbury, MA: Jones & Bartlett. **Becker, M. H. (Ed.). (1974). The health belief model and personal health behavior. Thorofare, NJ: Charles B. Slack. Carpenito-Moyet, L. J. (2013). Handbook of nursing diagnosis (14th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Chenoweth, K. H. (2011). Worksite health promotion (3rd ed.). Champaign, IL: Human Kinetics. Ebersole, P. & Touhy, T. A. (2006). Geriatric nursing: Growth of a specialty. New York, NY: Springer Publishing. Ebersole, P., Touhy, T. A., Hess, P., et al. (2008). Toward healthy aging: Human needs and nursing responses (7th ed.). St. Louis, MO: Mosby. Edelman, C. L., & Mandle, C. L. (2010). Health promotion throughout the life span (7th ed.). St. Louis, MO: Mosby. Giger, J. N., & Davidhizar, R. E. (2013). Transcultural nursing: Assessment and intervention (6th ed.). St. Louis, MO: Elsevier/Mosby. Herdman, T. H. (Ed.). (2012). NANDA International nursing diagnoses: Definitions & classifications, 2012–2014. Oxford, UK: Wiley-Blackwell. Keleher, H., MacDougall, C., & Murphy, B. (2011). Understanding health promotion. New York: Oxford University Press. **Lalonde, M. (1977). New perspectives on the health of Canadians: A working document. Ottawa, Canada: Minister of Supply and Services.



Basic Concepts in Nursing

Leininger, M. M., & McFarland, M. (2006). Culture care diversity and universality: A worldwide nursing theory (2nd ed.). Sudbury, MA: Jones & Bartlett. Miller, C. A. (2009). Nursing wellness in older adults (5th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Pender, N. J., Murdaugh, C., & Parsons, M. A. (2011). Health promotion in nursing practice (6th ed.). Upper Saddle River, NJ: Pearson. Redman, B. K. (2007). The practice of patient education (10th ed.). Philadelphia, PA: Elsevier Health Sciences. Reutter, L., & Kushner, K. E. (2010). The broad scope of health promotion in health assessment. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Bates’ guide to health assessment for nurses (1st ed., pp. 3–25). Philadelphia, PA: Wolters Kluwer Health/Lippincott, Williams & Wilkins. Reutter, L., & Kushner, K. E. (2012). The nurse’s role in health assessment. Jensen’s nursing health assessment. A best practice approach (1st ed., pp. 3–19). Philadelphia, PA: Wolters Kluwer Health/Lippincott, Williams & Wilkins. Touhy, T. A. (2005). Ebersole & Hess’ Geriatric nursing and healthy aging (1st Canadian ed.). Toronto, ON: Elsevier Canada.

JOURNALS AND ELECTRONIC DOCUMENTS *Brown, M. T., & Bussell, J. K. (2011). Medication adherence: WHO cares? Mayo Clinic Proceeding, 86(4), 304–314. Canadian Nurses Association (CNA). (2008). Code of Ethics for Registered Nurses. Ottawa, ON: Author. College and Association of Registered Nurse of Alberta (CARNA). (2013). Nursing Practice Standards. Edmonton, AB: Author. *Devries, K., Free, C., & Morison, L., et al. (2009). Factors associated with sexual behavior of Canadian Aboriginal young people and their implications for health promotion. American Journal of Public Health, 99(5), 855–862. **Becker, H. A., Stuifbergen, A. K., Oh, H., et al. (1993). The self-rated abilities for health practices scale: A health self-efficacy measure. Health Values, 17, 42–50. *Belguzar, K., Kayser, C., & Selim, K. (2007). Nonadherence with diet and fluid restriction and the level of perceived social support in patients receiving hemodialysis. Journal of Nursing Scholarship, 39(3), 243–248. Betz, C. (2007). Health literacy: The missing link in the provision of health care for children and their families. Journal of Pediatric Nursing, 22(4), 257–260. *Chao, M., Lian, L., Yu, C., et al. (2007). The effect of aerobic exercise training on blood indicators and physical fitness in middle-aged and older people with type 2 diabetes mellitus. Journal of Evidence-Based Nursing, 3(1), 34–43. *Chen, M., Shiao, Y., & Gau, Y. (2007). Comparison of adolescent health-related behavior in different family structures. Journal of Nursing Research, 15(1), 1–9. *de Jong, J., Lemmink, K., Stevens, M., et al. (2006). Six-month effects of the Groningen active living model (GALM) on physical activity, health and fitness outcomes in sedentary and underactive older adults aged 55–65. Patient Education & Counseling, 62(1), 132–141. *DiClemente, C. (2007). The transtheoretical model of intentional behavior change. Drugs & Alcohol Today, 7(1), 29–33. Doherty, W., & Mendenhall, T. (2006). Citizen health care: A model for engaging patients, families, and communities as coproducers of health. Families, Systems & Health: The Journal of Collaborative Family HealthCare, 24(3), 251–263. Greig, A., Constantin, E., Carsley, S., et al. (2010). Preventative health care visits for children and adolescents aged six to seventeen years: The Greig Health Record. Pediatric Child Health, 15(3), 157– 159.

*Guruge, S., & Collins, E. (2008). Working with immigrant women: Issues and strategies for mental health professionals. Toronto, ON: Canadian Center for Addiction and Mental Health. *Haines, D. J., Davis, L., Rancour, P., et al. (2007). A pilot intervention to promote walking and wellness and to improve the health of college faculty and staff. Journal of American College Health, 55(4), 219–225. *Harrington, K., Franklin, F., Davies, S., et al. (2005). Implementation of a family intervention to increase fruit and vegetable intake: The Hi5+ experience. Health Promotion Practice, 6(2), 180–189. Health Quality Council of Alberta. (2011). A citizen’s guide to health indicators. Toronto, ON: Author. Ho, P., Bryson, C., & Rumsfeld, J. (2009). Medication adherence: Its importance in cardiovascular outcomes. Circulation, 119, 3028–3035. *Hoffman-Goetz, L. & Donelle, L. (2007). Chat room computer-mediated support on health issues for Aboriginal women. Health Care for Women International, 28(4), 397–418. Iglar, K., Katyal, S., Matthew, R., et al. (2008). Complete health checkup for adults: Update on the Preventive Care Checklist Form. Canadian Family Physician, 54(1), 84–88 *Kim, Y. (2007). Application of the transtheoretical model to identify psychological constructs influencing exercise behavior: A questionnaire survey. International Journal of Nursing Studies, 44(6), 936–944. *Kushner, K. (2007). Meaning and action in employed mothers’ health work. Journal of Family Nursing, 13(1), 33–55. Latif, S., & McNicoll, L. (2009). Medication and non-adherence in the older adult. Geriatirics for the Practicing Physician, 92(12), 418–419. Law, M., Cheng, L., Dhalla, I., et al. (2012). The effect of cost adherence to prescription medications in Canada. Canadian Medical Association, doi:10.1503/cmaj.111270. Loke, Y., Hinz, I., Wang, X., et al. (2012). Systematic review of consistency between adherence to cardiovascular or diabetes medication and health literacy in older adults. Annals of Pharmacotheraputics, 46(6), 863–872. London, F. (2007). Patient education: Teaching patients about wound care. Home Healthcare Nurse, 25(8), 497–500. Nakasato, Y. R., & Carnes, B. A. (2006). Health promotion in older adults: Promoting successful aging in primary care settings. Geriatrics, 61(4), 27–31. *Perry, C., Rosenfeld, A., Bennett, J., et al. (2007). Heart-to-Heart: Promoting walking in rural women through motivational interviewing and group support. Journal of Cardiovascular Nursing, 22(4), 304–312. *Rovniak, L., Hovell, M., Wojcik, J., et al. (2005). Enhancing theoretical fidelity: An e-mail-based walking program demonstration. American Journal of Health Promotion, 20(2), 85–95. *Rowley, C., Dixon, L., & Palk, R. (2007). Promoting physical activity: Walking programs for mothers and children. Community Practitioner, 80(3), 28–32. Seals, J. (2007). Integrating the transtheoretical model into the management of overweight and obese adults. Journal of the American Academy of Nurse Practitioners, 19(2), 63–71. Vik, S., Hogan, D., Patten, S., et al. (2006). Medication nonadherence and subsequent risk of hospitalisation and mortality among older adults. Drugs and Aging, 23(4), 345–356.

RESOURCES Canadian Nurses Association: Canadian Task Force on Preventative Health Care: College of Family Physicians of Canada: Health Canada: Public Health Agency of Canada: Centers for Disease Control and Prevention: Health Promotion for Women with Disabilities, Villanova University College of Nursing: Disabilities/welcome.htm World Health Organization,


5 Adult Health and Nutritional Assessment Adapted by Rene A. Day

Learning Objectives On completion of this chapter, the learner will be able to: 1. Identify ethical considerations necessary for protecting a person’s rights related to data collected in the health history and physical assessment. 2. Describe the components of the health history. 3. Apply culturally competent and culturally safe interviewing skills and techniques to conduct a successful health history, physical examination, and nutritional assessment. 4. Identify genetic aspects nurses incorporate into the health history and physical assessment. 5. Identify modifications needed to obtain a health history and conduct a physical assessment for a person with a disability. 6. Describe the techniques of inspection, palpation, percussion, and auscultation to perform a basic physical assessment. 7. Discuss the techniques of measurement of body mass index, biochemical assessment, clinical examination, and assessment of food intake to assess a person’s nutritional status. 8. Describe factors that may contribute to altered nutritional status in high-risk groups such as adolescents and older adults. 9. Conduct a health history and physical and nutritional assessment of a person at home.




Basic Concepts in Nursing

The ability to assess patients is a skill integral to nursing, regardless of the practice setting. In all settings in which nurses interact with patients and provide care, eliciting a complete health history and using appropriate assessment skills are critical to identifying physical and psychological issues and concerns experienced by the patient. As the first step in the nursing process, patient assessment is necessary to obtain data that enable the nurse to make an accurate nursing diagnosis, identify and implement appropriate interventions, and assess their effectiveness. This chapter includes the complete health history and basic assessment techniques. Because a patient’s nutritional status is an important factor in overall health and well-being, a section on nutritional assessment is also addressed.

CONSIDERATIONS FOR CONDUCTING A HEALTH HISTORY AND PHYSICAL ASSESSMENT The Role of the Nurse All members of the health care team use their unique skills and knowledge to contribute to the resolution of patient problems by first obtaining some level of history and assessment (Skillen, 2012a). Because the focus of each member of the health care team is unique, a variety of health history and physical examination formats have been developed. Regardless of the format, the information obtained by the nurse complements the data obtained by other members of the health care team and focuses on nursing’s unique concerns for the patient. In health assessment, the nurse obtains the patient’s health history and performs a physical assessment, which can be carried out in a variety of settings, including acute care, clinic or outpatient office, schools, long-term care, correctional facility, or home. Nurses use a growing list of nursing diagnoses to identify and categorize patient issues that nurses have the knowledge, skills, and responsibility to treat independently (Herdman, 2012).

Communicating Effectively People who seek health care for a specific concern are often anxious. Their anxiety may be increased by fear about potential diagnoses, possible disruption of lifestyle, and other concerns. With this in mind, the nurse attempts

FIGURE 5-1. A comfortable, relaxed atmosphere and an attentive interviewer are essential for a successful clinical interview.

to establish rapport, put the patient at ease, encourage honest communication, make eye contact, and listen carefully to the patient’s responses to questions about health issues (Fig. 5-1). When obtaining a health history or performing a physical examination, the nurse is aware of his or her own nonverbal communication, as well as that of the patient. The nurse takes into consideration the patient’s educational and cultural background as well as language proficiency. Questions and instructions to the patient are phrased in a way that is easily understandable. Technical terms and medical jargon are avoided. In addition, the nurse considers the patient’s disabilities or impairments such as hearing, vision, cognitive, and physical limitations. At the end of the assessment, the nurse may summarize and clarify the information obtained and ask the patient if he or she has any questions; this gives the nurse and the patient the opportunity to correct misinformation and add facts that may have been omitted.

Ethical Use of History or Physical Examination Data Whenever information is elicited from a person through a health history or physical examination, the person has the right to know why the information is sought and how it will be used. For this reason, it is important to explain what the history and physical examination are, how the information will be obtained, and how it will be used (Stephen, 2012a). It is also important that the person be

Glossary auscultation: listening to sounds produced within different body structures created by the movement of air or fluid body mass index (BMI): a calculation done to estimate the amount of body fat of a person health history: a series of questions that provides an overview of the patient’s current health status

inspection: visual assessment of different aspects of the patient palpation: examination of different organs of the body using the sense of touch percussion: the use of sound to examine different organs of the body


aware that the decision to participate is voluntary. A private setting for the history interview and physical examination promotes trust and encourages open, honest communication. After the history and examination are completed, the nurse selectively records the data pertinent to the patient’s health status (Stephen, 2012b). This written record of the patient’s history and physical examination findings is then maintained in a secure place and made available only to those health professionals directly involved in the care of the patient. This protects confidentiality and promotes professional conduct.

Increasing Use of Technology The use of technology to augment the information-gathering process has become an increasingly important aspect of obtaining a health history and physical examination. Computerization of health records is becoming more common. Electronic health records are thought to improve the quality of care, reduce medical errors, and help reduce health care costs; therefore, their implementation is moving forward on a global scale (Stephen, 2012b).

HEALTH HISTORY The health history is a series of questions used to provide an overview of the current health status of the patient. When obtaining the health history, attention is focused on the impact of psychosocial, ethnic, and cultural background on a person’s health, illness, and health promotion behaviours. The interpersonal and physical environments, as well as the person’s lifestyle and activities of daily living, are explored in depth. Many nurses are responsible for obtaining a detailed history of the person’s current health problems, past medical history, and family history and a review of the person’s functional status. This results in a total health profile that focuses on health as well as illness. The format of the health history traditionally combines the medical history and the nursing assessment, although formats based on nursing frameworks, such as functional health patterns, have also become standard. Both the review of systems and the patient profile are expanded to include individual and family relationships, lifestyle patterns, health practices, and coping strategies. These components of the health history are the basis of nursing assessment and can be easily adapted to address the needs of any patient population in any setting, institution, or agency (Stephen, 2012a). Combining the information obtained by the physician and the nurse into one health history prevents duplication of information and minimizes efforts on the part of the patient to provide this information repeatedly. This also encourages collaboration among members of the health care team who share in the collection and interpretation of the data.

The Informant The informant, or the person providing the health history, may not always be the patient, as in the case of a

Adult Health and Nutritional Assessment


developmentally delayed, mentally impaired, disoriented, confused, unconscious, or comatose patient. The interviewer assesses the reliability of the informant and the usefulness of the information provided. For example, a patient who is disoriented is often unable to provide reliable information; people who use alcohol and illicit drugs often deny using these substances. The interviewer must make a clinical judgment about the reliability of the information (based on the context of the entire interview) and include this assessment in the record. Chart 5-1 provides special considerations for obtaining a health history from an older adult.

Components of the Health History When a patient is seen for the first time by a member of the health care team, the first requirement is that baseline information be obtained (except in emergency situations). The sequence and format of obtaining data about a patient may vary, but the content, regardless of format, usually addresses the same general topics. A traditional approach includes the following: biographical data, chief concern, present health concern (or present illness), past history, family history, review of systems, and patient profile.


Health Assessment in the Older Adult A health history is obtained from older patients in a calm, unrushed manner. Because of the increased incidence of impaired vision and hearing in the older adult, lighting needs to be adequate but not glaring, and distracting noises need to be kept to a minimum. The interviewer assumes a position that enables the person to read lips and facial expressions. People who usually use a hearing aid are asked to use it during the interview. The interviewer also recognizes that there is wide diversity among older adults and that differences exist in health practices, gender, income, and functional status (Skillen, 2012a). Older people often assume that new physical problems are a result of age rather than a treatable illness. In addition, the signs and symptoms of illness in older adults are often more subtle than those in younger people and may go unreported. Therefore, a question such as, “What interferes most in your daily activities?” may be useful in focusing the clinical evaluation (Soriano, Fernandes, Cassel, et al., 2007). Special care is taken in obtaining a complete history of medications used, because many older people take many different kinds of prescription and over-the-counter (OTC) medications. Although older people may experience a decline in mental function, it should not be assumed that they are unable to provide an adequate history (Anderson, Hunter, & Bickley, 2010). Nevertheless, including a member of the family in the interview process (e.g., spouse, adult child, sibling, caretaker) may validate information and provide missing details. However, this should be done after obtaining the patient’s permission. Further details about assessment of the older adult are provided in Chapter 13.



Basic Concepts in Nursing

Biographical Data Biographical information puts the patient’s health history into context. This information includes the person’s name, address, age, gender, marital status, occupation, and ethnic origins. Most interviewers prefer to wait to ask more personal questions later in the interview, when more trust and confidence have been established or until a patient’s immediate or urgent needs have been addressed. A patient who is in severe pain or has another urgent condition is unlikely to have a great deal of patience for an interviewer who is more concerned about marital or occupational status than with quickly addressing the issue at hand.

Chief Concern The chief concern is the issue that brings a person to the attention of the health care professional. Questions such as, “Why have you come to the health centre today?” or “Why were you admitted to the hospital?” usually elicit the chief concern. In the home setting, the initial question might be, “What is bothering you most today?” When an issue is identified, the person’s exact words are usually recorded in quotation marks. However, a statement such as, “My doctor sent me,” should be followed up with a question that identifies the probable reason why the person is seeking health care; this reason is then identified as the chief concern (Stephen, 2012a).

Present Health Concern or Illness The history of the present health concern or illness is the single most important factor in helping the health care team arrive at a diagnosis or determine the person’s needs. The physical examination is helpful but often only validates the information obtained from the history. A careful history assists in correct selection of appropriate diagnostic tests. Although diagnostic test results can be helpful, they often support rather than establish the diagnosis. If the present illness is only one episode in a series of episodes, the entire sequence of events is recorded. For example, a history from a patient whose chief concern is an episode of insulin shock describes the entire course of the diabetes to put the current episode in context. The details of the health concern or present illness are described from onset until the time of contact with the health care team. These facts are recorded in chronologic order, beginning with, for example, “The patient was in good health until . . . ” or “The patient first experienced abdominal pain 2 months prior to seeking help.” The history of the present illness or health concern includes such information as the date and manner (sudden or gradual) in which the problem occurred, the setting in which the concern occurred (at home, at work, after an argument, after exercise), manifestations of the problem, and the course of the illness or concern. This includes self-treatment (including complementary and alternative therapies), medical interventions, progress and effects of treatment, and the patient’s perceptions of the cause or meaning of the problem. Specific symptoms (pain, headache, fever, change in bowel habits) are described in detail, along with the location and radiation (if pain), quality, severity, and duration.

The interviewer also asks whether the concern is persistent or intermittent, what factors aggravate or alleviate it, and whether any associated manifestations exist. Associated manifestations are symptoms that occur simultaneously with the chief concern. The presence or absence of such symptoms may shed light on the origin or extent of the concern, as well as on the diagnosis. These symptoms are referred to as significant positive or negative findings and are obtained from a review of systems directly related to the chief concern. For example, if a patient reports a vague symptom such as fatigue or weight loss, all body systems are reviewed and included in this section of the history. If, on the other hand, a patient’s chief concern is chest pain, only the cardiopulmonary and gastrointestinal systems may be included in the history of the present illness. In either situation, both positive and negative findings are recorded to define the concern further.

Past Health History A detailed summary of a person’s past health is an important part of the health history (Stephen, 2012a). After determining the general health status, the nurse inquires about the immunization status according to the recommendations of the adult immunization schedule and records the dates of immunization (if known) (Public Health Agency of Canada [PHAC], 2012a,b). The nurse also inquires about any known allergies to medications or other substances, along with the type of allergy and adverse reactions. Other relevant material includes information, if known, about the patient’s last physical examination, chest x-ray, electrocardiogram, eye examination, hearing test, dental checkup (Chart 5-2), Papanicolaou (Pap) smear and mammogram (if female), digital rectal examination of the prostate gland (if male), bone density testing, colon cancer screening, and any other pertinent tests. The nurse then discusses previous illnesses and records negative as well as positive responses to a list of specific diseases. Dates of illness or the age of the patient at the time, as well as the names of the primary health care professional and hospital, the diagnosis, and the treatment are noted. The nurse elicits a history of the following areas: • Childhood illnesses—rubeola, rubella, polio, whooping cough, mumps, measles, chickenpox, scarlet fever, rheumatic fever, strep throat, meningitis • Adult illnesses • Psychiatric illnesses • Injuries—burns, fractures, head injuries • Hospitalizations • Surgical and diagnostic procedures • Current medications—prescription, over-the-counter (OTC), home remedies, complementary, and alternative therapies • Use of alcohol and other drugs • Smoking If a particular hospitalization or major medical intervention is related to the present illness, the account of it is not repeated; rather, the report refers to the appropriate part of the record, such as “See history of present illness” on the data sheet.



Adult Health and Nutritional Assessment


Chart 5-2. Oral Health Assessment Chen, C. C. H., Chyun, D. A., Li, C., et al. (2007). A singleitem approach to screening elders for oral health assessment. Nursing Research, 56 (5), 332–338. Purpose When performing health assessments for older patients, nurses are aware that oral health is an important indicator of overall health. The main purpose of this study was to evaluate the usefulness of asking the question, “Do you have regular dental checkups?” as a means of determining whether an oral health assessment or further referral is indicated for older adults. Design The study was a secondary analysis using a nutritional survey of 240 older participants who were living in the community. A gerontologic nurse practitioner was trained to rate each participant on three oral indices: the Kayser-Jones Brief Oral Health Status Examination, the self-reported General Oral Health Assessment Index, and the number of remaining teeth. During an assessment in their home, the participants were also asked about their pattern of dental checkups (regular vs. irregular).

Findings Approximately half (55%) of participants reported a dental visit within the past year for any reason, but only 81 (33.8%) reported having regular dental checkups. For participants with teeth (n = 147), an irregular dental checkup was associated with lower educational level, Protestant faith, and black race. Participants with a pattern of irregular dental checkups scored lower on all three oral indices. The question, “Do you have regular dental checkups?” was found to be valid for identifying those with teeth and good oral health; it was less effective for those participants without teeth. Nursing Implications During the general health assessment for older adults, the nurse is aware that a single question, “Do you have regular dental checkups?” can be used effectively to identify those with teeth and good oral health and not in need of further oral health assessment or referral. This one question was less effective in identifying those in need of further oral health assessment or referral.

Family History To identify diseases that may be genetic, communicable, or possibly environmental in origin, the nurse asks about the age and health status, or the age and cause of death, of first-order relatives (parents, siblings, spouse, children) and second-order relatives (grandparents, cousins). In general, the following conditions are included: cancer, hypertension, heart disease, diabetes, epilepsy, mental illness, tuberculosis, kidney disease, arthritis, allergies, asthma, alcoholism, and obesity. One of the easiest methods of recording such data is by using the family tree, or genogram (Fig. 5-2). The results of genetic testing or screening, if known, are recorded. Chart 5-3 provides genetic considerations related to health assessment; see also Chapter 9 for a detailed discussion of genetics.

75 Lung cancer Alzheimer dementia

52 Unknown cause

52 Brain tumour

45 Breast cancer

Review of Systems The review of systems includes an overview of general health as well as symptoms related to each body system. Questions are asked about each of the major body systems for information about past and present symptoms. Reviewing each body system helps reveal relevant data. Negative as well as positive answers are recorded. If a patient responds positively to questions about a particular system, further questioning is used and the information is analyzed carefully. If any illnesses were previously mentioned or recorded, it is not necessary to repeat them in this part of the history. Instead, reference is made to the appropriate place in the health history where the information can be found.

88 Heart disease Osteoporosis

78 Breast cancer

68 Breast cancer Diabetes

43 A+W


48 Multiple sclerosis

Key: Male Female Deceased

3 mos 12 15 17 SIDS A + W A + W A + W

A + W Alive and well Patient FIGURE 5-2. Diagram (called a genogram) used to record history of

family members, including their age and cause of death or, if living, their current health status.



Basic Concepts in Nursing


Chart 5-3. Genetics Aspects of Health Assessment Nurses incorporate a genetics focus into the following health assessments: • Family history—assess for genetics-related risk factors. • Cultural, social, and spiritual assessment—assess for individual and family perceptions and beliefs around genetics topics.

A review of systems can be organized in a formal checklist, which becomes a part of the health history. One advantage of a checklist is that it can be easily audited and is less subject to error than a system that relies heavily on the interviewer’s memory.

Patient Profile In the patient profile, more biographical information is gathered. A complete composite, or profile, of the patient is critical to analysis of the chief concern and of the

• Physical assessment—assess for clinical features that may

suggest a genetic condition is present (e.g., unusually tall stature—Marfan syndrome). • Ethnic background—since many conditions are more common in specific ethnic populations, the nurse gathers information about ethnic background (e.g., Tay–Sachs disease in Ashkenazi Jewish populations or thalassemia in Southeast Asian populations).

person’s ability to deal with the concern. A complete patient profile is summarized in Chart 5-4. At this point in the interview, the information elicited is highly personal and subjective. People are encouraged to express feelings honestly and to discuss personal experiences. It is best to begin with general, open-ended questions and to move to direct questioning when specific facts are needed. Interviews that progress from information that is less personal (birthplace, occupation, education) to information that is more personal (sexuality, body image, coping abilities) often reduce anxiety.


Patient Profile Past Events Related to Health Place of birth Places lived Significant childhood/adolescent experiences

Education and Occupation Jobs held in past Current position/job Length of time at position Educational preparation Work satisfaction and career goals

Financial Resources Income Coverage for prescription medications, dental care, treatments (massage, physical therapy, acupuncture, etc.)

Environment Physical—living arrangements (type of housing, neighbourhood, presence of hazards) Spiritual—extent to which religion is a part of individual’s life; religious beliefs related to perception of health and illness; religious practices Interpersonal—ethnic background (language spoken, customs and values held, practices used to maintain health or to cure illness); family relationships (family structure, roles, communication patterns, support system); friendships (quality of relationship)

Lifestyle Patterns Sleep (time person retires, hours per night, comfort measures, awakens rested) Exercise (type, frequency, time spent) Nutrition (24-hour diet recall, idiosyncrasies, restrictions) Recreation (type of activity, time spent)

Caffeine (coffee, tea, cola, chocolate–kind), amount Smoking (cigarette, pipe, cigar, marijuana–kind), amount per day, number of years, desire to quit Alcohol–kind, amount, pattern over past year Drugs-kind, amount, route of administration

Physical or Mental Disability Presence of a disability (physical or mental) Effect of disability on function and health access Accommodations needed to support functioning

Self-Concept View of self in present View of self in future Body image (level of satisfaction, concerns)

Sexuality Perception of self as a man or woman Quality of sexual relationships Concerns related to sexuality or sexual functioning

Risk for Abuse Physical injury in past Afraid of partner, caregiver, or family member Refusal of caregiver to provide necessary equipment or assistance

Stress and Coping Response Major concerns or problems at present Daily “hassles” Past experiences with similar problems Past coping patterns and outcomes Present coping strategies and anticipated outcomes Individual’s expectations of family/friends and health care team in problem resolution


A general patient profile consists of the following content areas: past life events related to health, education and occupation, environment (physical, spiritual, cultural), lifestyle (patterns and habits), presence of a physical or mental disability, self-concept, sexuality, risk for abuse, and stress and coping response.

Past Life Events Related to Health The patient profile begins with a brief life history. Questions about place of birth and past places of residence help focus attention on the earlier years of life. Personal experiences during childhood or adolescence that have special significance may be elicited by asking a question such as, “Was there anything that you experienced as a child or adolescent that would be helpful for me to know about?” The interviewer’s intent is to encourage the patient to make a quick review of his or her earlier life, highlighting information of particular significance. Although many patients may not recall anything significant, others may share information such as a personal achievement, a failure, a developmental crisis, or an instance of physical, emotional, or sexual abuse. The life history includes a brief medication history as appropriate for the patient.

Education and Occupation Inquiring about current occupation can reveal much about a person’s economic status and educational preparation. A statement such as, “Tell me about your job,” often elicits information about role, job tasks, and satisfaction with the position. Direct questions about past employment and career goals may be asked if the person does not provide this information. It is important to learn about a person’s educational background. Asking a person what kind of educational requirements were necessary to attain his or her present job is a more sensitive approach than asking whether he or she graduated from high school. Information about the patient’s general financial status may be obtained by questions such as, “Do you have any financial concerns at this time?” or “Sometimes there just doesn’t seem to be enough money to make ends meet. Are you finding this to be true?”

Environment The concept of environment includes a person’s physical environment and its potential hazards, spiritual awareness, cultural background, interpersonal relationships, and support system. PHYSICAL ENVIRONMENT. Information is elicited about the type of housing (apartment, duplex, singlefamily) in which the person lives, its location, the level of safety and comfort within the home and neighbourhood, and the presence of environmental hazards (e.g., isolation, potential fire risks, inadequate sanitation). If the patient has a disability, the nurse asks questions about the patient’s home environment. If the patient is homeless or living in a shelter the patient’s environment assumes special importance (Crowe, 2007). SPIRITUAL ENVIRONMENT. The term spiritual environment refers to the degree to which a person thinks about

Adult Health and Nutritional Assessment


or contemplates his or her existence, accepts challenges in life, and seeks and finds answers to personal questions. Spirituality may be expressed through identification with a particular religion. Spiritual values and beliefs often direct a person’s behaviour and approach to health issues and can influence responses to sickness (Skillen, 2012b). Illness may create a spiritual crisis and can place considerable stress on a person’s internal resources and beliefs. Inquiring about spirituality can identify possible support systems as well as beliefs and customs that need to be considered in planning care. Information is gathered about the extent to which religion is a part of the person’s life as well as religious beliefs and practices related to health and illness. A spiritual assessment may involve asking the following questions: • • • •

Is religion or God or a higher power important to you? If yes, in what way? If no, what is the most important thing in your life? Are there any religious practices that are important to you? • Do you have any spiritual concerns because of your present health condition? CULTURAL ENVIRONMENT. When obtaining the health history, the person’s cultural and religious backgrounds are taken into account. Cultural attitudes and beliefs about health, illness, health care, hospitalization, the use of medications, and use of complementary and alternative therapies, which are derived from personal experiences, vary according to ethnic, cultural, and religious background. A person from another culture may have different views of personal health practices from those of the health care professional (Skillen, 2012c). See Chapter 9 for more cultural considerations. The beliefs and practices that have been shared from generation to generation are known as cultural or ethnic patterns. They are expressed through language, dress, dietary choices, and role behaviours; in perceptions of health and illness; and in health-related behaviours. The influence of these beliefs and customs on how a person reacts to health issues and interacts with health care providers cannot be underestimated. The following questions may assist in obtaining relevant information:

• Where did your parents or ancestors come from? When? • What language do you speak at home? • Are there certain customs or values that are important to you? • Is there anything special you do to keep in good health? • Do you have any specific practices for treating illness? FAMILY RELATIONSHIPS AND SUPPORT SYSTEM. An assessment of family structure (members, ages, and roles), patterns of communication, and the presence or absence of a support system is an integral part of the patient profile. Although the traditional family is recognized as a mother, a father, and children, many different types of living arrangements exist within our society. “Family” may mean two or more people bound by emotional ties or commitments. Live-in companions, roommates, and close friends can all play a significant role in a person’s support system.



Basic Concepts in Nursing

Lifestyle The lifestyle section of the patient profile provides information about health-related behaviours. These behaviours include patterns of sleep, exercise, nutrition, and recreation, as well as personal habits such as smoking, use of alcohol, caffeine, and the use of illicit drugs. Although most people readily describe their exercise patterns or recreational activities, many are unwilling to report their smoking, alcohol use, and illicit drug use, and many deny or understate the degree to which they use such substances. Questions such as, “What kind of alcohol do you enjoy drinking at a party?” may elicit more accurate information than, “Do you drink?” The specific type of alcohol (e.g., wine, liquor, beer) and the amount ingested per day or per week (e.g., 500 mL of whiskey daily for 2 years) should be described (Stephen, 2012a). If alcohol abuse is suspected, additional information may be obtained by using common alcohol screening questionnaires such as the CAGE (Cutting down, Annoyance by criticism, Guilty feelings, and Eye-openers) (Ewing, 1984), AUDIT (Alcohol Use Disorders Identification Test), TWEAK (Tolerance, Worry, Eye-opener, Amnesia, Kut down) (Chan, Pristach, Welte, et al., 1993), or SMAST (Short Michigan Alcohol Screening Test). Chart 5-5 shows the CAGE Questions Adapted to Include Drugs (CAGEAID). The MAST (Michigan Alcohol Screening Test) has been updated to include drug use and has a geriatric version (The New York State Office of Alcoholism and Substance Abuse Services [OASAS], 2007). Similar questions can be used to elicit information about smoking and caffeine consumption. Questions about illicit drug use follow naturally after questions about smoking, caffeine consumption, and alcohol use. A nonjudgmental approach makes it easier for a person to respond truthfully and factually. If street names or unfaCHART 5-5

Assessing for Alcohol or Drug Use CAGE Questions Adapted to Include Drugs (CAGEAID)* Have you felt you ought to cut down on your drinking (or drug use)? _____Yes _____No Have people annoyed you by criticizing your drinking (or drug use)? _____Yes _____No Have you felt bad or guilty about your drinking (or drug use)? _____Yes _____No Have you ever had a drink (or used drugs) first thing in the morning to steady your nerves or get rid of a hangover (or to get the day started)? _____Yes _____No *Boldface text shows the original CAGE questions; boldface italic text shows modifications of the CAGE questions used to screen for drug disorders. In a general population, two or more positive answers indicate a need for more in-depth assessment. From Fleming, M. F., & Barry, K. L. (1992). Addictive disorders. St. Louis, MO: Mosby; and Ewing, J. A. (1984). Detecting alcoholism: The CAGE questionnaire. Journal of the American Medical Association, 252(14), 1905–1907.

miliar terms are used to describe drugs, the person is asked to define the terms used. Investigation of lifestyle also includes questions about complementary and alternative therapies. According to the Public Health Agency of Canada (PHAC), 70% of Canadians use complementary or alternative therapies (PHAC, 2008). Other types of therapies include: special diets, prayer, visualization or guided imagery, massage, acupuncture, meditation, herbal products, and many others. Marijuana is used for management of symptoms, especially pain, in a number of chronic conditions.

Disability The general patient profile contains questions about any hearing, vision, or other type of physical disability. Mental, sensory, or cognitive disabilities are inquired about as well. The presence of an obvious physical limitation (e.g., using crutches to walk or using a wheelchair to get around) necessitates further investigation. The etiology of the disability should be elicited, and the length of time the patient has had the disability, the impact on function, and health access are important to assess (Smeltzer, ShartsHopko, Ott, et al., 2007). Chart 5-6 presents specific issues that the nurse considers when obtaining health histories and conducting physical assessments of patients with disabilities. See Chapter 12.

Self-Concept Self-concept refers to a person’s view of himself or herself, an image that has developed over many years. To assess self-concept, the interviewer might ask how a person views life, using a question such as, “How do you feel about your life in general?” A person’s self-concept can be threatened very easily by changes in physical function or appearance or other threats to health. The impact of certain medical conditions or surgical interventions, such as a colostomy or a mastectomy, can threaten body image. The question, “Do you have any particular concerns about your body?” may elicit useful information about self-image.

Sexuality No area of assessment is more personal than the sexual history. Health care professionals are frequently uncomfortable with such questions and ignore this area of the patient profile or conduct a very cursory interview about this subject. Lack of knowledge about sexuality, preconceived notions (e.g., assuming all people are heterosexual), and anxiety about one’s own sexuality may hamper the interviewer’s effectiveness in dealing with this subject (Stephen, 2012a). Sexual assessment can be approached at the end of the interview, at the time interpersonal or lifestyle factors are assessed, or it may be easier to discuss sexuality as a part of the genitourinary history within the Review of Systems. In female patients, a discussion of sexuality would follow questions about menstruation. In male patients, a similar discussion would follow questions about the urinary system. Obtaining the sexual history provides an opportunity to discuss sexual matters openly and gives the person


Adult Health and Nutritional Assessment



Health Assessment of People With Disabilities Overview People with disabilities are entitled to the same level of health assessment and physical examination as people without disabilities. The nurse needs to be aware of the patient’s disabilities or impairments (hearing, vision, cognitive, and physical limitations) and take these into consideration when obtaining a health history and conducting a physical assessment. It is appropriate to ask the patient what assistance he or she needs rather than assuming that help is needed for all activities or that, if assistance is needed, the patient will ask for it.

Health History Communication between the nurse and the patient is essential. To ensure that the patient is able to respond to assessment questions and provide needed information, interpreters, assistive listening devices, or other alternative formats (e.g., Braille, large-print forms) may be required. When interpreters are needed, interpretation services should be arranged. Health care facilities have a responsibility to provide these services without charge to the patient. Family members (especially children) should not be used as interpreters, because doing so violates the patient’s right to privacy and confidentiality. The nurse speaks directly to the patient and not to family members or others who have accompanied the patient. If the patient has vision or hearing loss, usual tone and volume of the voice should be used when conducting the assessment. The patient should be able to see the nurse’s face clearly during the health history, so that speech reading and nonverbal clues can be used to aid communication. The health history addresses general health issues that are important to all patients, including sexual history and risk for abuse. It also addresses the impact of the patient’s disability on health issues and access to care and the effect of the patient’s current health concern on his or her disability. The nurse should verify what the patient has said; if the patient has difficulty communicating verbally, the nurse should ask for clarification rather than assume that it is too difficult for the patient to do so. Most people would rather be asked to explain again than run the risk of being misunderstood (Smeltzer et al., 2007).

Physical Examination Inaccessible facilities remain a major barrier to health care for people with disabilities. Barriers include lack of ramps and grab bars, inaccessible restrooms, small examination rooms, and examination tables that cannot be lowered to allow the patient to move himself or herself onto, or be transferred easily and safely to, the examination table. The patient may need

permission to express sexual concerns to an informed professional. The interviewer is nonjudgmental and uses language appropriate to the patient’s age and background (Stephen, 2012a). Determining whether a person is sexually active should precede any attempts to explore issues related to sexuality and sexual function. The assessment begins with an orienting sentence such as, “Next, I would like to ask about your sexual health and practices.” Such an opening may lead to a discussion of concerns related to sexual expression or the quality of a relationship, or to questions about contraception, risky sexual behaviours,

help getting undressed for the physical examination (and dressed again), moving on and off the examination table, and maintaining positions usually required during physical examination manoeuvres. It is important to ask the patient what assistance is needed. If the patient has impaired sensory function (e.g., lack of sensation, hearing or vision loss), it is important to inform the patient that you will be touching him or her. Furthermore, it is important to explain all procedures and manoeuvres. Gynecologic examinations should not be deferred because a patient has a disability or is assumed to be sexually inactive. Explanations of the examination are important for all women, and even more so for women with disabilities, because they may have had previous negative experiences. Slow, gentle moving and positioning of the patient for the gynecologic examination and warming the speculum before attempting insertion often minimize spasticity in women with neurologically related disabilities.

Health Screening and Testing Many people with disabilities report that they have not been weighed for years or even decades because they are unable to stand for this measurement. Alternative methods (e.g., use of wheelchair scales) are needed to monitor weight and body mass index. This is particularly important because of the increased incidence of obesity and its effects on health status and transfer of persons with disabilities. Patients with disabilities may require special assistance if urine specimens are to be obtained as part of the visit. They are often able to suggest strategies to obtain urine specimens based on previous experience. If it is necessary for the nurse to wear a mask during a procedure or if the patient is unable to see the face of the nurse during a procedure, it is important to explain the procedure and the expected role of the patient ahead of time. If the patient is unable to hear or is unable to communicate with the nurse or other health care provider verbally during an examination or diagnostic test, a method of communication (e.g., signaling the patient by tapping his or her arm, signaling the nurse by using a bell) is established beforehand. Inaccessible facilities have resulted in decreased participation of people with disabilities in recommended preventive screening, including gynecologic examinations, mammograms, and bone density testing (Smeltzer, Zimmerman, & Capriotti, 2005). Therefore, it is important to ask about health screening and recommendations for screening. In addition, people with disabilities should be asked about their participation in health promotion activities, because inaccessible environments may limit their participation in exercise, health programs, and other health promotion efforts.

and safer sex practices. Examples of other questions are, “How many sexual partners have you had?” and “Are you satisfied with your sexual relationships?” Care should be taken to initiate conversations about sexuality with older patients and patients with disabilities and not to treat them as asexual people. Questions are worded in such a way that the person feels free to discuss his or her sexuality regardless of marital status or sexual preference. Direct questions are usually less threatening when prefaced with such statements as, “Most people feel that . . .” or “Many people worry about. . . .”



Basic Concepts in Nursing

This suggests the normalcy of such feelings or behaviour and encourages the person to share information that might otherwise be omitted because of fear of seeming “different.” If a person answers abruptly or does not wish to carry the discussion any further, then the nurse moves to the next topic. However, introducing the subject of sexuality indicates to the person that a discussion of sexual concerns is acceptable and can be approached again in the future if so desired. Further discussion of the sexual history is presented in Chapters 47 and 50.

Risk for Abuse Physical, sexual, and psychological abuse is a topic of growing importance in today’s society (Stephen, 2012c). Such abuse occurs to people of both genders, of all ages, and from all socioeconomic, ethnic, and cultural groups. Patients rarely discuss this topic unless specifically asked about it. In fact, research shows that the majority of women currently in an abusive relationship have never told a health care professional. Therefore, it is important to ask direct questions, such as: • Is anyone physically hurting you? Or forcing you to have sexual activities? • Has anyone ever hurt you physically? Or threatened to do so? • Are you ever afraid of anyone close to you (your partner, caregiver, or other family members)? Patients who are older or have disabilities are at increased risk for abuse and should be asked about it as a routine part of assessment. However, when older patients are questioned directly, they rarely admit to abuse. Health care professionals should assess for risk factors, such as high levels of stress or alcoholism in caregivers, evidence of violence, and emotional outbursts, as well as financial, emotional, or physical dependency. Two additional questions have been found to be effective in uncovering specific types of abuse that may occur only in people with disabilities: • Does anyone prevent you from using a wheelchair? Cane? Respirator? Other assistive device? • Does anyone you depend on refuse to help you with an important personal need, such as taking your medicine? Getting to the bathroom? Getting in or out of bed? Bathing? Dressing? Getting food or drink? If a person’s response indicates that abuse is a risk, further assessment is warranted, and efforts are made to ensure the patient’s safety and provide access to appropriate community and professional resources and support systems. Further discussion of domestic violence and abuse is presented in Chapter 47.

Stress and Coping Responses Each person handles stress differently. How well people adapt depends on their ability to cope. During a health history, past coping patterns and perceptions of current stresses and anticipated outcomes are explored to identify the person’s overall ability to handle stress. It is especially important to identify expectations that a person may have of family, friends, and caregivers in providing emotional,

physical, or financial support. Further discussion of stress and coping is presented in Chapter 7.

Other Health History Formats The health history format discussed in this chapter is only one possible approach that is useful in obtaining and organizing information about a person’s health status. Some experts consider this traditional format to be inappropriate for nurses, because it does not focus exclusively on the assessment of human responses to actual or potential health problems. Several attempts have been made to develop an assessment format and database with this focus in mind. One example is a nursing database based on the North American Nursing Diagnosis Association International and its 13 domains: health promotion, nutrition, elimination/exchange, activity/rest, perception/cognition, self-perception, role relationship, sexuality, coping/stress tolerance, life principles, safety/protection, comfort, and growth/development (Herdman, 2012). Although there is support in nursing for using this approach, no consensus for its use has been reached. Other examples include electronic systems specific to home care and perioperative nursing. Groups from the public and private sectors have focused on assessing not only biologic health, but also other dimensions of health. These dimensions include physical, functional, emotional, mental, and social health. Efforts to assess health status have focused on the manner in which disease or disability affects a patient’s functional status— that is, the ability of the person to function and perform his or her usual physical, mental, and social activities. An emphasis on functional assessment is viewed as more holistic than the traditional health or medical history. Instruments to assess health status in these ways may be used by nurses along with their own clinical assessment skills to determine the impact of illness, disease, disability, and health concerns on functional status. Health concerns that are not complex (e.g., earache, sinusitis) and can be resolved in a short period usually do not require the depth or detail that is necessary when a person is experiencing a major illness or health concern. Additional assessments that go beyond the general patient profile may be used if the patient’s health concerns are acute and complex or if the illness is chronic. The person is asked about continuing health promotion and screening practices. If the person has not been involved in these practices in the past, information can be given about their importance and referred to appropriate health care professionals. Research has shown that health promotion is beneficial even for frail older home care clients. One study found that proactively providing older people with health promotion compared to providing standard nursing home care services resulted in better mental health functioning, decreased depression, and enhanced perceptions of social support with no increase in costs (Markle-Reid, Weir, Browne, et al., 2006). Regardless of the assessment format used, the focus of nurses during data collection is different from that of physicians and other health team members. However, the nursing focus complements these other approaches and encourages collaboration among the health care professionals, with each


member bringing his or her own expertise and focus to the situation.

PHYSICAL ASSESSMENT Physical assessment, or the physical examination, is an integral part of nursing assessment. The basic techniques and tools used in performing a physical examination are described in general in this chapter. The examinations of specific systems, including special manoeuvres, are described in the appropriate chapters throughout the book.

Examination Considerations The physical examination is usually performed after the health history is obtained. It is carried out in a welllighted, warm area. The patient is asked to (or helped to) undress and is draped appropriately so that only the area to be examined is exposed. The person’s physical and psychological comfort are considered at all times. It is necessary to describe procedures to the patient and explain what sensations to expect before each part of the examination. The examiner’s hands are washed before and immediately after the examination. Fingernails are kept short to avoid injuring the patient. If there is a possibility of coming into contact with blood or other body secretions during the physical examination, gloves should be worn. An organized and systematic examination is the key to obtaining appropriate data in the shortest time. Such an approach encourages cooperation and trust on the part of the patient. The person’s health history provides the examiner with a health profile that guides all aspects of the physical examination. A “complete” physical examination is not routine. Many of the body systems are selectively assessed on the basis of the presenting concern. For example, if a healthy 20-year-old college student requires a physical examination to study abroad and reports no history of neurologic abnormality, the neurologic assessment is brief. Conversely, a history of transient numbness and diplopia (double vision) usually necessitates a complete neurologic investigation. Similarly, a patient with chest pain receives a much more intensive examination of the chest and heart than one with an earache. In general, the health history guides the examiner in obtaining additional data for a complete picture of the patient’s health. The process of learning to perform a physical examination requires repetition and reinforcement in a clinical setting. Only after basic physical assessment techniques are mastered can the examiner tailor the routine screening examination to include thorough assessments of particular systems, including special manoeuvres (Skillen, 2012d).

Components of the Physical Examination The components of a physical examination include general observations and then a more focused assessment of the pertinent body systems. The tools of the physical

Adult Health and Nutritional Assessment


examination are the human senses of vision, hearing, touch, and smell. These may be augmented by special tools (e.g., stethoscope, ophthalmoscope, reflex hammer) that are extensions of the human senses; they are tools that anyone can learn to use well. Expertise comes with practice, and sophistication comes with the interpretation of what is seen and heard.

Initial Observations General inspection begins with the first contact with the patient. Introducing oneself and shaking hands provide opportunities for making initial observations: Is the person old? Or young? How old? How young? Does the person appear to be his or her stated age? Is the person thin? Or obese? Does the person appear anxious? Or depressed? Is the person’s body structure as expected? Or not? In what way, and how different from the expected? It is essential to pay attention to the details in observation. Vague, general statements are not a substitute for specific descriptions based on careful observation. Consider the following examples: • “The person appears sick.” In what way does he or she appear sick? Is the skin pale, jaundiced, or cyanotic? Is the person grimacing in pain? Or having difficulty breathing? Does he or she have edema? What specific physical features or behavioural manifestations indicate that the person is “sick”? • “The person appears chronically ill.” In what way does he or she appear chronically ill? Does the person appear to have lost weight? People who lose weight secondary to muscle-wasting diseases (e.g., acquired immunodeficiency syndrome [AIDS], malignancy) have a different appearance than those who are merely thin, and weight loss may be accompanied by loss of muscle mass or atrophy. Does the skin have the appearance of chronic illness (i.e., is it pale? Or does it give the appearance of dehydration? Or loss of subcutaneous tissue)? These important specific observations are documented in the patient’s chart or health record. Among general observations that are noted in the initial examination of the patient are posture and stature, body movements, gait, nutritional status, speech pattern, and vital signs.

Posture The posture that a person assumes often provides valuable information. Patients who have breathing difficulties (dyspnea) secondary to cardiac disease prefer to sit and may report feeling short of breath when lying flat for even a brief time. Patients with abdominal pain due to peritonitis prefer to lie perfectly still; even slight jarring of the bed causes agonizing pain. In contrast, patients with abdominal pain due to renal or biliary colic are often restless and may pace the room.

Body Movements Abnormalities of body movement are of two kinds: generalized disruption of voluntary or involuntary movement and asymmetry of movement. The first category includes tremors of a wide variety; some tremors may occur at rest (Parkinson’s disease), whereas others occur only on



Basic Concepts in Nursing

voluntary movement (cerebellar ataxia). Other tremors may exist during both rest and activity (alcohol withdrawal syndrome, thyrotoxicosis). Some voluntary or involuntary movements are described as “fine,” and others are “quite coarse.” At the extreme are the convulsive movements of epilepsy or tetanus and the choreiform (involuntary and irregular) movements of patients with rheumatic fever or Huntington disease. Asymmetry of movement, in which only one side of the body is affected, may occur with disorders of the central nervous system (CNS), primarily in those patients who have had a cerebrovascular accident (stroke). Patients may have drooping of one side of the face, weakness or paralysis of the extremities on one side of the body, and a foot-dragging gait. Spasticity (increased muscle tone) may also be present, particularly in patients with multiple sclerosis.

Nutritional Status Nutritional status is important to note. Obesity may be generalized as a result of excessive intake of calories, or it may be specifically localized to the trunk in patients who have an endocrine disorder (Cushing disease) or who have been taking corticosteroids for long periods. Loss of weight may be generalized as a result of inadequate caloric intake, or it may be seen in loss of muscle mass with disorders that affect protein synthesis. Nutritional assessment is discussed in more detail later in this chapter.

Speech Pattern Speech may be slurred because of CNS disease or because of damage to cranial nerves. Recurrent damage to the laryngeal nerve results in hoarseness, as do disorders that produce edema or swelling of the vocal cords. Speech may be halting, slurred, or interrupted in flow in patients with some CNS disorders (e.g., multiple sclerosis, stroke).

Vital Signs The recording of vital signs is a part of every physical examination (Skillen, 2012e). Blood pressure, pulse rate, respiratory rate, and body temperature measurements are obtained and recorded. Acute changes and trends over time are documented and unexpected changes and values that deviate significantly from a patient’s usual values are brought to the attention of the patient’s primary health care professional. The “fifth vital sign,” pain, is also assessed and documented, if indicated. A usual oral temperature for most people is 37°C; however, some variation is expected. Some people’s usual temperatures can be at 36.6° or 37.3°C. There is an expected diurnal variation of a degree or two in body temperature throughout the day; temperature is usually lowest in the morning and increases during the day to between 37.3° and 37.5°C (99° to 99.5°F), and it then decreases during the night (Skillen, 2012e).

Focused Assessment Following the general inspection, a more focused assessment is conducted. Although the sequence of physical examination depends on the circumstances and on the

patient’s reason for seeking health care, the complete examination usually proceeds in a head to toe format as follows (Skillen, 2012e): • • • • • • • • • • • •

Skin, hair, nails Head and neck Eyes, ears, nose, mouth, and throat Spine, thorax, and lungs Cardiovascular system (heart and great vessels) Breasts and axillae Abdomen Musculoskeletal system Neurologic system Arms and legs Rectum Genitalia

In clinical practice, all relevant body systems are tested throughout the physical examination, not necessarily in the sequence described. For example, when the face is examined, it is appropriate to check for facial asymmetry and, thus, for the integrity of the fifth and seventh cranial nerves; the examiner does not need to repeat this as part of a neurologic examination. When systems are combined in this manner the patient does not need to change positions repeatedly, which can be exhausting and time consuming. The traditional sequence in the focused portion of the examination is inspection, palpation, percussion, and then auscultation, except in the case of an abdominal examination.

Inspection The first fundamental technique is inspection or observation of each relevant body system in more detail as indicated from the health history or the general inspection. Characteristics such as skin colour, presence and size of lesions, edema, erythema, symmetry, and pulsations are noted. Specific body movements that are noted on inspection include spasticity, muscle spasms, and an abnormal gait (Pleuss, Matfin, & Moisey, 2010).

Palpation Palpation is a vital part of the physical examination. Many structures of the body, although not visible, may be assessed through the techniques of light and deep palpation (Fig. 5-3). Examples include the superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen and pelvis, and rectum. When the abdomen is examined, auscultation is performed before palpation and percussion to avoid altering bowel sounds (Roach, 2012). Sounds generated within the body, if within specified frequency ranges, also may be detected through touch. For example, certain murmurs generated in the heart or within blood vessels (thrills) may be detected. Thrills cause a sensation to the hand much like the purring of a cat. Voice sounds are transmitted along the bronchi to the periphery of the lung. These may be perceived by touch and may be altered by disorders affecting the lungs. The phenomenon is called tactile fremitus and is useful in assessing diseases of the chest. The significance of these findings is discussed in Chapters 22 and 27.



Adult Health and Nutritional Assessment


with a firm object. The sound produced reflects the density of the underlying structure. Certain densities produce sounds as percussion notes. These sounds, listed in a sequence that proceeds from the least to the most dense, are tympany, hyperresonance, resonance, dullness, and flatness. Tympany is the drumlike sound produced by percussing the air-filled stomach. Hyperresonance is audible when one percusses over inflated lung tissue in a person with emphysema. Resonance is the sound elicited over airfilled lungs. Percussion of the liver produces a dull sound, whereas percussion of the thigh produces a flat sound. Percussion allows the examiner to assess such usual anatomic details as the borders of the liver and the movement of the diaphragm during inspiration. It is also possible to determine the level of a pleural effusion (fluid in the pleural cavity) and the location of a consolidated area caused by pneumonia or atelectasis (collapse of alveoli). The use of percussion is described further with disorders of the thorax and abdomen (see Chapters 22 and 35).


B FIGURE 5-3. A, Light palpation. B: Deep palpation.

Percussion The technique of percussion translates the application of physical force into sound (Fig. 5-4). It is a skill requiring practice that yields much information about disease processes in the chest and abdomen (Harder, Skillen, & Bickley, 2010; Roach, 2012). The principle is to set the chest wall or abdominal wall into vibration by striking it

Auscultation is the skill of listening with a stethoscope to sounds produced within the body created by the movement of air or fluid. Examples include breath sounds, the spoken voice, bowel sounds, heart sounds, and cardiac murmurs. Physiologic sounds may be expected (e.g., first and second heart sounds) or pathologic (e.g., heart murmurs in diastole, crackles in the lung). Some expected sounds may be distorted by abnormalities of structures through which the sound must travel (e.g., changes in the character of breath sounds as they travel through the consolidated lung of a patient with lobar pneumonia). Sound produced within the body, if of sufficient amplitude, may be detected with the stethoscope, which functions as an extension of the human ear and channels sound. The nurse avoids touching the tubing or rubbing other surfaces (hair, clothing) during auscultation to minimize extraneous noises. Sound produced by the body, like any other sound, is characterized by intensity, frequency, and quality. The intensity, or loudness, associated with physiologic sound is low; therefore, the use of the stethoscope is needed. The frequency, or pitch, of physiologic sound is in reality “noise,” in that most sounds consist of a frequency spectrum, as opposed to the single-frequency sounds that we associate with music or a tuning fork. The frequency spectrum may be quite low, yielding a rumbling noise, or comparatively high, producing a harsh or blowing sound. Quality of sound relates to overtones that allow one to distinguish among various sounds. Sound quality enables the examiner to distinguish between the musical quality of high-pitched wheezing and the low-pitched rumbling of a diastolic murmur (Skillen, 2012d).

NUTRITIONAL ASSESSMENT FIGURE 5-4. Percussion technique. The middle finger of one hand

strikes the terminal phalanx of the middle finger of the other hand, which is placed firmly against the body. If the action is performed sharply, a brief, resonant tone will be produced. The clarity of the tone depends on the brevity of the action. The intensity of the tone varies with the force used.

Nutrition is important to maintain health and to prevent disease and death. When illness or injury occurs, optimal nutrition is essential for healing and resisting infection and other complications. An in-depth nutritional assessment is often integrated into the health history and



Basic Concepts in Nursing

physical examination. Assessment of nutritional status provides information about obesity, weight loss, undernutrition, malnutrition, deficiencies in specific nutrients, metabolic abnormalities, the effects of medications on nutrition, and special issues affecting patients both in hospitals and in the home and other community settings (Day, 2012). Disorders caused by nutritional deficiency, overeating, or eating unhealthy meals are among the leading causes of illness and death in Canada today. The three leading causes of death—heart disease, cancer, and stroke—are related, in part, to consequences of unhealthy nutrition (Day, 2012). Other examples of health issues associated with poor nutrition include obesity, osteoporosis, cirrhosis, diverticulitis, and eating disorders. Certain signs and symptoms that suggest possible nutritional deficiency, such as muscle wasting, poor skin integrity, loss of subcutaneous tissue, and obesity, are easy to note because they are specific; these are pursued further. Other physical signs may be subtle and need to be carefully assessed. For example, certain signs that appear to indicate nutritional deficiency may actually reflect other systemic conditions (e.g., endocrine disorders, infectious disease). Others may result from impaired digestion, absorption, excretion, or storage of nutrients in the body (Pleuss, Matfin, & Moisey, 2010).

Lifespan Considerations Adolescence is a time of critical growth and acquisition of lifelong eating habits, and therefore nutritional assessment, analysis, and intervention are critical (Day, 2012). In the past two decades rates of obesity in adolescents have increased at an alarming rate. Adolescent girls are at particular nutritional risk, because iron, folate, and calcium intakes are below recommended levels and they are a less physically active group compared to adolescent males. Adolescents with other nutritional disorders, such as anorexia and bulimia, have a better chance of recovery if these disorders are identified and treated in the adolescent years rather than in adulthood. Older adults are also at risk for altered nutrition. Special considerations for nutritional assessment in the older adult are presented in Chart 5-7.

Components of Nutritional Assessment The sequence of assessment of parameters may vary, but evaluation of nutritional status includes one or more of the following methods: measurement of body mass index and waist circumference, biochemical measurements, clinical examination findings, and dietary data.

Body Mass Index Body mass index (BMI) is a ratio based on body weight and height. The obtained value is compared to the established standards; however, trends or changes in val-


Nutritional Assessment in the Older Adult Nutritional screening in older adults is a first step in maintaining adequate nutrition and replacing nutrient losses to maintain the individual’s health and well-being. Aging is associated with increases in the incidence of weight loss, being underweight, and having protein–energy malnutrition (Soriano et al., 2007). Older people who are malnourished tend to have longer and more expensive hospital stays than those who are adequately nourished; the risk of costly complications is also increased in malnourished patients (Dudek, 2013). Inadequate dietary intake in older adults may result from physiologic changes in the gastrointestinal tract, social and economic factors, drug interactions, disease, excessive use of alcohol, and poor dentition or missing teeth. Malnutrition is a common consequence of these factors and in turn leads to illness and frailty of older adults. Important aspects of care of older adults in the hospital, home, outpatient setting, or extended care facility include recognizing risk factors and identifying those who are at risk for inadequate nutrition (Soriano et al., 2007). Many older adults take excessive and inappropriate medications; this is referred to as polypharmacy. The number of adverse reactions increases proportionately with the number of prescribed and over-the-counter medications taken. Agerelated physiologic and pathophysiologic changes may alter the metabolism and elimination of many medications. Medications can influence food intake by producing side effects such as nausea, vomiting, decreased appetite, and changes in sensorium. They may also interfere with the distribution, utilization, and storage of nutrients. Disorders affecting any part of the gastrointestinal tract can alter nutritional requirements and health status in people of any age; however, they are likely to occur more quickly and more frequently in older adults. Nutritional problems in older adults often occur or are precipitated by such illnesses as pneumonia and urinary tract infections. Acute and chronic diseases may affect the metabolism and utilization of nutrients, which already are altered by the aging process. Up-to-date immunizations, prompt treatment of bacterial infections, and social programs such as Meals on Wheels may reduce the risk of illness-associated malnutrition. Alcohol and substance abuse are potential factors in the older adult population that should not be overlooked (OASAS, 2007). Even the well older adults may be nutritionally at risk because of decreased odour perception, poor dental health, limited ability to shop and cook, financial hardship, and the fact that they often eat alone. Also, reduction in exercise with age without concomitant changes in carbohydrate intake places older adults at risk for obesity.

ues over time are considered more useful than isolated or one-time measurements. BMI (Fig. 5-5) is highly correlated with body fat, but increased lean body mass, large muscles, edema, or a large body frame can also increase the BMI. People who have a BMI lower than 24 (or who are 80% or less of their desirable body weight for height) are at increased risk for health issues associated with poor nutritional status. In addition, a low BMI is associated with a higher mortality rate among hospitalized patients



Adult Health and Nutritional Assessment

Body Mass Index The body mass index (BMI) is used to determine who is overweight.


703 " weight in pounds

weight in kilograms



(height in inches)


(height in metres)

BMI score is at the intersection of height and weight. A body mass index score of 25 or more is considered overweight and 30 or more is considered obese. Overweight

25 Overweight Limit

Weight 100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175 180 185 190 195 200 Height


5!0" 5!1" 5!2" 5!3" 5!4" 5!5" 5!6" 5!7" 5!8" 5!9" 5!10" 5!11" 6!0" 6!1" 6!2" 6!3" 6!4"

40 39 37 36 35 34 33 32 31 30 29 29 28 27 26 26 25

20 19 18 18 17 17 16 16 15 15 14 14 14 13 13 12 12

21 20 19 19 18 17 17 16 16 16 15 15 14 14 13 13 13

21 21 20 19 19 18 18 17 17 16 16 15 15 15 14 14 13

22 22 21 20 20 19 19 18 17 17 17 16 16 15 15 14 14

23 23 22 21 21 20 19 19 18 18 17 17 16 16 15 15 15

24 24 23 22 21 21 20 20 19 18 18 17 17 16 16 16 15

25 25 24 23 22 22 21 20 20 19 19 18 18 17 17 16 16

26 26 25 24 23 22 22 21 21 20 19 19 18 18 17 17 16

27 26 26 25 24 23 23 22 21 21 20 20 19 18 18 17 17

28 27 27 26 25 24 23 23 22 21 21 20 20 19 19 18 18

29 28 27 27 26 25 24 23 23 22 22 21 20 20 19 19 18

30 29 28 27 27 26 25 24 24 23 22 22 21 20 20 19 19

31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20 19

32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21 20

33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21 21

34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22 21

35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 22 22

36 35 34 33 32 31 30 29 28 27 27 26 25 24 24 23 23

37 36 35 34 33 32 31 30 29 28 27 26 26 25 24 24 23

38 37 36 35 33 32 31 31 30 29 28 27 26 26 25 24 24

39 38 37 35 34 33 32 31 30 30 29 28 27 26 26 25 24

Source: Shape Up America. National Institutes of Health. FIGURE 5-5. Body mass index.

and community-dwelling older adults. Those who have a BMI of 25 to 29 are considered overweight; those with a BMI of 30 to 39, obese; and those with a BMI greater than 40, extremely obese (Dudek, 2013). In analyzing BMI, the nurse is aware that cutoff scores for “normal,” “overweight,” and “obese” may differ for different ethnic groups. For example, in an Asian population, a BMI of 23 is considered overweight, while a BMI of 27 would be classified as obese (World Health Organization Expert Consultation, 2004). These scores may also differ by age. For adults 65 years and older, a BMI of 18.5 to 20 increases the risk of morbidity (Day, 2012; Brunet, Day, & Mager, 2010). It is important to assess for usual body weight and height and to compare these values with ideal weight. Current weight does not provide information about recent changes in weight; therefore, patients are asked about their usual body weight. Loss of height may be due to osteoporosis, an important problem related to nutrition, especially in postmenopausal women. A loss of 2 or 3 inches of height may indicate osteoporosis (Day, 2012; Brunet, Day, & Mager, 2010). In addition to the calculation of BMI, waist circumference measurement is particularly useful for adult patients who are categorized as being of normal weight or overweight (Dudek, 2013). To measure waist circumference, have patient stand with feet 25 to 30 cm apart, a tape measure is placed in a horizontal plane around the abdomen half way between the costal margin and the iliac crest (Fig. 5-6). The measurement is taken after the patient

exhales. A waist circumference greater than 102 cm for men or 88 cm for women indicates excess abdominal fat. Those with a high waist circumference are at increased risk for diabetes, dyslipidemias, hypertension, cardiovascular disease, and atrial fibrillation (Canadian Medical Association, 2005).

Biochemical Assessment Biochemical assessment reflects both the tissue level of a given nutrient and any abnormality of metabolism in the utilization of nutrients. These determinations are made

FIGURE 5-6. Measuring waist circumference.



Basic Concepts in Nursing

from studies of serum (albumin, transferrin, retinol-binding protein, electrolytes, hemoglobin, vitamin A, carotene, vitamin C, and total lymphocyte count) and studies of urine (creatinine, thiamine, riboflavin, niacin, and iodine). See Appendix A for expected serum and urine biochemical values. Some of these tests, while reflecting recent intake of the elements detected, can also identify below-normal levels when there are no clinical symptoms of deficiency. Low serum albumin and prealbumin levels are most often used as measures of protein deficit in adults. Albumin synthesis depends on normal liver function and an adequate supply of amino acids. Because the body stores a large amount of albumin, the serum albumin level may not decrease until malnutrition is severe; therefore, its usefulness in detecting recent protein depletion is limited. Decreased albumin levels may be caused by overhydration, liver or renal disease, or excessive protein loss due to burns, major surgery, infection, or cancer. Serial measurements of prealbumin levels are also used to assess the results of nutritional therapy. Prealbumin, also called thyroxin-binding protein, is a more sensitive indicator of protein status than albumin, but the test is more expensive and therefore less frequently ordered (Dudek, 2013). Additional laboratory data, such as levels of transferrin and retinol-binding protein, anergy panels, and lymphocyte and electrolyte counts, are used in many institutions. Transferrin is a protein that binds and carries iron from the intestine through the serum. Because of its short half-life, transferrin levels decrease more quickly than albumin levels in response to protein depletion. Although measurement of retinol-binding protein is not available from many laboratories, it may be a useful means of monitoring acute,

TABLE 5-1 Indicator

short-term changes in protein status. The total lymphocyte count may be reduced in people who are acutely malnourished as a result of stress and low-calorie feeding and in those with impaired cellular immunity. Anergy, the absence of an immune response to injection of small concentrations of recall antigen under the skin, may also indicate malnutrition because of delayed antibody synthesis and response. Serum electrolyte levels provide information about fluid and electrolyte balance and kidney function. The creatinine/height index calculated over a 24-hour period assesses the metabolically active tissue and indicates the degree of protein depletion, comparing expected body mass for height with actual body cell mass. A 24-hour urine sample is obtained, and the amount of creatinine is measured and compared to expected ranges based on the patient’s height and gender. Values lower than expected may indicate loss of lean body mass and protein malnutrition.

Clinical Examination The state of nutrition is often reflected in a person’s appearance. Although the most obvious physical sign of good nutrition is an appropriate body weight with respect to height, body frame, and age, other tissues can serve as indicators of general nutritional status and adequate intake of specific nutrients; these include the hair, skin, teeth, gums, mucous membranes, mouth and tongue, skeletal muscles, abdomen, lower extremities, and thyroid gland (Table 5-1). Specific aspects of clinical examination that are useful in identifying nutritional deficits include an examination and assessment of skin for turgor, edema, elasticity, dryness, subcutaneous tone, poorly

Physical Indicators of Nutritional Status Signs of Adequate Nutrition

Signs of Inadequate Nutrition

General appearance

Alert, responsive, energetic

Listless, appears acutely or chronically ill


Shiny, lustrous; minimal loss, healthy scalp

Dull and dry, brittle, depigmented, easily plucked; thin and sparse, flaking scalp


Skin colour uniform; smooth, moist

Skin dark over cheeks and under eyes, skin flaky, face swollen or hollow/sunken cheeks


Bright, clear, moist

Eye membranes pale, dry (xerophthalmia); increased vascularity, cornea soft (keratomalacia)


Pink colour, smooth

Swollen and puffy; angular lesion at corners of mouth (cheilosis)


Deep red in appearance; surface papillae present

Smooth appearance, swollen, beefy-red, sores, atrophic papillae


Straight, no crowding, no dental caries, uniform bright colour

Dental caries, missing teeth, mottled appearance (fluorosis), malpositioned, dentures no longer fit


Firm, pink colour, margins tight around teeth

Spongy, bleed easily, marginal redness, recession


No enlargement of the thyroid

Thyroid enlargement (simple goitre)


Smooth, uniform colour, moist, warm

Rough, dry, flaky, swollen, pale, pigmented; lack of or excess fat under skin


Firm, pink

Spoon shaped, ridged, brittle Poor posture, bending of ribs, bowed legs, or knock knees


Erect posture, no malformation


Well developed, firm

Flaccid, poor tone, wasted, underdeveloped


No tenderness or edema

Weak and tender; edematous



Scaphoid (concave or hollow), protruding

Nervous system

Reflexes present

Decreased or absent ankle and knee reflexes


Appropriate for height, age, and body build

Overweight or underweight


healing wounds and ulcers, purpura, and bruises (Pleuss, Matfin, & Moisey, 2010). The musculoskeletal examination also provides information about muscle wasting and weakness.

Dietary Data Commonly used methods of determining individual eating patterns include the food record, the 24-hour food recall, and a dietary interview. Each of these methods helps estimate whether food intake is adequate and appropriate. If these methods are used to obtain the dietary history, instructions should be given to the patient about measuring and recording food intake.

Methods of Collecting Data FOOD RECORD. The food record is used most often in nutritional status studies. A person is instructed to keep a record of food actually consumed over a period of time, varying from 3 to 7 days, and to accurately estimate and describe the specific foods consumed. Food records are fairly accurate if the person is willing to provide factual information and is able to estimate food quantities. Another option is to photograph all foods consumed. 24-HOUR RECALL. As the name implies, the 24-hour recall method is a recall of food intake over a 24-hour period. A person is asked to recall all foods eaten during the previous day and to estimate the quantities of each food consumed. Because information does not always represent usual intake, at the end of the interview the patient is asked whether the previous day’s food intake was typical. To obtain supplementary information about the typical diet, it is also necessary to ask how frequently the person eats foods from the major food groups. DIETARY INTERVIEW. The success of the interviewer in obtaining information for dietary assessment depends on effective communication, which requires that good rapport be established to promote respect and trust. The interviewer explains the purpose of the interview. The interview is conducted in a nondirective and exploratory way, allowing the respondent to express feelings and thoughts while encouraging him or her to answer specific questions. The manner in which questions are asked influences the respondent’s cooperation. The interviewer must be nonjudgmental and avoid expressing disapproval, either by verbal comments or by facial expression.

Character of General Intake. Several questions may be necessary to elicit the information needed. Assumptions are not made about the size of servings; instead, questions are phrased so that quantities are more clearly determined. For example, to help determine the size of one hamburger, the patient may be asked, “How many servings were prepared with the kilogram of meat you bought?” Another approach to determining quantities is to use food models of known sizes in estimating portions of meat, cake, or pie, or to record quantities in common measurements, such as cups or spoonfuls (or the size of containers, when discussing intake of bottled beverages). In recording a particular combination dish, such as a casserole, it is useful to ask about the ingredients, recording the largest quantities first. When recording quantities of ingredients, the interviewer notes whether the food item

Adult Health and Nutritional Assessment


was raw or cooked and the number of servings provided by the recipe. When a patient lists the foods for the recall questionnaire, it may help to read back the list of foods and ask whether anything was forgotten, such as fruit, cake, candy, between-meal snacks, or alcoholic beverages. Additional information obtained during the interview includes methods of preparing food, sources available for food (including donated foods and food bank use), foodbuying practices, use of vitamin and mineral supplements, and amount of income available for food purchases. Cultural and Religious Considerations. An individual’s culture determines to a large extent which foods are eaten and how they are prepared and served. Culture and religious practices together often determine whether certain foods are prohibited and whether certain foods and spices are eaten on certain holidays or at specific family gatherings. Because of the importance of culture and religious beliefs to many individuals, it is important to be sensitive to these factors when obtaining a dietary history. It is, however, equally important not to stereotype individuals and assume that because they are from a certain culture or religious group, they adhere to specific dietary customs. One particular area of consideration is the presence of fish and shellfish in the diet, where they come from (farmed vs. wild), and the method of preparation. These methods may put certain populations at risk for toxicity due to contaminants. Culturally sensitive versions of Canada’s Food Guide are available in a variety of languages and for First Nations, Inuit, and Metis (Health Canada, 2007a,b).

Evaluating Dietary Information After obtaining basic dietary information, the nurse evaluates the patient’s dietary intake and communicates the information to the dietitian and the rest of the health care team for more detailed assessment and for clinical nutrition intervention. If the goal is to determine whether the patient generally eats a healthful diet, his or her food intake may be compared with the dietary guidelines outlined in “Eating well with Canada’s Food Guide” (Fig. 5-7). The Food Guide divides foods into five major groups (grains, vegetables, fruits, milk products, and meat and beans), plus fats and oils. Recommendations are provided for variety in the diet, proportion of food from each food group, and moderation in eating fats, oils, and sweets. A person’s food intake is compared with recommendations based on various food groups for different age groups and activity levels (Health Canada, 2007a,b). If nurses or dietitians are interested in knowing about the intake of specific nutrients, such as vitamin A, iron, or calcium, the patient’s food intake is analyzed by consulting a list of foods and their composition and nutrient content. The diet is analyzed in terms of grams and milligrams of specific nutrients. The total nutritive value is then compared with the recommended dietary allowances specific for the patient’s age category, gender, and special circumstances such as pregnancy or lactation. Fat intake and cholesterol levels are additional aspects of the nutritional assessment. Trans fats are produced when hydrogen atoms are added to monounsaturated or polyunsaturated fats to produce a semisolid product, such as margarine. Trans fats, which are contained in many



Basic Concepts in Nursing

Recommended Number of Food Guide Servings per Day Children Age in Years




Teens 9–13

Girls and Boys


14–18 Females








Vegetables and Fruit





8 7–8 8–10 7


Grain Products





7 6–7 8



Milk and Alternatives


2 3–4 3–4 3–4 2




Meat and Alternatives


1 1–2







The chart above shows how many Food Guide Servings you need from each of the four food groups every day. Having the amount and type of food recommended and following the tips in Canada’s Food Guide will help: • Meet your needs for vitamins, minerals, and other nutrients. • Reduce your risk of obesity, type 2 diabetes, heart disease, certain types of cancer, and osteoporosis. • Contribute to your overall health and vitality.

FIGURE 5-7. Eating well with Canada’s Food Guide. (From Health Canada. (2007c). Eating well with Canada’s Food Guide. Ottawa, ON: Minister of Health Canada. Retrieved from print_eatwell_bienmang-eng.pdf.)



Adult Health and Nutritional Assessment

What is One Food Guide Serving? Look at the examples below.

Fresh, frozen, or canned vegetables 125 mL (1⁄ 2 cup)

Bread 1 slice (35g)

Bagel ⁄ 2 bagel (45 g)


Fresh, frozen, or canned fruits 1 fruit or 125 mL (1⁄ 2 cup)

Leafy vegetables Cooked: 125 mL (1⁄ 2 cup) Raw: 250 mL (1 cup)

Cooked rice, Flat breads 1 ⁄ 2 pita or 1⁄ 2 tortilla (35 g) bulgur, or quinoa 125 mL (1⁄ 2 cup)

Milk or powdered milk (reconstituted) 250 mL (1 cup)

Canned milk (evaporated) 125 mL (1⁄ 2 cup)

Cooked fish, shellfish, poultry, lean meat 75 g (2 1⁄ 2 oz.)/125 mL (1⁄ 2 cup)

Cooked legumes 175 mL (3⁄ 4 cup)

Fortified soy beverage 250 mL (1 cup)

Cereal Cold: 30 g Hot: 175 mL (3⁄ 4 cup)

Yogurt 175 g (3⁄ 4 cup)

Tofu 150 g or 175 mL (3⁄ 4 cup)

Eggs 2 eggs

100% Juice 125 mL (1⁄ 2 cup)

Kefir 175 g (3⁄ 4 cup)

Peanut or nut butters 30 mL (2 tbsp)

Cooked pasta or couscous 125 mL (1⁄ 2 cup)

Cheese 50 g (1 1⁄ 2 oz.)

Shelled nuts and seeds 60 mL (1⁄ 4 cup)

Oils and Fats

• Include a small amount – 30 to 45 mL (2 to 3 tbsp) – of unsaturated fat each day. This includes oil used for cooking, salad dressings, margarine and mayonnaise. • Use vegetable oils such as canola, olive, and soybean. • Choose soft margarines that are low in saturated and trans fats. • Limit butter, hard margarine, lard, and shortening.

FIGURE 5-7. Continued.

baked goods and restaurant foods, are a concern, because increased amounts of trans fats have been associated with increased risk for heart disease and stroke. Canada was the first country to require the inclusion of trans fats information on food labels.

Factors Influencing Nutritional Status in Various Situations One sensitive indicator of the body’s gain or loss of protein is its nitrogen balance. An adult is said to be in nitrogen equilibrium when the nitrogen intake (from food) equals the nitrogen output (in urine, feces, and perspiration); it is a sign of health. A positive nitrogen balance exists when nitrogen intake exceeds nitrogen output and indicates tis-

sue growth, such as occurs during pregnancy, childhood, recovery from surgery, and rebuilding of wasted tissue. A negative nitrogen balance indicates that tissue is breaking down faster than it is being replaced. In the absence of an adequate intake of protein, the body converts protein to glucose for energy. This can occur with fever, starvation, surgery, burns, and debilitating diseases. Each gram of nitrogen loss in excess of intake represents the depletion of 6.25 g of protein or 25 g of muscle tissue. Therefore, a negative nitrogen balance of 10 g/day for 10 days could mean the wasting of 2.5 kg (5.5 pounds) of muscle tissue as it is converted to glucose for energy. When conditions that result in negative nitrogen balance are combined with anorexia (loss of appetite), they can lead to malnutrition. Malnutrition interferes with wound healing, increases susceptibility to infection, and contributes to an increased incidence of complications,



Basic Concepts in Nursing

!Eat at least one dark green and one orange vegetable each day. • Go for dark green vegetables such as broccoli, romaine lettuce ,and spinach. • Go for orange vegetables such as carrots, sweet potatoes, and winter squash.

!Choose vegetables and fruit prepared with little or no added fat, sugar, or salt. • Enjoy vegetables steamed, baked, or stir-fried instead of deep-fried.

!Have vegetables and fruit more often than juice. !Make at least half of your grain products whole grain each day. • Eat a variety of whole grains such as barley, brown rice, oats, quinoa, and wild rice. • Enjoy whole grain breads, oatmeal, or whole wheat pasta.

!Choose grain products that are lower in fat, sugar, or salt. • Compare the Nutrition Facts table on labels to make wise choices. • Enjoy the true taste of grain products. When adding sauces or spreads, use small amounts.

!Drink skim, 1%, or 2% milk each day. • Have 500 mL (2 cups) of milk every day for adequate vitamin D. • Drink fortified soy beverages if you do not drink milk.

!Select lower fat milk alternatives. • Compare the Nutrition Facts table on yogurts or cheeses to make wise choices.

!Have meat alternatives such as beans, lentils and tofu often. !Eat at least two Food Guide Servings of fish each week.* • Choose fish such as char, herring, mackerel, salmon, sardines, and trout.

!Select lean meat and alternatives prepared with little or no added fat or salt. • Trim the visible fat from meats. Remove the skin on poultry. • Use cooking methods such as roasting, baking, or poaching that require little or no added fat. • If you eat luncheon meats, sausages, or prepackaged meats, choose those lower in salt (sodium) and fat.

Enjoy a variety of foods from the four food groups.

Satisfy your thirst with water! Drink water regularly. It’s a calorie-free way to quench your thirst. Drink more water in hot weather or when you are very active.

* Health Canada provides advice for limiting exposure to mercury from certain types of fish. Refer to fo r the latest information.

FIGURE 5-7. Continued.



Adult Health and Nutritional Assessment


Factors Associated with Potential Nutritional Deficits


Possible Consequences

Dental and oral issues (missing teeth, ill-fitting dentures, impaired chewing, or swallowing)

Inadequate intake of high-fibre foods

NPO for diagnostic testing

Inadequate caloric and protein intake; dehydration

Prolonged use of glucose and saline IV fluids

Inadequate caloric and protein intake

Nausea and vomiting

Inadequate caloric and protein intake; loss of fluid, electrolytes, and minerals

Stress of illness, surgery, and/or hospitalization

Increased protein and caloric requirement; increased catabolism

Wound drainage

Loss of protein, fluid, electrolytes, and minerals


Loss of appetite; inability to shop, cook, eat


Increased caloric and fluid requirement; increased catabolism

Gastrointestinal intubation

Loss of protein, fluid, and minerals

Tube feedings

Inadequate amounts; various nutrients in each formula

Gastrointestinal disease

Inadequate intake and malabsorption of nutrients


Inadequate intake of nutrients; increased consumption of calories without other nutrients; vitamin deficiencies


Loss of appetite; inability to shop, cook, eat

Eating disorders (anorexia, bulimia)

Inadequate caloric and protein intake; loss of fluid, electrolytes, and minerals


Inadequate intake due to medication side effects, such as dry mouth, loss of appetite, decreased taste perception, difficulty swallowing, nausea and vomiting, physical problems that limit shopping, cooking, eating; malabsorption of nutrients

Restricted ambulation or disability

Inability to help self to food, liquids, other nutrients

longer hospital stays, and prolonged confinement of patients to bed (Pleuss, Matfin, & Moisey, 2010). Patients who are hospitalized may have an inadequate dietary intake because of the illness or disorder that necessitated the hospital stay or because the hospital’s food is unfamiliar or unappealing. Patients who are cared for at home may feel too sick or fatigued to shop and prepare food, or they may be unable to eat because of other physical problems or limitations. Limited or fixed incomes or the high costs of medications may result in insufficient money to buy nutritious foods. Patients with inadequate housing or inadequate cooking facilities are unlikely to have an adequate nutritional intake (Day, 2012). Because complex treatments (e.g., mechanical ventilation, intravenous infusions, chemotherapy), once used only in the hospital setting, are now being provided in the home and outpatient settings, nutritional assessment of patients in these settings is an important aspect of home and community-based care. Many medications influence nutritional status by suppressing the appetite, irritating the oral or gastric mucosa, or causing nausea and vomiting. Others may influence bacterial flora in the intestine or directly affect nutrient absorption so that secondary malnutrition results. People who must take many medications in a single day often report feeling too full to eat. A patient’s use of prescription and OTC medications and their effects on appetite and dietary intake are assessed. Many of the factors that contribute to poor nutritional status are identified in Table 5-2.

Analysis of Nutritional Status Physical measurements (BMI, waist circumference) and biochemical, clinical, and dietary data are used in com-

bination to determine a patient’s nutritional status. Often, these data provide more information about the patient’s nutritional status than the clinical examination, which may not detect subclinical deficiencies unless they become so advanced that overt signs develop. A low intake of nutrients over a long period may lead to low biochemical levels and, without nutritional intervention, may result in characteristic and observable signs and symptoms (see Table 5-2). A plan of action for nutritional intervention is based on the results of the dietary assessment and the patient’s clinical profile. To be effective, the plan must meet the patient’s need for a healthy diet, maintain (or control) weight, and compensate for increased nutritional needs.

ASSESSMENT IN THE HOME AND COMMUNITY Assessment of people in community settings, including the home, consists of collecting information specific to existing health conditions, including data on the patient’s physiologic and emotional status, the community and home environment, the adequacy of support systems or care given by family and other care providers, and the availability of needed resources. In addition, it is important to evaluate the ability of the individual and family to cope with and address their respective needs. The physical assessment in the community and home consists of the same techniques used in the hospital, outpatient clinic, or office setting. Privacy is provided, and the person is made as comfortable as possible. See Chapter 2. Before the first home visit, the nurse calls the patient’s home to determine a convenient time to expect the home care nurse; this also gives the patient’s primary caregiver



Basic Concepts in Nursing


Assessing the Home Environment Physical Facilities (check all that apply) EXTERIOR ❑ steps ❑ unsafe steps ❑ porch ❑ litter ❑ noise ❑ inadequate lighting ❑ other INTERIOR ❑ accessible bathroom ❑ level, safe floor surface ❑ number of rooms ❑ privacy ❑ sleeping arrangements ❑ refrigeration ❑ garbage management ❑ animals ❑ adequate lighting ❑ steps/stairs ❑ other

❑ inadequate lighting ❑ unsafe gas/electric appliances ❑ inadequate heating ❑ inadequate cooling ❑ lack of fire safety devices ❑ unsafe floor coverings ❑ inadequate stair rails ❑ lead-based paint ❑ improperly stored hazardous material ❑ improper wiring/electrical cords ❑ other

Safety Factors (check all that apply) ❑ fire/smoke detectors ❑ fire extinguisher ❑ carbon monoxide detector ❑ telephone ❑ placement of electrical cords ❑ emergency plan ❑ emergency phone numbers displayed ❑ safe portable heaters ❑ obstacle-free paths ❑ other

Safety Hazards found in the patient’s current residence (check all that apply) ❑ none ❑ inadequate floor, roof, or windows

the opportunity to be available. During the home visit, assessment is not limited to physical assessment of the patient. Other aspects of assessment are related to the home environment and support systems (Chart 5-8). The patient may not have family members available to assist him or her and may live alone in substandard housing or in a shelter for the homeless. Therefore, the nurse needs to be aware of resources available in the community and methods of obtaining those resources for the patient.

Critical Thinking Exercises 1 Your health history and physical examination of a young adult male patient alerts you to the possibility of substance abuse. Explain how you would pursue this. What is the evidence base for available assessments to assist in a more comprehensive evaluation? Identify the criteria used to evaluate the strength of the evidence for this practice. 2

Your health assessment of a female college freshman reveals that she has a high fat intake, has a minimal calcium intake, and gets little exercise. What recommendations would you make for this patient? If the patient is a vegetarian, what dietary instructions would

you develop for her? What is the evidence base for the type of instructional method to use with a college student? Identify the criteria used to evaluate the strength of the evidence for this practice. 3 How would you modify your health history and physical assessment technique if your patient has the following disabilities: (1) impaired communication due to aphasia secondary to stroke, (2) impaired mobility due to spinal cord injury, or (3) cognitive impairment?

REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles. **Double asterisks indicate classic reference.

BOOKS Anderson, M. C., Hunter, K., & Bickley, L. S. (2010). The older adult. In T.C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Bates’ guide to health assessment for nurses (1st ed., pp. 887–932). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Brunet, K., Day, R. A., & Mager, D. (2010). Nutritional assessment. In T.C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Bates’ guide to health assessment for nurses (1st ed., pp. 167–201). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Crowe, C. (2007). Dying for a home: Homeless activists speak out. Toronto, ON: Between the Lines.

CHAPTER 5 Day, R. A. (2012). Nutrition assessment. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Jensen’s ursing health assessment: A best practice approach (1st ed., pp. 152–184). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Dudek, S. G. (2013). Nutrition essentials for nursing practice (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Harder, N., Skillen, D. L., & Bickley, L. S. (2010). The Abdomen. In Canadian Bates’ guide to health assessment for nurses (1st ed., pp. 509– 561). Philadelphia, PA: Wolters Klluwer Health/Lippincott Williams & Wilkins. Herdman, T. H. (2012). NANDA International nursing diagnoses: Definitions and classification, 2012–2014 (9th ed.). Oxford, UK: Wiley-Blackwell. Karch, A. M. (2012). Lippincott’s Nursing Drug Guide. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Pleuss, J. Matfin, G., & Moisey, L. L. (2010). Alterations in nutritional status. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds.), Alterations in nutritional status (pp. 943–966). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Roach, S. (2012). Abdominal assessment. In T.C. Stephen, D.L. Skillen, & R.A. Day, et al. (eds.), Canadian Jensen’s nursing health assessment: A best practice approach (1st ed., pp. 602–644). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Skillen, D. L. (2012a). Older adults. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach (1st ed., pp. 925–956). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Skillen, D. L. (2012b). Assessment of social, cultural, and spiritual health. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Jensen’s health assessment for nurses: A best practice approach (1st ed., pp. 231–247. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Skillen, D. L. (2012c). Techniques of physical examination and equipment. In T. C. Stephen, D. L. Skillen, R. A.Day, et al. (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach (1st. ed., pp. 231–247). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Skillen, D. L. (2012d). General survey and vital signs assessment. In T. C Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach (1st ed., pp. 91–124). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C. (2012a). The interview and therapeutic dialogue. In T. C. Stephen, D. L. Skillen, R .A. Day, et al. (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach (1st ed., pp. 20–36). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C. (2012b). The health history. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach (pp. 37--51). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C. (2012c). Documentation and interprofessional communication. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach (1st ed, pp. 69–88). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C. (2012d). Assessment of human violence. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Canadian Jensen’s nursing health assessment: A best practice approach (1st ed., pp. 248–264). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

JOURNALS AND ELECTRONIC DOCUMENTS General Assessment Aboriginal Nurses Association of Canada, Canadian Association of Schools of Nursing, & Canadian Nurses Association. (2009). Cultural Competence

Adult Health and Nutritional Assessment


and Cultural Safety in Nursing Education. Ottawa, ON: Aboriginal Nurses Association of Canada. Retrieved from **Chan, A. W. K., Pristach, E. A., Welte, J. W., et al. (1993). Use of the TWEAK test in screening for alcoholism/heavy drinking in three populations. Alcoholism: Clinical and Experimental Research, 17 (6), 1188–1192. *Chen, C. C.-H., Chyun, D. A., Li, C. Y., et al. (2007). A single-item approach to screening elders for oral health assessment. Nursing Research, 56 (5), 332–338. **Ewing, J. A. (1984). Detecting alcoholism: The CAGE questionnaire. Journal of the American Medical Association, 252(14), 1906. Institute for Safe Medication Practices Canada. (2012). Safer medication use in older persons. Retrieved from *Irving, K., Treacy, M., Scott, A., et al. (2006). Discursive practices in the documentation of patient assessments. Journal of Advanced Nursing, 53(2), 151–159. *Markle-Reid, M., Weir, R., Browne, G., et al. (2006). Health promotion for frail older home care clients. Journal of Advanced Nursing, 55(3), 381–395. *Neville, S., & Henrickson, M. (2006). Perceptions of lesbian, gay and bisexual people of primary healthcare services. Journal of Advanced Nursing, 55(4), 407–415. The New York State Office of Alcoholism and Substance Abuse Services (OASAS). (2007). Elderly alcohol and substance abuse. Available at: PHAC (2008). Complementary and alternative health. Ottawa, ON: Author. Retrieved from PHAC (2012a). Canadian immunization guide: Part 2, Vaccine safety and adverse events following immunization. Retrieved from http:// PHAC (2012b). Canadian immunization guide: Part 4, Active vaccines. Retrieved from *Secrest, J. A., Norwood, B. R., & DuMont, P. D. (2005). Physical assessment skills: A descriptive study of what is taught and what is practiced. Journal of Professional Nursing, 21(2), 114–118. Smeltzer, S. C., Sharts-Hopko, N., Ott, B., et al. (2007). Perspectives of women with disabilities on reaching those who are hard to reach. Journal of Neuroscience Nursing, 39 (3), 163–171. Smeltzer, S. C., Zimmerman, V., & Capriotti, T. (2005). Bone mineral density and osteoporosis risks in women with disabilities. Archives of Physical Medicine and Rehabilitation, 86 (3), 582–586. Nutritional Assessment *Berry, D., Savoye, M., Melkus, G., et al. (2007). An intervention for multiethnic obese parents and overweight children. Applied Nursing Research, 20(2), 63–71.

RESOURCES Alliance of Cannabis Therapeutics: alliance.htm Canadian Cancer Society, Cancer Information Service: Canadian Diabetes Association: Heart and Stroke Foundation of Canada:

GENETICS RESOURCES FOR NURSES AND PATIENTS ON THE WEB Gene Clinics: Genetic Alliance: National Organization of Rare Disorders: OMIM: Online Mendelian Inheritance in Man: Omim/mimstats.html

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6 Obesity Written by Pauline Paul and Rene A. Day

Learning Objectives On completion of this chapter, the learner will be able to: 1. Discuss the prevalence of obesity. 2. Identify and understand determinants of obesity. 3. Identify health issues related to obesity. 4. Discuss the importance of individual intervention, community-based interventions, and policies to deal with obesity.

*Selected chapter content adapted from Hannon, R. A., & Porth, C. M. (2017). Porth pathophysiology: Concepts of altered states (2nd Canadian ed.). Philadelphia, PA: Wolters Kluwer and Grossman, S., & Porth, C. M. (2014). Porth’s pathophysiology: Concepts of altered states (9th ed.). Philadelphia, PA: Wolters Kluwer. 77

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Basic Concepts in Nursing

In this chapter we provide a general overview about the prevalence and determinants of obesity. We present a brief overview of health issues related to obesity, as well as selected considerations relative to the prevention and management of obesity. It is important to begin this chapter on obesity with the need for “people first language” (Wittert, Huang, & Heilbronn, 2015, p. 309). While progress has been made with other medical conditions (e.g., the person with a disability), even journals with a focus on obesity are still putting the disease first. “It is well past time we put people before their medical diagnosis of obesity and make a concerted effort to reduce the stigma that is associated with obesity” (Wittert et al., 2015). Using “people first language” is “more respectful and less stigmatising than labelling people by their disease” (Wittert et al., 2015, p. 309).

DEFINITION Overweight and obesity are defined by the World Health Organization (WHO) as “abnormal or excessive fat accumulation that may impair health” (WHO, 2015, p. 1). The body mass index (BMI) is often used to classify people as being overweight (BMI greater than or equal to 25) or obese (BMI greater than or equal to 30). The BMI is defined as “a person’s weight in kilograms divided by the square of his height in metres (kg/m2)” (WHO, 2015, p. 1). Obesity has become a significant global health problem. In 2008, almost 1.5 billion people were classified as overweight, 500 million of which were obese (WHO, 2014). See Chart 6-1 for facts from WHO about obesity. Clinically, obesity and overweight have been defined in terms of the BMI (Fig. 6-1). Historically, various world

Glossary adiposity: another word for obesity bariatrics: “The branch of medicine that deals with prevention, control, and treatment of obesity” (Taber’s Cyclopedic Medical Dictionary, 2009, p. 244) binge eating: period of uncontrolled or excessive indulgence eating or drinking, occasionally followed by purging body mass index (BMI): a simple index of weight-forheight that is commonly used to classify overweight and obesity in adults. It is defined as a person’s weight in kilograms divided by the square of his/her height in metres (kg/m2). BMI provides the most useful population-level measure of overweight and obesity as it is the same for both sexes and for all ages of adults. However, it should be considered a rough guide because it may not correspond to the same degree of fatness in different individuals depression: obesity increases the risk of being diagnosed with major depression by 37%, whereas obese men have a 37% lower risk of depression than men of normal weight. In men, underweight is associated with significantly higher risks of depression and suicide, although whether the association is causal, or whether depressed men smoke more heavily, for example, is unclear drug therapy: may be a helpful component of the treatment regimen for subjects who are obese; with a BMI greater than 30, or a BMI of 27 to 29.9 if they have comorbid conditions (Padwal, Li, & Lau, 2004). The role of drug therapy has been questioned because of concerns about efficacy, the potential for abuse, and side effects dyslipidemia: progressively develops as BMI increases from 21 with a rise in proatheromatous, dense, smallparticle–sized low-density lipoprotein. This change increases the risk of coronary heart disease by a rise in proatheromatous, dense, small-particle–sized lowdensity lipoprotein concentrations, as well as high concentrations of triglycerides, coronary heart disease risk increases

LWBK1562-C06-P76-89.indd 78

grazing: eating small amounts of food continuously left ventricular hypertrophy: occurs in 70% of women with both obesity and hypertension, and around 14% of cases of heart failure in women (11% in men) are attributable to obesity. The effect of obesity on heart function is probably due to a combination of factors including hypertension, dyslipidemia, diabetes mellitus, increased fat mass and left ventricular mass, endothelial dysfunction, and atherosclerosis night eating syndrome: consumption of at least 25% (and usually more than 50%) of energy between the evening meal and the next morning; a well-known pattern of disturbed eating in people who are obese obesity: “an unhealthy accumulation of body fat” (Taber’s Cyclopedic Medical Dictionary, 2009, p. 1614); a BMI greater than or equal to 30 obesogenic environment: an environment that contributes to weight gain in a population; this environment includes changes in the food environment and in the level of activity of people (Standing Senate Committee on Social Affairs, Science and Technology, 2016) overweight: a BMI greater than or equal to 25 sleep apnea: the mechanical effects of bulky fatty tissue around the neck induce an obstruction to breathing, particularly during sleep, leading to this. A neck circumference of 43 cm or more in men or 40.5 cm or more in women is associated with episodes of disrupted breathing, recurring up to 30 times a night. Observers describe loud snoring, followed by a pause of 10 seconds or longer in breathing, then a loud grunt and resumption of usual respiration surgical treatment: is increasingly used, particularly in the United States, on patients with BMI of more than 40 and those with severe comorbidity at BMI more than 35. Laparoscopic adjustable banding of the stomach along with roux-en-Y and other forms of gastric bypass are now favoured.



LWBK1562-C06-P76-89.indd 79


94 97 100 104 107 110 114 118 121 125 128 132 136 140 144 148 152 156

59 !

60 !

61 !

62 !

63 !

64 !




68 !

69 !

70 !

71 !

72 !

73 !

74 !


76! 164











































































































































Weight, pounds*



















































































FIGURE 6.1 Determining body mass index from weight and height.

The health risk from any level of BMI is increased if the patient has gained more than 5 kg (11 pounds) since age 25, or if the waist circumference is above 100 cm (40 in) due to central fatness. BMI: body mass index. * Divide weight by 2.2 to convert pounds into kilograms; multiply height by 2.54 to convert inches into centimeters.



58 !

Height, inches*

BMI, kg/m2

Good weights












































Basic Concepts in Nursing


Ten Facts About Obesity (WHO, 2014) 1. Overweight and obesity are defined as “abnormal or excessive fat accumulation that may impair health” 2. More than 1.4 billion adults were overweight in 2008, and more than half a billion were obese 3. Globally, 42 million preschool children were overweight in 2013 4. Overweight and obesity are linked to more deaths worldwide than underweight 5. For an individual, obesity is usually the result of an imbalance between calories consumed and calories expended 6. Supportive environments and communities are fundamental in shaping people’s choices and preventing obesity 7. Children’s choices, diet, and physical activity habits are influenced by their surrounding environment 8. Eating a healthy diet can help prevent obesity 9. Regular physical activity helps maintain a healthy body 10. Curbing the global obesity epidemic requires a population-based multisectoral, multidisciplinary, and culturally relevant approach

bodies have used different BMI cutoff points to define obesity. In 1997, WHO defined the various classifications of overweight (BMI ≥25) and obesity (BMI ≥30); this classification system is also employed by Health Canada (Health Canada, 2003; Health Statistics Division, 2012). In Canada, data from the Canadian Health Measures Survey (CHMS) (2009–2011) showed that almost two of three adults are overweight or obese, with approximately 40% of adults classified as overweight and a further 27% classified as obese (Health Statistics Division, 2012). In the Aboriginal population, the prevalence of obesity is 38%, significantly higher than in the rest of the population (Katzmarzyk, 2008; Public Health Agency of Canada, Canadian Institute for Health Information [PHAC/CIHI], 2011). The prevalence of overweight and obesity is alarming not only because of the number of people affected but because the prevalence continues to increase from previous surveys. In comparing data from the 1978/1979 to the 2009/2011 Canadian Community Health Surveys, the prevalence of obesity has increased from 13.8% of the population to 27% (Health Statistics Division, 2012; Tjepkema, 2005). Perhaps of greater concern is that 32% of Canadian children (5 to 17 years of age) are overweight or obese (Statistics Canada, 2012).

TYPES OF OBESITY Two types of obesity based on distribution of fat have been described: upper body and lower body obesity. Upper body obesity is also referred to as central, abdominal, visceral, or male (“android”) obesity. Lower body obesity is also known as peripheral, gluteal-femoral, or

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female (“gynoid”) obesity. Subjects with upper body obesity are often referred to as being shaped like an “apple,” compared with lower body obesity, which is more “pear” shaped (Fig. 6-2). In general, men have more intra-abdominal fat and women more subcutaneous fat. As men age, the proportion of intra-abdominal fat to subcutaneous fat increases. After menopause, women tend to acquire more central fat distribution. The obesity type is determined by dividing the waist by the hip circumference. A waist-to-hip ratio greater than 1.0 in men and 0.8 in women indicates upper body or central obesity. Central obesity can be further differentiated into intra-abdominal adipose tissue (visceral fat) and subcutaneous abdominal adipose tissue by the use of CT or MRI scans. Waist circumference, which is a measure of central fat distribution, measures both subcutaneous abdominal adipose tissue and intra-abdominal adipose tissue. One of the characteristics of visceral fat is the release of adipokines (such as TNF-α and adiponectin) and fatty acids directly to the liver before entering the systemic circulation, having a potentially greater impact on hepatic function (i.e., the increased fatty acids are deposited in the liver, causing fatty liver, resulting in insulin resistance in the liver). Higher levels of these adipokines and circulating free fatty acids in people with obesity, particularly those with upper body obesity, are thought to be associated with many of the adverse effects of obesity (Ruderman, Carling, Prentki, et al., 2013). The presence of excess fat in the abdomen out of proportion to total-body fat is an independent predictor of risk factors and mortality. Both BMI and waist circumference are positively correlated with totalbody adipose tissue, but waist circumference is a better predictor of abdominal or visceral fat content than BMI (Heart & Stroke Foundation, 2010). A waist circumference greater than 102 cm in men and 88 cm in women is considered high risk for cardiovascular disorders for most Canadians but for some ethnicities (i.e., Asians and south Americans) the cutoff numbers are 90 cm for men and 80 cm for women (Heart & Stroke Foundation, 2010). Weight loss causes a preferential loss of visceral fat (due to higher turnover of visceral fat cells than subcutaneous) and can result in improvements in metabolic and hormonal abnormalities. Although peripheral obesity is associated with varicose veins in the legs and mechanical problems, it is not as strongly associated with cardiometabolic risk. In terms of weight reduction, some studies have shown that persons with upper body obesity are easier to treat than those with lower body obesity. Other studies have shown no difference in terms of success with weight reduction programs between the two types of obesity. Weight cycling (the losing and regaining of weight) has been found to have little or no effect on metabolic variables, central obesity, or cardiovascular risk factors or future amount of weight loss. More research is needed to determine its effect on dietary preference for fat, psychological adjustment, disordered eating, and mortality. It is postulated that it is the underlying obesity and not the weight fluctuation that affects life expectancy (Montani, Viecelli, Prevot, et al., 2006).







FIGURE 6.2 Distribution of adipose tissue in (A) upper body or central (visceral) obesity and (B) lower body or peripheral (subcutaneous) obesity.

People with upper body obesity are often described as having an “apple-shaped” body and those with lower body obesity as having a “pear-shaped” body.

PREVALENCE OF OBESITY According to WHO, the prevalence of obesity has more than doubled since 1980, and “most of the world’s population live in countries where overweight and obesity kills more people than underweight” (WHO, 2015, p. 1). WHO (2015) estimates that in 2014 more than 1.9 billion adults were overweight, including in this number more than 600 million persons who were obese. Based on weight data from 2007 to 2009, the Public Health Agency of Canada and the Canadian Institute for Health Information (PHAC/ CIHI, 2011) estimate that one in four Canadian adults is obese. It is alarming that in Canada, between 1981 and 2007/09, obesity is considered to have doubled in both men and women (PHAC/CIHI, 2011). It has been estimated that “obesity costs Canada between $4.6 billion and $7.1 billion annually in health care and lost productivity” (Standing Senate Committee on Social Affairs, Science and Technology, 2016, p. iv). Vanasse, Demers, Hemiari, et al. (2006), analyzed data from the 2003 Canadian Community Survey and found that rates of obesity were the highest in Newfoundland and Labrador, followed by the Prairies and the North, and the lowest in British Columbia, Quebec, and Ontario.

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Obesity was also found to be less prevalent in the three largest metropolitan areas of the country (Toronto, Montreal, and Vancouver). In Canada, obesity is higher in indigenous populations, and more common in men than women (PHAC/CIHI, 2011).

Childhood Obesity The global prevalence of childhood obesity is rising dramatically over the past three decades with substantially greater increases observed in economically developed regions (Han, Lawlor, & Kimm, 2010; Ng, Fleming, Robinson, et al., 2014). In 2014, the Canadian adapted WHO BMI-for-age growth charts for boys and girls aged 2 to 19 years was released (Dieticians of Canada, 2014). Other growth charts that are used less frequently in Canada are the U.S. Center for Disease Control (CDC) charts. Subsequently, the definition for obesity in Canadian children (ages 5 to 19) using the WHO charts is defined as a BMI at or above the sex- and age-specific 97th percentile, whereas a BMI between the 85th and 97th percentiles is defined as being overweight (Dieticians of Canada, 2014). In North America, childhood obesity has become rampant. Findings from the CHMS indicated obesity has increased 2.5 times in the last decades (Fig. 6-3) (PHAC/CIHI, 2011).




Basic Concepts in Nursing

Percentage overweight or obese, by sex and age group, household population aged 2 to 17, Canada (2004) and United States (1992–2002) Overweight Obese


32 29


25 19

21 19


30 26

24 18

19 17*


20 19



14 13

11* 10 E 10








S. U. a ad




S. U. a ad

Boy’s age group






S. U. a





S. U. a ad




S. U. a ad



S. U. a ad





14 11


Girl’s age group

Data sources: 2004 Canada Community Health Survey: Nutrition; 1992–2002. National Health and Nutrition Examination Survey Note: Because of rounding, detail may not add to totals. E Coefficient of variation 16.6% to 33.3% (interpret with caution) *Significantly different from estimate for Canada (p < 0.05) FIGURE 6.3 Percentage of overweight or obese children and youth by sex and age groups, comparing Canada (2004) and the United States (1999–

2002). (From Minister of Industry. (2012). Health fact sheet: Body mass index of Canadian children and youth, 2009 to 2011. Statistics Canada, Catalogue No. 82–625-X.)

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Childhood obesity prevalence data surveys were further stratified by ethnicity and in Canada, the prevalence of obesity amongst young individuals of Aboriginal origin is much greater than the national average. In the United States, obesity prevalence amongst young black, Hispanic, and Mexican Americans was significantly greater than among their Caucasian counterparts. The major concern of childhood obesity is that obese children will grow up to become obese adults. Pediatricians are now beginning to see hypertension, dyslipidemia, type 2 diabetes, orthopedic complications, and psychosocial stigma in obese children and adolescents (Han, Lawlor, & Kimm, 2010). In Canada, a study found that 95% of children newly diagnosed with type 2 diabetes were obese (Amed, Dean, Panagiotopoulos, et al., 2010). In addition, there is a growing concern that childhood and adolescent obesity may be associated with negative psychosocial consequences, such as low self-esteem and discrimination by adults and peers (PHAC/CIHI, 2011). Childhood obesity is determined by a combination of hereditary and environmental factors. It is associated with parents who are obese, gestational diabetes and excessive weight gain during pregnancy, formula feeding, parenting style, parental eating, energy-dense food choices, erratic eating patterns, ethnicity, and sedentary lifestyle (Han et al., 2010; PHAC/CIHI, 2011). Children with overweight parents are at highest risk. One of the factors leading to childhood obesity is the increase in inactivity, including increased time indoors engaging in sedentary activities such as television viewing and computer usage. Television viewing is associated with consumption of calorie-dense snacks and decreased indoor activity. Studies have shown preschool children watching more than 2 hours per days of screens (TV or video games) were 34% more likely to be overweight or at risk for becoming overweight compared to children who watch less than 2 hours per day (Steffen, Sinaiko, Zhou, et al., 2013). Obese children also may have a deficit in recognizing hunger sensations, stemming perhaps from parents who use food as gratification. Increasing perceptions that neighbourhoods are unsafe has resulted in less time spent outside playing and walking. Fast food, increased portion sizes, increased energy density, sugarsweetened soft drinks, and foods with a high glycemic index are all likely contributing to the increased weights in children and adolescents. Because of the enormity of the problem of overweight and obesity in children, Obesity Canada (a not-for-profit organization) convened a panel of experts to establish Canadian recommendations for the management of both adult and pediatric obesity (Lau, Douketis, Morrison, et al., 2007). The Canadian guidelines recommend measuring BMI in all children and adolescents aged 2 years and older (Lau et al., 2007). Assessment of the dietary habits of the child who is overweight or obese is an important component of the overall health assessment. This assessment should include self-efficacy and readiness to change; frequency of eating at restaurants or fast food outlets; frequency of consumption of sweetened beverages, 100% fruit juice, and foods high in energy density; examination of portion sizes in relation to appropriateness for

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age; frequency and quality of breakfast and snacks; and frequency of vegetable and fruit consumption. Time spent engaging in physical and sedentary activities should also be assessed. Because adolescent obesity is predictive of adult obesity, treatment of childhood obesity is desirable (Amed et al., 2010; Dieticians of Canada, 2014; Han et al., 2010; Steffen et al., 2013). The goals of therapy in uncomplicated obesity are directed toward healthy eating and activity behaviours, with the focus on sustainable lifestyle changes rather than weight or food restrictions. Families should be taught awareness of current eating habits, activity, and parenting behaviour and how to modify them. For children with complications secondary to the obesity, the goal should be normalization of weight and treatment of the complications. The weight loss interventions should include all family members and caregivers; begin early at a point when the family is ready for change; assist the family to learn to monitor eating and activity patterns and make small and acceptable changes in these patterns; and be designed to encourage and emphasize, not criticize. They should include information about the medical complications of obesity and be directed at permanent changes, not short-term diets or exercise programs aimed at rapid weight loss. It is recommended that health care providers counsel parents and caregivers of children with a BMI between the 5th and 84th percentiles to limit sugar-sweetened beverages and encourage the recommended amount of vegetables and fruits, limit screen time to no more than 2 hours daily, remove television and computer screens from the child’s sleeping area, have the child eat breakfast daily, limit portion size and eating out, especially at fast food restaurants, and encourage family meals where parents and children eat together (Lau et al., 2007; PHAC/ CIHI, 2011). Primary and secondary schools (grades 1 through 12) are pivotal in the promotion of active living and schools have been encouraged to increase daily physical activity and opportunities for recreation (Lau et al., 2007). Education regarding the prevention of childhood obesity can begin in the prenatal stage. The Canadian obesity guidelines encourage discussions regarding the prevention of childhood obesity with pregnant women. In addition, it is recommended that infants be breast-fed exclusively to 6 months of age and that discussion should ensue with the family encouraging limited intake of energy-dense snacks and foods that are high in fat and sugar (Lau et al., 2007). The first treatment options for children who are overweight or obese include dietary counselling (with the goal of reducing energy intake) and promotion of regular physical activity. An optimal diet plan to achieve a healthy body weight should be developed by a qualified health practitioner (preferably a Registered Dietitian) (Lau et al., 2007). Dietary goals should focus on wellbalanced, healthy meals with a healthy approach to eating. Specific strategies can include reduction of specific high-calorie foods or an appropriate balance of foods that are low, medium, and high calorie. Commercial diets should be used with caution. Pharmacologic therapy (i.e., orlistat) may be considered in adolescents to aid in weight reduction and/or maintenance when added to a regimen of lifestyle intervention (Han et al., 2010). Due




Basic Concepts in Nursing

to lack of evidence, pharmacologic therapy is not recommended in prepubertal children. Bariatric surgery in adolescents should be limited to exceptional cases and only be carried out by experienced health care teams (Lau et al., 2007).

HEALTH IMPACT OF OBESITY Obesity is a condition that affects overall health. The excess body fat associated with obesity often impairs health. It has been predicted that the health effects of

Cerebral atherosclerosis, stroke

Hypoventilation (“Pickwickian” syndrome)



obesity will result in a shorter life expectancy for today’s youth. People who are obese have a 50% to 100% increased risk of premature death from all causes compared to people with a healthy weight. Obesity affects nearly every body system. It is associated with an increased risk of cardiac disease, hypertension, hypertriglyceridemia, and decreased high-density lipoprotein (HDL) cholesterol. Significant weight gain increases the risk of developing type 2 diabetes, obstructive sleep apnea, gastric reflux, urinary stress incontinence, and gallbladder disease (Fig. 6-4). Limited mobility and increased joint disorders are functional results of increased weight on the body’s skeletal system. In women, obesity can contribute to infertility, higher risk pregnancy,

Hypertension, left ventricular hypertrophy

Coronary artery atherosclerosis, myocardial infarction



FIGURE 6.4 Complications of obesity. (From Rubin, R., Strayer, D. (Eds.). (2012). Rubin’s pathology: Clinicopathologic foundations of medicine (p. 1085). Philadelphia, PA: Lippincott Williams & Wilkins.)

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gestational diabetes, maternal hypertension, and difficulty in labour and delivery. Infants who are born to obese mothers are more likely to be high birth weight, contributing to an increased rate of caesarean section delivery. Several types of cancer are seen in higher frequency in people who are obese, including endometrial, colon, gallbladder, prostate, kidney, and postmenopausal breast cancer. Obesity also causes nonalcoholic steatohepatitis and fatty liver disease. Because some drugs are lipophilic and exhibit increased distribution in fat tissue, the administration of these drugs, including some anesthetic agents, can be more dangerous in persons who are obese. If surgery is required, the person who is obese often heals more slowly than the nonobese person of the same age. Massive obesity, because of its close association with so many health problems, can be regarded as a disease in its own right.

Stigma Individuals who suffer from obesity are often stigmatized and this has an important impact on their psychological health, which may in turn make it more difficult for them to have healthy eating behaviour (Puhl & Heuer, 2010; Schmaltz & Colistra, 2016). It is critical that health professionals reflect on their own perceptions about obesity in order to be able to provide good care. “Although nurses, physicians, and other health professionals are aware of the low success rate and difficulty in treating weight problems, they still may place the blame on the obese patient” (Pleuss, Matfin, & Moisey, 2010, p. 956). Multiple factors come into play in the development of obesity and one must understand that it is a complex condition that has multiple determinants that can interact with each other in a given individual. In Canada and many other countries, there are many negative stereotypes associated with obesity (Puhl & Heuer, 2009; 2010). People, especially women, are expected to be thin, and obesity may be seen as a sign of lack of self-control. Obesity may negatively affect employment and educational opportunities, as well as marital status. Obesity also may play a role in a person’s treatment by health professionals. Although nurses, physicians, and other health professionals are aware of the low success rate and difficulty in treating weight problems, they still may place the blame on the patient who is obese (Puhl & Heuer, 2009; Teixeira & Budd, 2010).

DETERMINANTS OF OBESITY Commonly cited determinants of obesity include physical activity, diet, socioeconomic status, ethnicity and immigration, and environmental factors (PHAC/CIHI, 2011). Although information is presented for each determinant successively, it is critical to understand that obesity is often the result of a combination of determinants.

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Lack of sleep is increasingly being seen as a determinant of obesity and because of this we have added information about the role of sleep in keeping a healthy weight. Psychological and medical and genetic factors have also been added.

Physical Activity Lack of physical activity combined with overeating has long been associated with obesity. Simplistically, eating without burning calories results in weight gain. It is also common knowledge that a sedentary life style leads to ill-health. Sitting too much is associated with many occupations. However, small interventions may have a great impact in reducing this type of immobility. Interventions do not have to be sophisticated; for example, an Australian study used an e-health intervention that prompted employees to move at their work station and saw an increase in activity (Pedersen, Cooley, & Mainsbridge, 2014)

Diet Having healthy eating patterns and access to healthy food are correlated with maintaining a healthy weight (PHAC/ CIHI, 2011). Details about nutrition assessment are presented in Chapter 5. The epidemic of obesity has brought to the forefront issues related to ever-increasing portion sizes, and to the unhealthy amounts of sugar, fat, and salt found in manufactured food. The internet is replete with websites that propose “miracle diets.” It should be understood that changing unhealthy eating habits takes time and is difficult, and that keeping healthy habits is critical to weight control. Some individuals who have weight problems may suffer from additional conditions such as the binge eating disorder and the night eating syndrome. Binge eating is characterized by eating excessively for a number of episodes or days (Goracci, Casamassima, Iovieno, et al., 2015; Grilo, 2002), while the night eating syndrome is characterized by insomnia and overeating during the night (Stunkard, 2002). In both situations, mood disturbances come into play.

Socioeconomic Status Low income has been found to be a contributing factor to obesity in women (Hajizadeh, Campbell, & Sarma, 2014; PHAC/CIHI, 2011). Obesity is less frequent in women who have a higher income. This relationship has not been found for the male population. However, in both men and women there is an association between higher obesity rates and lower level of education (PHAC/ CIHI, 2011). In a recent study conducted with a sample of 5,391 adults living in rural Saskatchewan, researchers found that those who did not live on a farm were more




Basic Concepts in Nursing

likely to be obese than those who lived on a farm. However, living on a farm while having a low income increased the risk of obesity. In the same study, researchers found that individuals who had completed postsecondary education were less likely to be obese (Chen, Rennie, Karunanayake, et al., 2015).

Ethnicity and Immigration Using data from the 2000/2001 Canadian Community Health Survey of Statistics Canada, Tremblay, Pérez, Ardem, et al. (2005) found that obesity was more prevalent in certain ethnic groups. Indigenous people were the most likely to be overweight and obese, while East and South Asians were the least likely to be overweight and obese. In another study, McDonald & Kennedy (2005) found that immigrants were less likely to be overweight but that their weight increased with the number of years they spent in Canada. However, Chinese immigrants did not show the same correlation between increased weight and number of years in Canada. Interestingly, McDonald and Kennedy also found that if an immigrant is from an ethnic group less likely to be obese and this immigrant lives in a neighbourhood where there are more members of his ethnic group, it is less likely that he will become overweight. This may in part explain why Chinese immigrants are less likely to gain weight, as they tend to have established communities and thus may become less acculturated (McDonald & Kennedy, 2005).

Environmental Factors Environmental factors can also play a role in becoming overweight or obese. In Canada, recent research has examined the distribution of supermarkets and fast food outlets in Edmonton neighbourhoods. Smoyer-Tomic, Spence, Raine, et al. (2007) found that fast food outlets were more often in a walking distance in poorer neighbourhoods. Even if a causal relationship cannot be established between the presence of fast food outlets and obesity, it is important to reflect on the impact these outlets may have on weight gain (Hemphill, Raine, Spence, et al., 2008). Similarly, Prince, Kristjansson, Russell, et al. (2012) conducted a study in Ottawa, where 86 neighbourhoods were examined to ascertain if there were links between obesity and multiple variables, including the density of fast food outlets and convenience stores and availability of park areas. The results of this study revealed that when parks were present, females were more likely to be active, and that a greater density of fast food outlets and convenience stores was associated with increased obesity. This type of situation corresponds well to an obesogenic environment as defined by the Standing Senate Committee on Social Affairs, Science and Technology (2016).

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Psychological Factors Psychological factors are another area of influence on behaviour related to weight gain. Eating may be a way to cope with stress, boredom, or anxiety. However, the relationships of these behaviours to mental health and obesity are complex and poorly understood (Koch, Sepa, & Ludvigsson, 2008; Talen & Mann, 2009). No specific personality traits characteristic of people who are obese have been identified (Talen & Mann, 2009). While the causal relationship of psychological behaviours is not clear, binge-eating disorder (BED) behaviours, described as uncontrolled consumption of large quantities of food, have been found in 20% to 30% of people who are obese seeking weight loss treatment (Talen & Mann, 2009). Culture and socioeconomic status are also believed to be contributing factors in the increased rates of overweight and obesity. Increased rates of obesity are seen in Canadian Aboriginal populations, African American, and Hispanic groups, particularly in women. Although many theories have been set forth it is not yet clear what impact cultural food choices and accepted cultural behaviours have on these rates. It is clear that interventions will need to be developed to address the needs of different cultures, as well as address the socioeconomic barriers to improved dietary choices (Calzada & Anderson-Worts, 2009). Much discussion and debate will continue related to causative factors, especially as effective means to treat and prevent obesity are sought.

Medical and Genetic Factors Medical conditions such as thyroid disorder, Cushing syndrome, and polycystic ovarian syndrome can also contribute to weight gain and obesity, as do many medications. The relationship between genetics and weight gain is complex, and, as yet, not fully understood. The most recent and last update of the human obesity gene map series, completed in 2005, reported 135 candidate genes had been identified that are associated with obesity-related phenotypes (Choquet & Meyre, 2011; Rankinen, Zuberi, Chagnon, et al., 2006). Many of these relate to known brain-gut controls of hunger and satiety, metabolism, and the body’s storage mechanisms. Researchers theorize this may help to explain differences in obesity levels found in various populations. Identification of these genetic influences may allow for more targeted treatment interventions in the future. It is yet unknown how genes and mutations may directly or indirectly interact with environmental causes of obesity. One description for the complex interaction between environment and genetics is attributed to George Bray, a noted expert on obesity, who stated “the genetic background loads the gun, but the environment pulls the trigger” (Bray, 2004). There is new evidence that behaviour-based interventions may attenuate the genetic influence of obesity (Temelkova-Kurktschiev & Stefanov, 2012). Though genetic research gives new insight into the genesis of obesity, environmental influence remains the



major contributor to this worldwide issue (Swinburn, Sacks, Hall, et al., 2011).

Sleep Lack of sleep has been associated with increased obesity in both children and adults. For example, Chaput, Lambert, Gray-Donald, et al. (2015) studied 550 Quebec children and found that “. . . short sleep duration is a risk factor for overweight and obesity, independent of potential covariates” (2015, p. 369). An association has also been made between lack of sleep and weight gain in adults (Patel, Malhotra, White, et al., 2006). There is mounting evidence that lack of sleep negatively affects the metabolic and endocrine systems, resulting in increased appetite and greater fatigue, which would in turn affect energy levels and thus reduce the extent to which the person is physically active (Zimberg, Dâmaso, Del Re, et al., 2012).

PREVENTION OF OBESITY Obesity in epidemic proportions has led to much discussion on methods of prevention, yet few effective approaches have resulted. More research is now being focused on prevention efforts directed at children and adolescents. Most interventions involve modification of lifestyle behaviours to promote healthy food choices and more physical activity. Public debate is also focused on policy methods to regulate availability of less desirable food choices, such as high-calorie snacks and sweetened drinks. Major public education and policy efforts are being undertaken by federal agencies. The Pan-Canadian Healthy Living Strategy is a government endorsed conceptual framework that aspires to a future where the health of Canadians is improved and chronic disease reduced. The targets of this program, to be achieved by 2015, include increasing the proportion of Canadians making healthy food choices, participating in physical activity 30 minutes per day and achieving a BMI within the healthy range (18.5 to 24.9) by 20% (ACPHHS, 2005). Health Canada has developed Canada’s Food Guide which translates dietary guidelines into demonstratable eating behaviours. In addition to the traditional print version, Canada’s Food Guide is also accessible via an interactive websites and applications for electronics that enables individuals to create a personalized food guide and provides tips on maintaining healthy habits (i.e., (Health Canada, 2011). Mass media strategies employed to combat obesity have included the nationwide ParticipACTION campaign (ParticipACTION, 2013) which brings together partners from the public, private, and nonprofit sectors to promote physical activity and fitness, and the Half Your Plate campaign (Canadian Produce Marketing Association, 2014) that aims to increase fruit and vegetable consumption. Ultimately, successful prevention measures will utilize not

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only governmental agency strategies and regulatory measures, but also private sector initiatives and communication as well (Gortmaker, Swinburn, Levy, et al., 2011; Swinburn et al., 2011 ).

MANAGEMENT OF OBESITY Considering the complexity of obesity, the management of this condition requires three levels of interventions; individual-based interventions, community-based interventions, and public policy (PHAC/CIHI, 2011). Before treatment begins, an assessment should be made of the degree of overweight and the overall risk status. This should include assessment of the following risk factors or complications (as well as many other important considerations): coronary heart disease and other atherosclerotic diseases, sleep apnea, gynecologic abnormalities, osteoarthritis, gallstones, stress incontinence, cigarette smoking, depression, eating and/or mood disorders, hypertension, high low-density lipoprotein (LDL) cholesterol levels, reduced HDL cholesterol levels, high triglyceride levels, prediabetes or type 2 diabetes, family history of premature coronary heart disease, and physical inactivity (Lau et al., 2007). It also is advisable to determine the person’s barriers and readiness to lose weight (Lau et al., 2007). Several factors can be evaluated to make this assessment. These include reasons and motivations for weight loss, previous history of weight loss attempts, social support, attitude toward physical activity, ability to participate in physical activity, time available for attempting intervention, and understanding the causes of the obesity and its contribution to disease. These help identify the person’s emotional, psychological, physical, and social barriers for making changes.

Individual Interventions Individual interventions target what can be done at the individual level to manage obesity. Life style interventions, dietary interventions, physical activity, pharmacological management, and surgical treatment have been included in the 2006 Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children (Lau et al., 2007). Lifestyle modification is an essential factor in treating weight loss. Lifestyle interventions are designed to help individuals change their habits. Strategies include helping participants learn to self-monitor eating habits, including where and when they eat, and identifying situations that trigger eating behaviour. Techniques for changing behaviour include stress management, stimulus control, problem solving, contingency management, cognitive restructuring, social support, and relapse prevention (Jacob & Isaac, 2012). Another important aspect to behaviour modification is helping the person to set realistic weight loss goals (Jacob & Isaac, 2012). Weight loss from diet therapy, exercise, and behavioural




Basic Concepts in Nursing

therapy typically is 10% below the initial baseline (Wadden, Butryn, Wilson, et al., 2007). In many cases, this level can lessen health risks, but often falls short of individual expectations. Dietary interventions include reducing the caloric intake, changing eating habits, and help individuals learn to eat a balanced diet (Lau et al., 2007). The two major components of all diet therapy are caloric restriction and diet composition. While diet modification and caloric restriction are important components of weight loss therapy, no one method has been shown to be most effective. Therefore, dietary therapy should be individually prescribed based on the person’s overweight status and risk profile. The diet should be a personalized plan with realistic goals. Caloric restriction may vary from low-calorie diets to very low-calorie diets. Low-calorie diets typically restrict caloric intake to 1,200 kcal/day. This results in a variable reduction, depending on the initial dietary intake of the individual. Very low–calorie diets restrict calories to approximately 450 kcal/day, primarily made up of protein. This diet has higher risks, including abnormal heart rhythms, and cholelithiasis, and anyone on this diet should be under direct supervision of a medical professional. A more conservative dietary approach is to reduce the current dietary intake by 500 to 1,000 kcal/day. Total caloric intake should be distributed in four or five meals or snacks throughout the day. Portion control is an effective technique to help achieve calorie reduction. Many people who are overweight have not practiced or monitored portion size. Chart 6-2 shows how portion sizes have changed over the years. One strategy for individual portion control is to keep daily diet logs of all food ingested to facilitate awareness of both content and frequency. Meal replacements, such as protein shakes with vitamins and minerals, may also be used as a substitute for solid food meals. After caloric restriction is determined diet composition should be addressed. There are many methods of altering dietary content, including low fat diets, and low carbohydrate/ high protein diets. Low fat diets strive to limit daily calo-

ries from fat to 10% to 15% of total calorie intake. This level may be difficult to achieve, and often is less palatable. Low carbohydrate/high protein diets became popular in the 1960s and 1970s. Although effective for weight loss, especially in the initial stages, they can contribute to health risks. Higher protein diets can increase the risk of kidney stones, and the decrease in fibre can also increase risks of cancer and raise cholesterol levels. Increasing physical activity is also commonly recommended. There is convincing evidence that increased physical activity decreases the risk of overweight and obesity. “Physical activity and exercise should be sustainable and tailored to the individual” (Lau et al., 2007, p. 54). In addition, it reduces cardiovascular and diabetes risk beyond that achieved by weight loss alone. Physical activity is an important part of weight loss therapy and helps with maintaining weight loss. In addition, it may help reduce abdominal fat, increase cardiorespiratory fitness, and prevent the decrease in muscle mass that often occurs with weight loss. Exercise should be started slowly with the duration and intensity increased independently of each other. The goal should be 60 minutes or more of moderate to vigorous activity on most days of the week to maintain weight, and 60 to 90 minutes when trying to sustain weight loss (ACPHHS, 2005; Health Canada, 2011; ParticipACTION, 2013). The activity can be performed at one time or intermittently over the day. It is however telling that only 15% of Canadian adults reach this target (Standing Senate Committee on Social Affairs, Science and Technology (2016). Pharmacotherapy can be used as an adjunct to the aforementioned regimen in some patients with a BMI of 30 or more with no other risk factors or diseases, and for patients with a BMI of 27 or more with concomitant risk factors or diseases. Risk factors and diseases defined as warranting pharmacotherapy are coronary heart disease, type 2 diabetes, metabolic syndrome, gynecologic abnormalities, osteoarthritis, gallbladder disease, stress incontinence, and sleep apnea (Lau et al., 2007). In selected patients with acceptable operative risk factors, surgical therapy is currently the most effective treatment


Portion Distortion (National Heart, Lung, and Blood Institute, 2015)

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Portion Size 20 Years Ago

Present Portion Size Today

Soda pop

200 mL (85 calories)

600 mL (250 calories)


(333 calories)

(590 calories)

French fries

2.4 oz (210 calories)

6.9 oz (610 calories)


3-in diametre (140 calories)

6-in diametre (350 calories)

Turkey sandwich

320 calories

820 calories



of severe obesity with respect to degree and duration of weight reduction achieved (Dixon, Zimmet, Albertit, et al., 2011). Bariatric surgery, although invasive, does afford significant weight loss, long-term weight loss maintenance, improved quality of life, decreased incidence of associated diseases, and decreased all-cause mortality (including mortality due to cardiovascular disease and cancer). This option is usually limited to persons with a BMI greater than 40; those with a BMI greater than 35 who have comorbid conditions and in whom efforts at medical therapy have failed; and those who have complications of extreme obesity. Pharmacological management and surgical management (bariatric surgery) of obesity are presented in more detail in Chapter 38.

Community-based Interventions Community-based interventions consist of the development and implementation of programs at the community level. For example, physical activity programs at work can be considered community-based programs. Communitybased interventions can also include comprehensive programs that target multiple determinants of obesity. Social marketing programs are also considered to be communitybased interventions (PHAC/CIHI, 2011). ParticipAction is probably the most famous Canadian social marketing campaign. It has been proposing ways for Canadians to be more active since the 1970s. An example of a community-based intervention program is the Healthy Foods North nutrition and lifestyle intervention program, which targeted Inuit and Inuvialuit communities. The program used behaviour change strategies as well as environmental strategies. For example, it used pedometer challenges at work and promoted the use of traditional food instead of manufactured products. The importance of using traditional food is key when one considers the cost of bringing fresh produce to the North. Such costs can make it very difficult for the average person to buy perishable foods and instead pushes them to purchase unhealthy items that could be replaced by cheaper and healthier traditional foods (Sharma, Gittelsohn, Rosol, et al., 2010).

Public Policy From a public health perspective, it is important that policy makers be involved in the management of obesity. For example, one of the recommendations of a study by Smoyer-Tomic et al. (2007) is that urban centres may want to consider zoning bylaws that would regulate the extent to which food stores can be present in a given neighbourhood. Similarly, schools’ board can also play a role in preventing obesity in children by limiting the

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number of vending machines and replacing them by fresh food. Higher level policy makers such as provincial and federal governments can bring legislation that regulated the amounts of salt and sugar included in processed food. They can also create measures that facilitate access to healthy food, or limit access to unhealthy food. In March 2016, the Standing Senate Committee on Social Affairs, Science and Technology released its report on obesity in Canada (Standing Senate Committee on Social Affairs, Science and Technology, 2016). The report includes an exhaustive list of recommendations that will hopefully be addressed by policy makers. These very comprehensive recommendations are presented in Chart 6-3. Much needs to be done by policy makers to better regulate the food industry. For example, “there are 56 different names for sugar alone and manufacturers do not have to group them together” (Standing Senate Committee on Social Affairs, Science and Technology, 2016, p. iv). It has also been noted that the absence of stringent regulations mean that manufacturers create their own versions of food labelling systems, which are very confusing for consumers.

SUMMARY OF KEY POINTS multiple organ-specific pathologic consequences. factors, psychological influences, and activity levels have been implicated as causative factors in the development of obesity. The health risks associated with obesity affect almost every body system. body obesity. Upper body obesity is associated with a higher incidence of complications. ing the Canadian pediatric populations. Factors that predispose to childhood obesity include erratic eating patterns, calorie-dense food choices, and lack of exercise and sedentary lifestyle. The major concern of childhood obesity is that obese children will grow up to become obese adults. Pediatricians are now beginning to see hypertension, dyslipidemia, type 2 diabetes, orthopedic complications, and psychosocial stigma in obese children and adolescents. Because of the scope of the problem, it is recommended that the weight status of all children be evaluated yearly and that measures to prevent and treat obesity be included in the health care plan for all children. interventions; individual-based interventions, community-based interventions, and public policy (PHAC/ CIHI, 2011). The treatment of obesity focuses on nutritionally adequate weight loss diets, behaviour modification, exercise, social support, and, in situations of marked obesity, pharmacotherapy and surgical methods.




Basic Concepts in Nursing


Recommendations of the Standing Senate Committee on Social Affairs, Science, and Technology (Standing Senate Committee on Social Affairs, Science and Technology, 2016, pp. 40–44). Recommendation 1—The committee recommends that the federal government, in partnership with the provinces and territories and in consultation with a wide range of stakeholders, create and implement a National Campaign to Combat Obesity which includes goals, timelines, and annual progress reports. Recommendation 2—The committee recommends that the federal government: Immediately conduct a thorough assessment of the prohibition on advertising food to children in Quebec; and, Design and implement a prohibition on the advertising of foods and beverages to children based on that assessment. Recommendation 3—The committee recommends that the federal government: Assess the options for taxation levers with a view to implementing a new tax on sugar-sweetened as well as artificially sweetened beverages; and, Conduct a study, and report back to this committee by December 2016, on potential means of increasing the affordability of healthy foods including, but not limited to, the role of marketing boards, food subsidies, and the removal or reduction of existing taxes. Recommendation 4—The committee further recommends that the Indigenous and Northern Affairs Canada immediately: Address the recommendations made by the Auditor General with respect to the Nutrition North program and report back to this committee on its progress by December 2016. Recommendation 5—The committee further recommends that the federal government conduct assessments of the Children’s Fitness Tax Credit, the Working Income Tax Benefit, and the Universal Child Care Benefit with a view to determining how fiscal measures could be used to help Canadians of lower socioeconomic status, including our Aboriginal population, choose healthy lifestyle options. Recommendation 6—The committee recommends that the Minister of Health immediately undertake a complete revision of Canada’s Food Guide in order that it better reflect the current state of scientific evidence. The revised food guide must: Be evidence based; Apply meal-based rather than nutrient-based principles; Effectively and prominently describe the benefits of fresh, whole foods compared to refined grains, ready-to-eat meals, and processed foods; and Make strong statements about restricting consumption of highly processed foods. Recommendation 7—The committee further recommends that the Minister of Health revise the food guide on the guidance of an advisory body which: Comprises experts in relevant areas of study, including but not limited to nutrition, medicine, metabolism, biochemistry, and biology; and Does not include representatives of the food or agriculture industries. Recommendation 8—The committee therefore recommends that the Minister of Health prohibit the use of partially hydrogenated oils, to minimize trans fat content in food, unless specifically permitted by regulation. Recommendation 9—The committee further recommends that the Minister of Health: Reassess the daily value applied to total carbohydrates based on emerging evidence regarding dietary fat and the fat promoting nature of carbohydrates; Ensure that the regulatory proposals for serving size have addressed all of the concerns raised by stakeholders during public consultation; and Require that the daily intake value for protein be included in the Nutrition Facts table. Recommendation 10—The committee further recommends that the Minister of Health assess whether sugar and starch should be combined under the heading of total carbohydrate within the Nutrition Facts table and report back to this committee by December 2016. Recommendation 11—The committee therefore recommends that the Minister of Health implement strict limits on the use of permitted health claims and nutrient content claims based on a measure of a food’s energy density relative to its total nutrient content.

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Recommendation 12—The committee therefore recommends that the Minister of Health: Immediately undertake a review of front-of-package labelling approaches that have been developed in other jurisdictions and identify the most effective one; Report back to this committee on the results of the review by December 2016; Amend the food regulations to mandate the use of the identified front-of-package approach on those foods that are required to display a Nutrition Facts table; and Encourage the use of this labelling scheme by food retailers and food service establishments on items not required to display a Nutrition Facts table. Recommendation 13—The committee therefore recommends that the Minister of Health encourage nutrition labelling on menus and menu boards in food service establishments. Recommendation 14—The committee therefore recommends that the federal government increase funding to ParticipACTION to a level sufficient for the organization to: Proceed with Active Canada 20/20; and Become the national voice for Canada’s physical activity messaging. Recommendation 15—The committee further recommends that the Minister of Health and the Minister of Sport and Persons with Disabilities together use the recently established National Health and Fitness Day to promote the Canadian Physical Activity Guidelines. Recommendation 16—The committee further recommends that the Public Health Agency of Canada provide sustained or bridged funding for pilot projects that have been assessed as effective. Recommendation 17—The committee further recommends that the Minister of Health in discussion with provincial and territorial counterparts as well as nongovernmental organizations already engaged in these initiatives: Encourage improved training for physicians regarding diet and physical activity; Promote the use of physician counselling, including the use of prescriptions for exercise; Bridge the gap between exercise professionals and the medical community by preparing and promoting qualified exercise professionals as a valuable part of the health care system and health care team; Address vulnerable populations, such as Canadians of lower socioeconomic status including Canada’s Aboriginal population, and pregnant women; Advocate for childcare facility and school programs related to breakfast and lunch programs, improved physical education, physical activity, and nutrition literacy courses; and, Engage provincial governments in discussions about infrastructure requirements for communities that encourage active transportation and active play. Recommendation 18—The committee further recommends that the federal government provide funding under the New Building Canada Fund to communities for infrastructure that enables, facilitates, and encourages an active lifestyle, both indoors and outdoors. Recommendation 19—The committee therefore recommends that the Public Health Agency of Canada implement a strategy to increase the visibility, uptake, and use of the Best Practices Portal by stakeholders across the country. Recommendation 20—The committee therefore recommends that Health Canada design and implement a public awareness campaign on healthy eating based on tested, simple messaging. These messages should relate to, but not be limited to: Most of the healthiest food doesn’t require a label; Meal preparation and enjoyment; Reduced consumption of processed foods; and The link between poor diet and chronic disease. Recommendation 21—The committee further recommends that Health Canada and other relevant departments and agencies, together with existing expertise and trusted organizations, implement a comprehensive public awareness campaign on healthy active lifestyles.

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Basic Concepts in Nursing


Ditmier, L. F. (2006). New developments in obesity research. New York, NY: Nova Science Publishers, Inc. Fairburn, C. G., & Brownell, K. D. (2002). Eating disorder and obesity (2nd ed.). New York, NY: The Guildford Press. Grilo, C. M. (2002). Binge eating disorders. In C. G. Fairburn, & K. D. Brownell (Eds.). Eating disorder and obesity (2nd ed., pp. 178–182). New York, NY: The Guildford Press. Health Canada. (2003). Canadian guidelines for body weight classification in adults. Ottawa: Health Canada Publications. Pleuss, J., Maftin, G., & Moisey, L. (2010). Alterations in nutritional status. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds.). Porth pathophysiology concepts of altered health (1st Canadian ed, pp. 943–966). Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins. Rubin, R., & Strayer, D. (Eds.). (2012). Rubin’s pathology: Clinicopathologic foundations of medicine (p. 1085). Philadelphia, PA: Lippincott Williams & Wilkins. Stunkard, A. J. (2002). Night eating syndrome. In C. G. Fairburn, & K. D. Brownell (Eds.). Eating disorder and obesity (2nd ed., pp. 183–187). New York, NY: The Guildford Press. Taber’s Cyclopedic Medical Dictionary. (2009). (21st ed.). Philadelphia, PA: F.A. Davis Company.

JOURNALS AND ELECTRONIC DOCUMENTS Abramkovitch, S. L., Reddigan, J. I., Harmadeh, M. J., et al. (2012). Underestimating a serving size may lead to increased food consumption when using Canada’s Food Guide. Applied Physiology Nutrition Metabolism, 37, 923–930. Aleem, S., Lasky, R., Brooks, W., et al. (2015). Obesity perceptions and documentation among primary care clinicians at a rural academic health center. Obesity Research & Clinical Practice, 9(4), 408–415. Amed, S., Dean, H. J., Panagiotopoulos, C., et al. (2010). Type 2 diabetes, medication-induced diabetes, and monogenic diabetes in Canadian children. Diabetes Care, 33(4), 786–791. Bell, J. A., Kivimaki, M., & Hamer, M. (2014). Metabolically healthy obesity and risk of incident type 2 diabetes: a meta-analysis of prospective cohort studies. Obesity Reviews, 15, 504–515. Bell, J. A., Mamer, M., Sabia, S., et al. (2015). The natural course of healthy obesity over twenty years. Journal of the American College of Cardiology, 65(1), 101–102. Biswas, A., Oh, P. I., Faulkner, G. E., et al. (2015). Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults. Annals of Internal Medicine, 162(2), 123–142. Bleau, C., Karelis, A. D., St-Pierre, D. H., et al. (2015). Crosstalk between intestinal microbiota, adipose tissue and skeletal muscle as an early event in systematic low-grade inflammation and the development of obesity and diabetes. Diabetes/Metabolism Research and Reviews, 31, 545–561. Boyers, D., Avenell, A., Stewart, F., et al. (2015). A systematic review of the cost-effectiveness of non-surgical obesity interventions in men. Obesity Research and Clinical Practice, 9, 310–327. Bray, G. A. (2004). The epidemic of obesity and changes in food intake: The fluoride hypothesis. Physiological Behavior, 82(1), 115–121. Cairney, J., & Østbye, T. (1999). Time since immigration and excess body weight. Canadian Journal of Public Health/Revue Canadienne de Santé Publique, 90(2), 120–124. Calzada, P., & Anderson-Worts, P. (2009). The obesity epidemic: Are minority individuals equally affected? Primary Care: Clinics in Office Practice, 36, 307–317. Canadian Produce Marketing Association. (2014). Fruits and veggies! Half your plate. Available at: Canadian Society for Exercise Physiology. (2012). Canadian physical activity guidelines. Available at: Canadian Task Force on Preventive Health Care. (2015). Recommendations for growth monitoring, and prevention and management of overweight and obesity in children and youth in primary care. Canadian Medical Association Journal, 187(6), 411–421. Cedernaes, J., Schiöth, H. L., Benedict, C. (2015). Determinants of shortened, disrupted, and mistimed sleep and associated metabolic health consequences in health humans. Diabetes, 64, 1073–1080.

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Chaput, J. P., Lambert, M., Gray-Donald, K., et al. (2011). Short sleep duration is independently associated with overweight and obesity in Quebec children. Canadian Journal of Public Health, 102(5), 369– 374. Chau, J. Y., van der Ploeg, H. P., Merom, D., et al. (2012). Cross-sectional associations between occupational and leisure-time sitting, physical activity and obesity in working adults. Preventive Medicine, 54, 195– 200. Chen, Y., Rennie, D. C., Karunanayake, C. P., et al. (2015). Income adequacy and education associated with the prevalence of obesity in rural Saskatchewan, Canada. BMC Public Health, 15, 700. Choquet, H., & Meyre, D. (2011). Genetics of obesity: What have we learned? Current Genomics, 12(3), 169–179. Cossrow, N. H., Jeffery, R. W., & McGuire, M. T. (2001). Understanding weight stigmatization: A focus group study. Journal of Nutrition Education, 33(4), 208–214. De Maio, F. G. (2010). Immigration as pathogenic: A systematic review of the health of immigrants to Canada. International Journal for Equity and Health, 9, 27. deZwaan, M., Marshchollek, M., & Allison, K. C. (2015). The night eating syndrome (NES) in bariatric surgery patients. European Eating Disorders Review, 23, 426–434. Dieticians of Canada. (2014). WHO growth charts for Canada: Updated March 2014. Available at: Public/WHO-Growth-Charts.aspx Dixon, J. B., Zimmet, P., Albertit, K. G., et al. (2011). Bariatric surgery: An IDF statement for obese type 2 diabetes. Diabetic Medicine, 28(6), 628–642. Dunn, J. R., & Dyck, I. (2000). Social determinants of health in Canada’s immigrant population: Results from the National Population Health Survey. Social Science and Medicine, 51, 1573–1593. Fencl, J. L., Walsh, A., & Vocke, D. (2015). The bariatric patient: An overview of perioperative care. AORN Journal, 102(2), 116–131. Flattum, C., Draxten, M., Horning, M., et al. (2015). HOME Plus: Program intervention to promote the frequency and healthfulness of family meals, reduce children’s sedentary behavior, and prevent obesity. International Journal of behavioral Nutrition and Physical Activity, 12(53), 1–9. Galloway, T., Johnson-Down, L., & Egeland, G. M. (2015). Socioeconomic and cultural correlates of diet quality in the Canadian Arctic: Results from the 2007–2008 Inuit Health Survey. Canadian Journal of Dietetic Practice and Research, 76(3), 117–125. Goracci, A., Casamassima, F., Iovieno, N., et al. (2015). Binge eating disorder: From clinical research to clinical practice. Journal of Addiction Medicine, 9(1), 20–24. Gortmaker, S. L., Swinburn, B. A., Levy, D., et al. (2011). Changing the future of obesity: Science, policy and action. Lancet, 378(9793), 838– 847. Hajizadeh, M., Campbell, M. K., & Sarma, S. (2014). Socioeconomic inequalities in adult obesity risk in Canada: Trends and decomposition analyses. The European Journal of Health Economics, 15, 203–221. Han, J. C., Lawlor, D. A., & Kimm, S. Y. (2010). Childhood obesity. Lancet, 375(9727), 1737–1748. Health Canada. (2011). Eating well with Canada’s food guide. Available at: Health Statistics Division. (2012). Body composition of Canadian adults, 2009 to 2011. Available at: article/11708-eng.htm Heart & Stroke Foundation. (2010). Healthy waists. Available at: http:// Hemphill, E., Raine, K., Spence, J. C., et al. (2008). Exploring obesogenic food environments in Edmonton, Canada: The association between socioeconomic factors and fast-food outlet access. American Journal of Health Promotion, 22(8), 426–432. Hieke, S., Palascha, A., Jola, C., et al. (2016). The pack size effect: Influence on consumer perceptions of portion sizes. Appetite, 96, 225–238. Hopping, B. N., Erber, E., Mead, E., et al. (2010). High levels of physical activity and obesity co-exist amongst Inuit adults in Arctic Canada. Journal of Human Nutrition and Dietetics, 23(Suppl 1), 110–114. Jacob, J. J., & Isaac, R. (2012). Behavioral therapy for management of obesity. Indian Journal of Endocrinology and Metabolism, 16(1), 28–32. Katzmarzyk, P. (2008). Obesity and physical activity among Aboriginal Canadians. Obesity, 16(1), 184–190. Koch, F. S., Sepa, A., & Ludvigsson, J. (2008). Psychological stress and obesity. Journal of Pediatrics, 153(6), 839–844.


CHAPTER 6 Kuk, J. L. (2014). The influence of ethnicity and gender on the association between measured obesity and cardiorespiratory fitness with selfrated overweight, physical activity and health. Perspectives in Public Health, 134(1), 38–43. Lau, D. C., Douketis, J. D., Morrison, K. M., et al.; Obesity Canada Clinical Guidelines Expert Panel. (2007). 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]. Canadian Medical Association Journal, 176(Suppl 8), S1–13. McDonald, J. T., & Kennedy, S. (2005). Is immigration to Canada associated with unhealthy weight gain? Overweight and obesity among Canada’s immigrants. Social Science and Medicine, 61, 2469–2481. Montani, J., Viecelli, A. K., Prevot A., et al. (2006). Weight cycling during growth and beyond as a risk factor of later cardiovascular diseases: The ‘repeated overshoot’ theory. International Journal of Obesity, 30(Suppl 4), S58–S66. Mooney, S. J., El-Sayed, A. M. (2006). Stigma and the etiology of depression among the obese: An agent-based exploration. Social Science and Medicine, 148, 1–7. National Heart, Lung, and Blood Institute. (2015). Portion Distortion. Do you know how food portions have changed in twenty years? Washington, DC: Author. Available at: Neil, J. A., Robertson, D. W. (2015). Enhancing nursing care by understanding the bariatric patient’s journey. AORN Journal, 102, 132– 140. Ng, M., Fleming, T., Robinson, M., et al. (2014). Global, regional and national prevalence of overweight and obesity in children and adults during 1980–2013: A systemic analysis for the Global Burden of Disease Study 2013. Lancet, 384(9945), 766–781. O’Donnell, S., Rusu, C., Bernatsky, S., et al. (2013). Exercise/physical activity and weight management efforts in Canadians with selfreported arthritis. Arthritis Care & Research, 65(12), 2015–2023. Padwal, R., Li, S. K., & Lau, D. C. (2004). Long-term pharmacology for obesity and overweight. Cochrane Database of Systematic Reviews, (3), CD004094. ParticipACTION. (2013). Participaction: Let’s get moving. Available at: Patel, S. R., Malhotra, A., White, D. P., et al. (2006). Association between sleep and weight gain in women. American Journal of Epidemiology, 164, 947–954. Pearl, R. L., & Lebowitz, M. S. (2016). Beyond personal responsibility: Effects of causal attributions for overweight and obesity on weightrelated beliefs, stigma, and policy support. Psychology & Health, 29(10), 1176–1191. Pederson, S. J., Cooley, P. D., & Mainsbridge, C. (2014). An e-health intervention designed to increase workday energy expenditure by reducing prolonged occupational sitting habits. Work, 49(2), 289– 295. Pietinläinen, K. H., Saarni, S. E., Kaprio, J., et al. (2012). Does dieting make you fat? A twin study. International Journal of Obesity, 36, 456– 464. Prince, S. A., Kristjansson, E. A., Russell, K., et al. (2012). Relationship between neighborhoods, physical activity, and obesity: A multilevel analysis of a large Canadian city. Obesity, 20(10), 2093–2100. Public Health Agency of Canada and Canadian Institute for Health Information. (2011). Obesity in Canada. Ottawa: Authors. Available at: Puhl, R. M., & Heuer, C. A. (2009). The stigma of obesity: a review and update. Obesity, 17(5), 941–964. Puhl, R. M., & Heuer, C. A. (2010). Obesity stigma: Important considerations for public health. American Journal of Public Health, 100(6), 1019–1028. Pysarenko, S., & Yu, W. (2015). The effects of demographic, socio-economic and lifestyle component on adult obesity in Canada: Empirical study. International Journal of Business and Public Administration, 12(1), 133–151. Raine, K. D., Plotnikoff, R., Schopflocher, D., et al. (2013). Healthy Alberta Communities: Impact of a three-year community-based obesity and chronic disease prevention intervention. Preventive Medicine, 57, 955–962. Rankinen, T., Zuberi, A., Chagnon, Y. C., et al. (2006). The human obesity gene map: The 2005 update. Obesity, 14(4), 529–644. Rockingham, L. (2016). Ethical aspects of nurses’ thought ‘too fat to care’. Nursing Ethics, 23(1), 117–120.

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Rowen, L., & Huseman, S. (2010). Possibilities for nursing classroom and curricula changes: Obesity trends require a new way to educate student nurses. Bariatric Nursing And Surgical Patient Care, 5(2), 95–102. Ruderman, N. B., Carling, D., Prentki, M., et al. (2013). AMPK, insulin resistance, and the metabolic syndrome. Journal of Clinical Investigation, 123(7), 2764–2772. Runfola, C. D., Allison, K. C., Hardy, K., et al. (2014). Prevalence and clinical significance of night eating syndrome in university students. Journal of Adolescent Health, 59, 41–48. Schmaltz, D. L., & Colistra, C. M. (2016). Obesity stigma as a barrier to healthy eating behavior. Topics in Clinical Nutrition, 31(1), 86–94. symptom: An aetiological framework for the assessment and management of obesity. Obesity Reviews, 11, 362–370. Sharma, S., Gittelsohn, J., Rosol, R., et al. (2010). Addressing the public burden caused by the nutrition transition through the Healthy Foods North nutrition and lifestyle intervention programme. Journal of Human Nutrition and Dietetics, 23(Suppl 1), 120–127. Smoyer-Tomic, K. E., Spence, J. C., Raine, K. D., et al. (2007) The association between neighborhood socioeconomic status and exposure to supermarkets and fast food outlets. Health & Place, 14, 740–754. Standing Senate Committee on Social Affairs, Science and Technology. (2016). Report of the Standing Senate Committee on Social Affairs, Science and Technology. Obesity in Canada; A whole-of-society approach for a healthier Canada. Ottawa: Author. Available at: http://www.parl. Statistics Canada. (2012). Body mass index of Canadian children and youth, 2009 to 2011. Available at: Steffen, L. M., Sinaiko, A. R., Zhou, X., et al. (2013). Relation of adiposity, television and screen time in offspring to their parents. BMC Pediatrics, 13, 133. Swinburn, B. A., Sacks, G., Hall, K. D., et al. (2011). The global obesity pandemic: Shaped by global drivers and local environments. Lancet, 378(9793), 804–814. Talen, M. R., & Mann, M. M. (2009). Obesity and mental health. Primary Care, 36(2), 287–305. Teixeira, M. E., & Budd, G. M. (2010). Obesity stigma: A newly recognized barrier to comprehensive and effective type 2 diabetes management. Journal of the American Academy of Nurse Practitioners, 22(10), 527–533. Temelkova-Kurktschiev, T., & Stefanov, T. (2012). Lifestyle and genetics in obesity and type 2 diabetes. Experimental and Clinical Endocrinologyand Diabetes, 120(1), 1–6. The Secretariat for the Intersectoral Healthy Living Network in partnership with the F/P/T Healthy Living Task Group and the F/P/T Advisory Committee on Population Health and Health Security (ACPHHS). (2005). The integrated Pan-Canadian healthy living strategy. Health Canada, Catalogue No. HP10–1/2005. Tjepkema, M. (2005). Adult obesity in Canada: Measured height and weight. Statistics Canada Catalogue no. 82–620-MWE2005001. Towns, C., Cooke, M., Rysdale, L., et al. (2014). Healthy weights interventions in Aboriginal children and youth: A review of the literature. Canadian Journal of Dietetic Practice and Research, 75(3), 125–131. Tremblay, A., & Chaput, J. P. (2008). About unsuspected potential determinants of obesity. Applied Physiology Nutrition and Metabolism, 33, 791–796. Tremblay, M. S., Pérez, C. E., Ardem, C. I., et al. (2005). Obesity, overweight and ethnicity. Statistics Canada Catalogue 82–003, Health Reports, 16(4), 23–34. Tu, A. W., & Mâsse, L. C. (2012). The relationship between income and weight control strategies among Canadian adults. Canadian Journal of Public Health, 103(6), 438–442. Vanasse, A., Demers, M., Hemiari, A., et al. (2006). Obesity in Canada: Where and how many? International Journal of Obesity, 30, 677–783. Wadden, T. A., Butryn, M. L., & Wilson, C. (2007). Lifestyle modification for the management of obesity. Gastroenterology, 132(6), 2226– 2238. Wansink, B., & Wansink, C. S. (2010). The largest Last Supper: Depictions of food portions and plate size increased over the millennium. International Journal of Obesity, 34, 943–944. Ward, H., Tarasuk, B., & Mendelson, R. (2007). Socioeconomic patterns of obesity in Canada: Modeling the role of health behaviour. Applied Physiology Nutrition Metabolism, 32, 206–216.




Basic Concepts in Nursing

Witter, G. A., Huang, K. C., & Heilbron, L. K. (2015). Supporting for callout for people first language in obesity. Obesity Research and Clinical Practice, 9(4), 309. World Health Organization. (2014). Ten facts about obesity. Geneva: Author. Available at: World Health Organization. (2015). Obesity and overweight. Fact Sheet 311. Geneva: Author. Available at: factsheets/fs311/en/ Zimberg, I. Z., Dâmaso, A., Del Re, M., et al. (2012). Short sleep duration and obesity: Mechanisms and future perspectives. Cell Biochemistry and Function, 30, 524–529.

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RESOURCES Canada’s Food Guides: healthy-eating-saine-alimentation/food-guide-aliment/index-eng. php Canadian Obesity Network: Canadian Society for Exercise Physiology, Canadian Physical Activity Guidelines: National Association of bariatric Nurses: ParticipAction: The Obesity Society:


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Case Study Applying Concepts From NANDA-I, NIC, and NOC A Patient With Fear Accompanied by Somatic Complaints Unsubstantiated by Physical Findings Mr. Roberts is a 40-year-old man who comes to the emergency department (ED) for treatment of high blood pressure. On his previous visit to the ED he reported chest pressure, feelings of numbness and tingling in his arms, and extreme fearfulness that he was having a heart attack. Even though a myocardial infarction was ruled out and subsequent testing revealed that he had no heart disease, Mr. Roberts continues to have feelings of chest pressure and fear that he is having a heart attack. The only unexpected finding has been an elevation of blood pressure (158/88 mm Hg). The nurse interviews Mr. Roberts, who reveals he is under intense financial pressure. The nurse assesses his adherence with his antihypertensive therapy and suggests interventions to help with Mr. Robert’s anxiety. Visit to view a concept map that illustrates the relationships that exist between the nursing diagnoses, interventions, and outcomes for the patient’s clinical problems.

Biophysical and Psychosocial Concepts in Nursing Practice

A patient with fear accompanied by somatic complaints unsubstantiated by physical findings receives the nursing diagnoses Anxiety

is managed by

requires nursing interventions Anxiety Reduction

outcomes should show improvement in may lead to improved



Coping Enhancement



Ineffective Coping

may benefit from


and may lead to improved

may lead to improved

and may help improve Support System Enhancement


Nursing Classifications and Languages NANDA-I Nursing Diagnoses

NIC Nursing Interventions

NOC Nursing Outcomes

Anxiety—Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat.

Anxiety Reduction—Minimizing apprehension, dread, foreboding, or uneasiness related to unidentified source of anticipated danger

Anxiety Self-Control—Personal actions to eliminate or reduce feelings of apprehension, tension, or uneasiness from an unidentifiable source

Ineffective Coping—Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources

Coping Enhancement—Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles

Coping—Personal actions to manage stressors that tax an individual’s resources

Return to functional baseline status, stabilization of, or improvement in:

Counseling—Use of an interactive helping process focusing on the needs, problems, or feelings of the patient and significant others to enhance or support coping, problem solving, and interpersonal relationships Support System Enhancement— Facilitation of support to patient by family, friends, and community From Bulechek, G. M., Butcher, H. K., Dochterman, J. M., et al. (Eds.). (2013). Nursing interventions classification (NIC) (6th ed.). St Louis, MO: Mosby-Elsevier; Herdman, T. H. (Ed.). (2012). NANDA International Nursing Diagnoses: Definitions & classification, 2012–2014. Oxford, UK: Wiley-Blackwell; Moorhead, S., Johnson, M., Maas, M. L., et al. (Eds). (2013). Nursing outcomes classification (NOC): Measurement of health outcomes. (5th ed.). St. Louis, MO: Mosby-Elsevier.



7 Homeostasis, Stress, and Adaptation Adapted by Beverly Williams

Learning Objectives On completion of this chapter, the learner will be able to: 1. Relate the principles of internal constancy, homeostasis, stress, and adaptation to the concept of steady state. 2. Identify the significance of the body’s compensatory mechanisms in promoting adaptation and maintaining the steady state. 3. Identify physiologic and psychosocial stressors. 4. Compare the sympathetic–adrenal–medullary and hypothalamic–pituitary responses to stress. 5. Describe the general adaptation syndrome as a theory of adaptation to biologic stress. 6. Describe the relationship of the process of negative feedback to the maintenance of the steady state. 7. Compare the adaptive processes of hypertrophy, atrophy, hyperplasia, dysplasia, and metaplasia. 8. Describe the inflammatory and reparative processes. 9. Assess the health patterns of a person and determine their effects on maintenance of the steady state. 10. Identify ways in which maladaptive responses to stress can increase the risk of illness and cause disease. 11. Identify individual and group measures that are useful in reducing stress.



When the body is threatened or suffers an injury, its response may involve functional and structural changes; these changes may be adaptive (having a positive effect) or maladaptive (having a negative effect). The defense mechanisms that the body uses determine the difference between adaptation and maladaptation—health and disease. This chapter discusses homeostasis, stress, adaptation, health problems associated with maladaptation, and ways nurses can intervene to reduce stress and its healthrelated effects.

FUNDAMENTAL CONCEPTS Each body system performs specific functions to sustain optimal life for an organism. Mechanisms for adjusting internal conditions promote the usual steady state of the organism and its survival. These mechanisms are compensatory in nature and work to restore balance in the body. An example of this restorative effort is the development of rapid breathing (hyperpnea) after intense exercise in an attempt to compensate for an oxygen deficit and excess lactic acid accumulated in the muscle tissue. Pathophysiologic processes result when cellular injury occurs at such a rapid rate that the body’s compensatory mechanisms can no longer make the adaptive changes necessary to remain healthy. An example of a pathophysiologic change is the development of heart failure; the body reacts by retaining sodium and water and increasing venous pressure, which worsens the condition. These pathophysiologic responses give rise to symptoms that are reported by patients or signs that are observed by patients, nurses, or other health care providers. These observations,

Homeostasis, Stress, and Adaptation


plus a sound knowledge of physiologic and pathophysiologic processes, can assist in determining the existence of a problem and can guide nurses in planning the appropriate course of action.

Steady State Physiologic mechanisms must be understood in the context of the body as a whole. Each person, as a living system, has both an internal and an external environment, between which information and matter are continuously exchanged. Within the internal environment, each organ, tissue, and cell is also a system or subsystem of the whole, each with its own internal and external environment, each exchanging information and matter (Fig. 7-1). The goal of the interaction of the body’s subsystems is to produce a dynamic balance or steady state (even in the presence of change), so that all subsystems are in harmony with each other. Four concepts—constancy, homeostasis, stress, and adaptation—are key to the understanding of steady state. Claude Bernard, a 19th-century French physiologist, developed the biologic principle that for life there must be a constancy or “fixity of the internal milieu” despite changes in the external environment. The internal milieu was the fluid that bathed the cells, and the constancy was the balanced internal state maintained by physiologic and biochemical processes. His principle implied a static process. Homeostasis refers to a steady state within the body. When a change or stress occurs that causes a body function to deviate from its stable range, processes are initiated

Glossary adaptation: a change or alteration designed to assist in adjusting to a new situation or environment adrenocorticotropic hormone (ACTH): a hormone produced by the anterior lobe of the pituitary gland that stimulates the secretion of cortisol and other hormones by the adrenal cortex antidiuretic hormone (ADH): a hormone secreted by the posterior lobe of the pituitary gland that constricts blood vessels, elevates blood pressure, and reduces the excretion of urine catecholamines: any of the group of amines (such as epinephrine, norepinephrine, or dopamine) that serve as neurotransmitters coping: the cognitive and behavioural strategies used to manage the stressors that tax a person’s resources dysplasia: bizarre cell growth resulting in cells that differ in size, shape, or arrangement from other cells of the same tissue type glucocorticoids: the group of steroid hormones, such as cortisol, that are produced by the adrenal cortex; they are involved in carbohydrate, protein, and fat metabolism and have anti-inflammatory properties gluconeogenesis: the formation of glucose by the liver from noncarbohydrate sources, such as amino acids and the glycerol portion of fats

guided imagery: the mindful use of a word, phrase, or visual image to achieve relaxation or direct attention away from uncomfortable sensations or situations homeostasis: a steady state within the body; the stability of the internal environment hyperplasia: an increase in the number of new cells of a tissue hypoxia: inadequate supply of oxygen to the cell inflammation: a localized, protective reaction of tissue to injury, irritation, or infection, manifested by pain, redness, heat, swelling, and sometimes loss of function metaplasia: a cell transformation in which there is conversion of one type of mature cell into another type of cell negative feedback: feedback that decreases the output of a system positive feedback: feedback that increases the output of a system steady state: a stable condition that does not change over time, or when change in one direction is balanced by change in an opposite direction stress: a disruptive condition that occurs in response to adverse influences from the internal or external environments



Biophysical and Psychosocial Concepts in Nursing Practice

External environment: Family Group Community Society as a whole Humans

Organ system




FIGURE 7-1. Constellation of systems. Each system is a subsystem of

the larger system (suprasystem) of which it is a part. In this figure the cells represent the smallest system and are a subsystem of all other systems.

to restore and maintain dynamic balance. When these adjustment processes or compensatory mechanisms are not adequate, steady state is threatened, function becomes disordered, and dysfunctional responses occur. This can lead to disease, which is a threat to steady state. Disease is an unexpected variation in the structure or function of any part of the body. It disrupts function and therefore can limit freedom of action.

Stress and Adaptation Stress is a state produced by a change in the environment that is perceived as challenging, threatening, or damaging to a person’s dynamic balance or equilibrium. The person may feel unable to meet the demands of the new situation. The change or stimulus that evokes this state is the stressor. The nature of the stressor is variable; an event or change that is stressful for one person may not be stressful for another, and an event that produces stress at one time and place may not do so at another time and place. A person appraises and copes with changing situations. The desired goal is adaptation or adjustment to the change so that the person is again in equilibrium and has the energy and ability to meet new demands. This is the process of coping with the stress, a compensatory process that has physiologic and psychological components. Adaptation is a constant, ongoing process that requires a change in structure, function, or behaviour so that a person is better suited to the environment; it involves an interaction between the person and the environment. The outcome depends on the degree of “fit” between the skills and capacities of the person, the type of social support available, and the various challenges or stressors encountered. As such, adaptation is an individual process: Each

person has varying abilities to cope or respond. As new challenges are met, this ability to cope and adapt can change, thereby providing the person with a wide range of adaptive ability. Adaptation occurs throughout the lifespan as the person encounters many developmental and situational challenges, especially related to health and illness. The goal of adaptation is optimal wellness. Because both stress and adaptation may exist at different levels of a system, it is possible to study these reactions at the cellular, tissue, and organ levels. Biologists are concerned mainly with subcellular components or with subsystems of the total body. Behavioural scientists, including many nurse researchers, study stress and adaptation in individuals, families, groups, and societies; they focus on how a group’s organizational features are modified to meet the requirements of the social and physical environment in which the group exists. In any system, the desired goals of adaptation are survival, growth, and reproduction.

OVERVIEW OF STRESS Types of Stressors Each person operates at a certain level of adaptation and regularly encounters a certain amount of change. Such change is expected; it contributes to growth and enhances life. A stressor can upset this equilibrium. A stressor may be defined as an internal or external event or situation that creates the potential for physiologic, emotional, cognitive, or behavioural changes in an individual. Stressors exist in many forms and categories. They may be described as physical, physiologic, or psychosocial. Physical stressors include cold, heat, and chemical agents; physiologic stressors include pain and fatigue. An example of a psychosocial stressor is fear (e.g., fear of failing an examination, losing a job, and waiting for a diagnostic test result). Stressors can also occur as expected life transitions that require some adjustment, such as going from childhood into puberty, getting married, or giving birth. Stressors have also been classified as (1) day-to-day frustrations or hassles, (2) major complex occurrences involving large groups, and (3) stressors that occur less frequently and involve fewer people. The first group, the day-to-day stressors, includes such common occurrences as getting caught in a traffic jam, experiencing computer downtime, and having an argument with a spouse or roommate. These experiences vary in effect. For example, encountering a rainstorm while you are vacationing at the beach will most likely evoke a more negative response than it might at another time. These daily hassles have been shown to have a greater health impact than major life events because of the cumulative effect they have over time. They can lead to high blood pressure, palpitations, or other physiologic changes (Rice, 2005). The second group of stressors influences larger groups of people, sometimes even entire nations. These include events of history, such as terrorism and war, experienced either directly in the war zone or indirectly through live news coverage. The demographic, economic, and


technologic changes occurring in society also serve as stressors. The tension produced by any stressor is sometimes a result not only of the change itself, but also of the speed with which the change occurs. The third group of stressors has been studied most extensively and concerns relatively infrequent situations that directly affect people. This category includes the influence of life events such as death, birth, marriage, divorce, and retirement. It also includes the psychosocial crises that occur in the life cycle stages of the human experience. More enduring chronic stressors may include having a permanent disability or coping with the need to provide long-term care to a frail older parent. Duration may also be used to categorize stressors, as in the following: • An acute, time-limited stressor, such as studying for final examinations • A stressor sequence—a series of stressful events that result from an initial event such as job loss or divorce • A chronic intermittent stressor, such as daily hassles • A chronic enduring stressor that persists over time, such as chronic illness, a disability, or poverty

Stress as a Stimulus for Disease Relating life events to illness (the theoretical approach that defines stress as a stimulus) has been a major focus of psychosocial studies. Research has revealed that people under constant stress have a high incidence of psychosomatic disease. Holmes and Rahe (1967) developed life event scales that assign numerical values, called life-change units, to typical life events. Because the items in the scales reflect events that require a change in a person’s life pattern, and stress is defined as an accumulation of changes in one’s life that require psychological adaptation, one can theoretically predict the likelihood of illness by checking off the number of recent events and deriving a total score. The Recent Life Changes Questionnaire (Tausig, 1982) contains 118 items such as death, birth, marriage, divorce, promotions, serious arguments, and vacations. The items include both desirable and undesirable events. Sources of stress for people have been well researched (Barnard, Street, & Love, 2006; Lunney, 2006; Tak, 2006). People typically experience distress related to alterations in their physical and emotional health status, changes in their level of daily functioning, and decreased social support or the loss of significant others. Fears of immobilization, isolation, loneliness, sensory changes, financial issues, and death or disability increase a person’s anxiety level. Loss of one’s role or perceived purpose in life can cause intense discomfort. Any of these identified variables, plus myriad other conditions or overwhelming demands are likely to cause ineffective coping, and a lack of necessary coping skills is often a source of additional distress for the person. When a person endures prolonged or unrelenting suffering, the outcome is frequently the development of a stress-related illness. Nurses have the skills to assist people to alter their distressing circumstances and manage their responses to stress.

Homeostasis, Stress, and Adaptation


Psychological Responses to Stress After recognizing a stressor, a person consciously or unconsciously reacts to manage the situation. This is termed the mediating process. A theory developed by Lazarus (1991a) emphasizes cognitive appraisal and coping as important mediators of stress. Appraisal and coping are influenced by antecedent variables, including the internal and external resources of the individual person.

Appraisal of the Stressful Event Cognitive appraisal (Lazarus, 1991a; Lazarus & Folkman, 1984) is a process by which an event is evaluated with respect to what is at stake (primary appraisal) and what might and can be done (secondary appraisal). What a person sees as being at stake is influenced by his or her personal goals, commitments, or motivations. Important factors include how important or relevant the event is to the person, whether the event conflicts with what the person wants or desires, and whether the situation threatens the person’s own sense of strength and ego identity. Primary appraisal results in the situation being identified as either nonstressful or stressful. Secondary appraisal is an evaluation of what might and can be done about the situation. Reappraisal, a change of opinion based on new information, may occur. The appraisal process is not necessarily sequential; primary and secondary appraisal and reappraisal may occur simultaneously. The appraisal process contributes to the development of an emotion. Negative emotions such as fear and anger accompany harm/loss appraisals, and positive emotions accompany challenge. In addition to the subjective component or feeling that accompanies a particular emotion, each emotion also includes a tendency to act in a certain way. For example, unprepared students may view an unexpected quiz as threatening. They might feel fear, anger, and resentment and might express these emotions through hostile behaviour or comments. Lazarus (1991a) expanded his initial ideas about stress, appraisal, and coping into a more complex model relating emotion to adaptation. He called this model a “cognitivemotivational-relational theory,” with the term relational “standing for a focus on negotiation with a physical and social world” (p. 13). A theory of emotion was proposed as the bridge to connect psychology, physiology, and sociology: “More than any other arena of psychological thought, emotion is an integrative, organismic concept that subsumes psychological stress and coping within itself and unites motivation, cognition, and adaptation in a complex configuration” (p. 40).

Coping With the Stressful Event Coping consists of the cognitive and behavioural efforts made to manage the specific external or internal demands that tax a person’s resources and may be emotion focused or problem focused. Coping that is emotion focused seeks to make the person feel better by lessening the emotional distress. Problem-focused coping aims to make direct



Biophysical and Psychosocial Concepts in Nursing Practice

changes in the environment so that the situation can be managed more effectively. Both types of coping usually occur in a stressful situation. Even if the situation is viewed as challenging or beneficial, coping efforts may be required to develop and sustain the challenge—that is, to maintain the positive benefits of the challenge and to ward off any threats. In harmful or threatening situations, successful coping reduces or eliminates the source of stress and relieves the emotion generated. Appraisal and coping are affected by internal characteristics such as health, energy, personal belief systems, commitments or life goals, self-esteem, control, mastery, knowledge, problem-solving skills, and social skills. The characteristics that have been studied most often in nursing research are health-promoting lifestyles and hardiness. A health-promoting lifestyle buffers the effect of stressors. From a nursing practice standpoint, this outcome— buffering the effect of stressors—supports nursing’s goal of promoting health. In many circumstances, promoting a healthy lifestyle is more achievable than altering the stressors. Hardiness is a general quality that comes from having rich, varied, and rewarding experiences. Hardy people perceive stressors as something they can change and therefore control. To them, potentially stressful situations are interesting and meaningful; change and new situations are viewed as challenging opportunities for growth. Researchers have found positive support for hardiness as a significant variable that positively influences rehabilitation and overall improvement after an onset of an illness (Ayalon & Covinsky, 2007; Baumgartner, 2007; Greeff & Holtzkamp, 2007; Travis, 2007).

Physiologic Response to Stress The physiologic response to a stressor, whether it is physical or psychological, is a protective and adaptive mechanism to maintain the homeostatic balance of the body. When a stress response occurs, it activates a series of neurologic and hormonal processes within the brain and body systems. The duration and intensity of the stress can cause both short-term and long-term effects. A stressor can disrupt homeostasis to the point where adaptation to the stressor fails, and a disease process results.

Selye’s Theory of Adaptation Hans Selye developed a theory of adaptation that profoundly influenced the scientific study of stress (1976). Selye first described a syndrome consisting of enlargement of the adrenal cortex; shrinkage of the thymus, spleen, lymph nodes, and other lymphatic structures; and the appearance of deep, bleeding ulcers in the stomach and duodenum. He identified this as a nonspecific response to diverse, noxious stimuli.

General Adaptation Syndrome Selye then developed a theory of adaptation to biologic stress that he named the general adaptation syndrome (GAS), which has three phases: alarm, resistance, and exhaustion. During the alarm phase, the sympathetic

“fight-or-flight” response is activated with release of catecholamines and the onset of the adrenocorticotropic hormone (ACTH)–adrenal cortical response. The alarm reaction is defensive and anti-inflammatory but self-limited. Because living in a continuous state of alarm would result in death, people move into the second stage, resistance. During the resistance stage, adaptation to the noxious stressor occurs, and cortisol activity is still increased. If exposure to the stressor is prolonged, the third stage, exhaustion, occurs. During the exhaustion stage, endocrine activity increases, and this has negative effects on the body systems (especially the circulatory, digestive, and immune systems) that can lead to death. Stages one and two of this syndrome are repeated, in different degrees, throughout life as the person encounters stressors. Selye compared the GAS with the life process. During childhood, too few encounters with stress occur to promote the development of adaptive functioning, and children are vulnerable. During adulthood, a number of stressful events occur, and people develop resistance or adaptation. During the later years, the accumulation of life’s stressors and wear and tear on the organism again decrease people’s ability to adapt, resistance falls, and eventually death occurs.

Local Adaptation Syndrome According to Selye, a local adaptation syndrome also occurs. This syndrome includes the inflammatory response and repair processes that occur at the local site of tissue injury. The local adaptation syndrome occurs in small, topical injuries, such as contact dermatitis. If the local injury is severe enough, the GAS is activated as well. Selye emphasized that stress is the nonspecific response common to all stressors, regardless of whether they are physiologic, psychological, or social. The many conditioning factors in each person’s environment account for why different demands are experienced by different people as stressors. Conditioning factors also account for differences in the tolerance of different people for stress: Some people may develop diseases of adaptation, such as hypertension and migraine headaches, whereas others are unaffected.

Interpretation of Stressful Stimuli by the Brain Physiologic responses to stress are mediated by the brain through a complex network of chemical and electrical messages. The neural and hormonal actions that maintain homeostatic balance are integrated by the hypothalamus, which is located in the centre of the brain, surrounded by the limbic system and the cerebral hemispheres. The hypothalamus is made up of a number of nuclei and integrates autonomic nervous system mechanisms that maintain the chemical constancy of the internal environment of the body. Together with the limbic system, which contains the amygdala, hippocampus, and septal nuclei, along with other structures, the hypothalamus regulates emotions and many visceral behaviours necessary for survival (e.g., eating, drinking, temperature control, reproduction, defense, aggression).


Each of the brain structures responds differently to stimuli. The cerebral hemispheres are concerned with cognitive functions: thought processes, learning, and memory. The limbic system has connections with both the cerebral hemispheres and the brain stem. In addition, the reticular activating system (RAS), a network of cells that forms a two-way communication system, extends from the brain stem into the midbrain and limbic system. This network controls the alert or waking state of the body. In the stress response, afferent impulses are carried from sensory organs (eye, ear, nose, skin) and internal sensors (baroreceptors, chemoreceptors) to nerve centres in the brain. The response to the perception of stress is integrated in the hypothalamus, which coordinates the adjustments necessary to return to homeostatic balance. The degree and duration of the response vary; major stress evokes both sympathetic and pituitary adrenal responses. Neural and neuroendocrine pathways under the control of the hypothalamus are also activated in the stress response. Initially, there is a sympathetic nervous system discharge, followed by a sympathetic–adrenal–medullary discharge. If the stress persists, the hypothalamic–pituitary system is activated (Fig. 7-2).

Physiology/Pathophysiology Stressors

Cortex, limbic system, reticular formation Norepinephrine neurons

CRH neurons

CRH neurons


Sympathetic neurons


Spinal cord ACTH

Arousal, Feeding and behavioural sexual activity activation, aggressiveness

Growth and reproductive function

Medulla Adrenal gland Epinephrine

Energy mobilization and redistribution, cardiovascular responsivity

Stimulate Inhibit Inflammatory and immune responses

Homeostasis, Stress, and Adaptation


Sympathetic Nervous System Response The sympathetic nervous system response is rapid and short lived. Norepinephrine is released at nerve endings that are in direct contact with their respective end organs to cause an increase in function of the vital organs and a state of general body arousal. The heart rate is increased and peripheral vasoconstriction occurs, raising the blood pressure. Blood is also shunted away from abdominal organs. The purpose of these responses is to provide better perfusion of vital organs (brain, heart, skeletal muscles). Blood glucose is increased, supplying more readily available energy. The pupils are dilated, and mental activity is increased; a greater sense of awareness exists. Constriction of the blood vessels of the skin limits bleeding in the event of trauma. The person is likely to experience cold feet, clammy skin and hands, chills, palpitations, and “knots” in the stomach. Typically, the person appears tense, with the muscles of the neck, upper back, and shoulders tightened; respirations may be rapid and shallow, with the diaphragm tense.

Sympathetic–Adrenal–Medullary Response In addition to its direct effect on major end organs, the sympathetic nervous system stimulates the medulla of the adrenal gland to release the hormones epinephrine and norepinephrine into the bloodstream. The action of these hormones is similar to that of the sympathetic nervous system and has the effect of sustaining and prolonging its actions. Epinephrine and norepinephrine are catecholamines that stimulate the nervous system and produce metabolic effects that increase the blood glucose level and increase the metabolic rate. The effect of the sympathetic– adrenal–medullary responses is summarized in Table 7-1. This effect is called the “fight-or-flight” reaction.

Hypothalamic–Pituitary Response


Cortex Cortisol

Visceral function

FIGURE 7-2. Integrated responses to stress mediated by the sympa-

thetic nervous system and the hypothalamic–pituitary–adrenocortical axis. The responses are mutually reinforcing at both the central and peripheral levels. Negative feedback by cortisol also can limit an overresponse that might be harmful to the individual. Coloured arrows represent stimulation; open arrows, inhibition. CRH, corticotropinreleasing hormone; ACTH, adrenocorticotropic hormone. (Reproduced with permission from Berne, R. M. & Levy, M. N. [2003]. Physiology. St. Louis, MO: C. V. Mosby.)

The longest-acting phase of the physiologic response, which is more likely to occur in persistent stress, involves the hypothalamic–pituitary pathway. The hypothalamus secretes corticotropin-releasing factor, which stimulates the anterior pituitary to produce ACTH, which in turn stimulates the adrenal cortex to produce glucocorticoids, primarily cortisol. Cortisol stimulates protein catabolism, releasing amino acids; stimulates liver uptake of amino acids and their conversion to glucose (gluconeogenesis); and inhibits glucose uptake (anti-insulin action) by many body cells but not those of the brain and heart. These cortisol-induced metabolic effects provide the body with a ready source of energy during a stressful situation. This effect has some important implications. For example, a person with diabetes who is under stress, such as that caused by an infection, needs more insulin than usual. Any patient who is under stress (e.g., illness, surgery, trauma, or prolonged psychological stress) catabolizes body protein and needs supplements. The actions of the catecholamines (epinephrine and norepinephrine) and cortisol are the most important in the general response to stress. Other hormones that play a role are antidiuretic hormone (ADH) released from the posterior pituitary and aldosterone released from the adrenal cortex. ADH and aldosterone promote sodium




Biophysical and Psychosocial Concepts in Nursing Practice

Sympathetic–Adrenal–Medullary Response to Stress




Increased heart rate and blood pressure Increased blood glucose level

Better perfusion of vital organs

Mental acuity

Alert state

Dilated pupils Increased tension of skeletal muscles Increased ventilation (may be rapid and shallow) Increased coagulability of blood

Increased awareness Preparedness for activity, decreased fatigue Provision of oxygen for energy

Increased cardiac output due to increased myocardial contractility and heart rate; increased venous return (peripheral vasoconstriction) Increased liver and muscle glycogen breakdown; increased breakdown of adipose tissue triglycerides Increase in amount of blood shunted to the brain from the abdominal viscera and skin Contraction of radial muscle of iris Excitation of muscles; increase in amount of blood shunted to the muscles from the abdominal viscera and skin Stimulation of respiratory centre in medulla; bronchodilation

Increased available energy

Prevention of hemorrhage in event of trauma

Vasoconstriction of surface vessels

and water retention, which is an adaptive mechanism in the event of hemorrhage or loss of fluids through excessive perspiration. ADH has also been shown to influence learning and may thus facilitate coping in new and threatening situations. Secretion of growth hormone and glucagon stimulates the uptake of amino acids by cells, helping to mobilize energy resources. Endorphins, which are endogenous opioids, increase during stress and enhance the threshold for tolerance of painful stimuli. They may also affect mood and have been implicated in the so-called high that long-distance runners experience. The secretion of other hormones is also affected, but their adaptive function is less clear.

Immunologic Response Research findings show that the immune system is connected to the neuroendocrine and autonomic systems. Lymphoid tissue is richly supplied by autonomic nerves capable of releasing a number of different neuropeptides that can have a direct effect on leukocyte regulation and the inflammatory response. Neuroendocrine hormones released by the central nervous system and endocrine tissues can inhibit or stimulate leukocyte function. The wide variety of stressors a person experiences may result in different alterations in autonomic activity and subtle variations in neurohormone and neuropeptide synthesis. All of these possible autonomic and neuroendocrine responses can interact to initiate, weaken, enhance, or terminate an immune response. The study of the relationships among the neuroendocrine system, the central and autonomic nervous systems, and the immune system and the effects of these relationships on overall health outcomes is called psychoneuroimmunology. Because one’s perception of events and one’s coping styles determine whether, and to what extent, an event activates the stress response system, and because the stress response affects immune activity, one’s perceptions, ideas, and thoughts can have profound neurochemical and immunologic consequences. Studies have demonstrated alteration of immune function in people who are under stress (Kendall-Tackett, 2007; Leserman & Drossman, 2007; Mertin, Sawatzky, Diehl-Jones, et al., 2007). Other studies have identified certain personality traits, such as optimism and active coping, as having positive effects on health (Dilworth-Anderson, Boswell, & Cohen,

2007; Krucoff, 2007; Verhaeghe, van Zuuren, DeFloor, et al., 2007). As research continues, this field of study will likely uncover to what extent and by what mechanisms people can consciously influence their immunity.

Maladaptive Responses to Stress The stress response, as indicated earlier, facilitates adaptation to threatening situations, and is retained from humans’ evolutionary past. The “fight-or-flight” response, for example, is an anticipatory response that mobilized the bodily resources of our ancestors to deal with predators and other harsh factors in their environment. This same mobilization comes into play in response to emotional stimuli unrelated to danger. For example, a person may get an “adrenaline rush” when competing over a decisive point in a ball game, or when excited about attending a party. When responses to stress are ineffective, they are referred to as maladaptive. Maladaptive responses are chronic, recurrent responses or patterns of response that do not promote the goals of adaptation. The goals of adaptation are somatic or physical health (optimal wellness); psychological health or having a sense of well-being (happiness, satisfaction with life, morale); and enhanced social functioning, which includes work, social life, and family (positive relationships). Maladaptive responses that threaten these goals include faulty appraisals and inappropriate coping (Lazarus, 1991a). The frequency, intensity, and duration of stressful situations contribute to the development of emotions and subsequent patterns of neurochemical discharge. By appraising situations adequately and coping appropriately, it is possible to anticipate and defuse some of these situations. For example, frequent stressful encounters (e.g., marital discord) might be avoided with better communication and problem solving, or a pattern of procrastination (e.g., delaying work on tasks) could be corrected to reduce stress when deadlines approach. Coping processes that include the use of alcohol or drugs to reduce stress increase the risk of illness. Other inappropriate coping patterns may increase the risk of illness less directly. For example, people who demonstrate


“type A” behaviours, including impatience, competitiveness, and achievement orientation, have an underlying aggressive approach to life and are more prone than others to develop stress-related illnesses. Type A behaviours increase the output of catecholamines, the adrenal– medullary hormones, with their attendant effects on the body. Additional forms of inappropriate coping include denial, avoidance, and distancing. Denial may be illustrated by the woman who feels a lump in her breast but downplays its seriousness and delays seeking medical attention. The intent of denial is to control the threat, but it may also endanger life. Models of illness frequently include stress and maladaptation as precursors to disease. A general model of illness, based on Selye’s theory, suggests that any stressor elicits a state of disturbed physiologic equilibrium. If this state is prolonged or the response is excessive, it increases the susceptibility of the person to illness. This susceptibility, coupled with a predisposition in the person (from genetic traits, health, or age), leads to illness. If the sympathetic adrenal–medullary response is prolonged or excessive, a state of chronic arousal develops that may lead to high blood pressure, arteriosclerotic changes, and cardiovascular disease. If the production of ACTH is prolonged or excessive, behaviour patterns of withdrawal and depression are seen. In addition, the immune response is decreased, and infections and tumours may develop. Selye (1976) proposed a list of disorders known as diseases of maladaptation: high blood pressure (including hypertension of pregnancy), diseases of the heart and blood vessels, diseases of the kidney, rheumatic and rheumatoid arthritis, inflammatory diseases of the skin and eyes, infections, allergic and hypersensitivity diseases, nervous and mental diseases, sexual dysfunction, digestive diseases, metabolic diseases, and cancer.

Homeostasis, Stress, and Adaptation



Assessing for Stress Be alert for the following signs and symptoms: Restlessness Depression Dry mouth Overpowering urge to act out Fatigue Loss of interest in life activities Intense periods of anxiety Strong startle response Hyperactivity Gastrointestinal distress Diarrhea Nausea or vomiting Changes in menstrual cycle Change in appetite Injury prone Palpitations Impulsive behaviours Emotional lability Concentration difficulties Feeling weak or dizzy Increased body tension Tremors Nervous habits Nervous laughter Bruxism (grinding of teeth) Difficulty sleeping Excessive perspiration Urinary frequency Headaches Pain in back, neck, or other parts of the body Increased use of tobacco Substance use or abuse Unintentional weight loss or gain

Indicators of Stress Indicators of stress and the stress response include both subjective and objective measures. Chart 7-1 lists signs and symptoms that may be observed directly or reported by a person. They are psychological, physiologic, or behavioural and reflect social behaviours and thought processes. Some of these reactions may be coping behaviours. Over time, each person tends to develop a characteristic pattern of behaviour during stress to warn that the system is out of balance. Laboratory measurements of indicators of stress have helped in understanding this complex process. Blood and urine analyses can be used to demonstrate changes in hormonal levels and hormonal breakdown products. Blood levels of catecholamines, glucocorticoids, ACTH, and eosinophils are reliable measures of stress. Serum cholesterol and free fatty acid levels can be used to measure stress. When the body experiences distress, there are changes in adrenal hormones such as cortisol and aldosterone. As the levels of these chemicals increase, there is a simultaneous release of additional cholesterol into the general circulation. Both physical and psychological distress can trigger an elevated cholesterol level. In addition, the results of immunoglobulin assays are increased when a person is exposed to a variety of stressors, especially

infections and immunodeficiency conditions. With greater attention to the field of neuroimmunology, improved laboratory measures are likely to follow. In addition to using laboratory tests, researchers have developed questionnaires to identify and assess stressors, stress, and coping strategies. The work of Rice (2005), a compilation of information gained from research on stress, coping, and health, includes some of these questionnaires. Research reports also contain examples of instruments that nurses use to measure levels of patient distress and patient functioning (Caetano, Ramisetty-Miller, CaetanoVaeth, et al., 2007; Weisel, Most, & Michael, 2007). Miller and Smith (1993) provided a stress audit and a stress profile measurement tool that is available in the popular lay literature.

Nursing Implications It is important for nurses to realize that the optimal point of intervention to promote health is during the stage when a person’s own compensatory processes are still functioning effectively. A major role of nurses is the early identification of both physiologic and psychological stressors.



Biophysical and Psychosocial Concepts in Nursing Practice

Nurses should be able to relate the presenting signs and symptoms of distress to the physiology they represent and identify a person’s position on the continuum of function, from health and compensation to pathophysiology and disease. For example, if an anxious, middle-aged woman presented for a checkup and was found to be overweight with a blood pressure of 150/85 mm Hg, the nurse would counsel her with respect to diet, stress management, and activity. The nurse would also encourage weight loss and discuss the woman’s intake of salt (which affects fluid balance) and caffeine (which provides a stimulant effect). The patient and the nurse would identify both individual and environmental stressors and discuss strategies to decrease her lifestyle stress, with the ultimate goal being to create a healthy lifestyle and prevent hypertension and its sequelae.

STRESS AT THE CELLULAR LEVEL Pathologic processes may occur at all levels of the biologic organism. If the cell is considered the smallest unit or subsystem (tissues being aggregates of cells, organs aggregates of tissues, and so on), the processes of health and disease or adaptation and maladaptation can all occur at the cellular level. Indeed, pathologic processes are often described by scientists at the subcellular or molecular level. The cell exists on a continuum of function and structure, ranging from the usual cell, to the adapted cell, to the injured or diseased cell, to the dead cell (Fig. 7-3). Changes from one state to another may occur rapidly and may not be readily detectable, because each state does not have discrete boundaries, and disease represents disruption of usual processes. The earliest changes occur at the molecular or subcellular level and are not perceptible until steady-state functions or structures are altered. With cell injury, some changes may be reversible; in other instances, the injuries are lethal. For example, tanning of the skin is an adaptive, morphologic response to exposure to the rays of the sun. However, if the exposure is continued, sunburn and injury occur, and some cells may die, as evidenced by desquamation (“peeling”).

Physiology/Pathophysiology HEALTH Normal cell

Adapted cell

Compensatory mechanisms; cell remains intact

DISEASE Injured or diseased cell

Dead cell

Pathophysiologic mechanisms; loss of cell integrity

FIGURE 7-3. The cell on a continuum of function and structure.

Changes in the cell are not as easily discerned as the diagram depicts, and the point at which compensation subsides and pathophysiology begins is not clearly defined.

Different cells and tissues respond to stimuli with different patterns and rates of response, and some cells are more vulnerable to one type of stimulus or stressor than others. The cell involved, its ability to adapt, and its physiologic state are determinants of the response. For example, cardiac muscle cells respond to hypoxia (inadequate oxygenation) more quickly than do smooth muscle cells. Other determinants of cellular response are the type or nature of the stimulus, its duration, and its severity. For example, neurons that control respiration can develop a tolerance to regular, small amounts of a barbiturate, but one large dose may result in respiratory depression and death.

Control of the Steady State The concept of the cell as existing on a continuum of function and structure includes the relationship of the cell to compensatory mechanisms, which occur continuously in the body to maintain the steady state. Compensatory processes are regulated primarily by the autonomic nervous system and the endocrine system, with control achieved through negative feedback.

Negative Feedback Negative feedback mechanisms throughout the body monitor the internal environment and restore homeostasis when conditions shift out of the usual range. These mechanisms work by sensing deviations from a predetermined set point or range of adaptability and triggering a response aimed at offsetting the deviation. Blood pressure, acid– base balance, blood glucose level, body temperature, and fluid and electrolyte balance are examples of functions regulated through such compensatory mechanisms. Most of the human body’s control systems are integrated by the brain with feedback from the nervous and endocrine systems. Control activities involve detecting deviations from the predetermined reference point and stimulating compensatory responses in the muscles and glands of the body. The major organs affected are the heart, lungs, kidneys, liver, gastrointestinal tract, and skin. When stimulated, these organs alter their rate of activity or the amount of secretions they produce. Because of this, they have been called the “organs of homeostasis or adjustment.” In addition to the responses influenced by the nervous and endocrine systems, local responses consisting of small feedback loops in a group of cells or tissues are possible. The cells detect a change in their immediate environment and initiate an action to counteract its effect. For example, the accumulation of lactic acid in an exercised muscle stimulates dilation of blood vessels in the area to increase blood flow and improve the delivery of oxygen and removal of waste products. The net result of the activities of feedback loops is homeostasis. A steady state is achieved by the continuous, variable action of the organs involved in making the adjustments and by the continuous exchange of chemical substances among cells, interstitial fluid, and blood. For example, an increase in the CO2 concentration of the extracellular fluid leads to increased pulmonary


ventilation, which decreases the CO2 level. On a cellular level, increased CO2 raises the hydrogen ion concentration of the blood. This is detected by chemosensitive receptors in the respiratory control centre of the medulla of the brain. The chemoreceptors stimulate an increase in the rate of discharge of the neurons that innervate the diaphragm and intercostal muscles, which increases the rate of respiration. Excess CO2 is exhaled, the hydrogen ion concentration returns to a steady state, and the chemically sensitive neurons are no longer stimulated (Kunert, 2010).

Positive Feedback Another type of feedback, positive feedback, perpetuates the chain of events set in motion by the original disturbance instead of compensating for it. As the system becomes more unbalanced, disorder and disintegration occur. There are some exceptions to this; blood clotting in humans, for example, is an important positive feedback mechanism.

Cellular Adaptation Cells are complex units that dynamically respond to the changing demands and stresses of daily life. They possess a maintenance function and a specialized function. The maintenance function refers to the activities that the cell must perform with respect to itself; specialized functions are those that the cell performs in relation to the tissues and organs of which it is a part. Individual cells may cease to function without posing a threat to the organism. However, as the number of dead cells increases, the specialized functions of the tissues are altered, and health is threatened. Cells can adapt to environmental stress through structural and functional changes. Some of these adaptations include cellular hypertrophy, atrophy, hyperplasia, dysplasia, and metaplasia (Table 7-2). These adaptations reflect changes in the usual cell in response to stress. If TABLE 7-2

Homeostasis, Stress, and Adaptation


the stress is unrelenting, cellular injury and death may occur. Hypertrophy and atrophy lead to changes in the size of cells and hence the size of the organs they form. Compensatory hypertrophy is the result of an enlarged muscle mass and commonly occurs in skeletal and cardiac muscle that experiences a prolonged, increased workload. One example is the bulging muscles of the athlete who engages in body building. Atrophy can be the consequence of disease, decreased use, decreased blood supply, loss of nerve supply, or inadequate nutrition. Disuse of a body part is often associated with the aging process and immobilization. Cell size and organ size decrease, and the structures principally affected are the skeletal muscles, the secondary sex organs, the heart, and the brain. Hyperplasia is an increase in the number of new cells in an organ or tissue. As cells multiply and are subjected to increased stimulation, the tissue mass enlarges. This mitotic response (a change occurring with mitosis) is reversible when the stimulus is removed. This distinguishes hyperplasia from neoplasia or malignant growth, which continues after the stimulus is removed. Hyperplasia may be hormonally induced. An example is the increased size of the thyroid gland caused by thyroidstimulating hormone (secreted from the pituitary gland) when a deficit in thyroid hormone occurs. Dysplasia is bizarre cell growth resulting in cells that differ in size, shape, or arrangement from other cells of the same tissue type. Dysplastic cells have a tendency to become malignant; dysplasia is seen commonly in epithelial cells in the bronchi of people who smoke. Metaplasia is a cell transformation in which there is a conversion of one type of mature cell into another type of cell. This serves a protective function, because less transformed cells are more resistant to the stress that stimulated the change. For example, the ciliated columnar epithelium lining the bronchi of people who smoke is replaced by squamous epithelium. The squamous cells can survive; loss of the cilia and protective mucus, however, can have damaging consequences.

Cellular Adaptation to Stressors




Hypertrophy—increase in cell size leading to increase in organ size

Increased workload

Leg muscles of runner Arm muscles in tennis player Cardiac muscle in person with hypertension

Atrophy—shrinkage in size of cell, leading to decrease in organ size

Decrease in: Use Blood supply Nutrition Hormonal stimulation Innervation

Secondary sex organs in aging person Extremity immobilized in cast

Hyperplasia—increase in number of new cells (increase in mitosis)

Hormonal influence

Breast changes of girl in puberty or of pregnant woman Regeneration of liver cells New red blood cells in blood loss

Dysplasia—bizarre changes in the appearance of cells

Reproduction of cells with resulting alteration of their size and shape

Alterations in epithelial cells of the skin or the cervix, producing irregular tissue changes that could be the precursors of a malignancy

Metaplasia—transformation of one adult cell type to another (reversible)

Stress applied to highly specialized cell

Changes in epithelial cells lining bronchi in response to smoke irritation (cells become less specialized)



Biophysical and Psychosocial Concepts in Nursing Practice

Cellular Injury


Injury is defined as a disorder in steady-state regulation. Any stressor that alters the ability of the cell or system to maintain optimal balance of its adjustment processes leads to injury. Structural and functional damage then occurs, which may be reversible (permitting recovery) or irreversible (leading to disability or death). Homeostatic adjustments are concerned with the small changes within the body’s systems. With adaptive changes, compensation occurs and a new steady state may be achieved. With injury, steady-state regulation is lost, and changes in functioning ensue. Causes of disorder and injury in the system (cell, tissue, organ, body) may arise from the external or internal environment (Fig. 7-4) and include hypoxia, nutritional imbalance, physical agents, chemical agents, infectious agents, immune mechanisms, genetic defects, and psychogenic factors. The most common causes are hypoxia (oxygen deficiency), chemical injury, and infectious agents. In addition, the presence of one injury makes the system more susceptible to another injury. For example, inadequate oxygenation and nutritional deficiencies make the system vulnerable to infection. These agents act at the cellular level by damaging or destroying: • The integrity of the cell membrane, necessary for ionic balance • The ability of the cell to transform energy (aerobic respiration, production of adenosine triphosphate) • The ability of the cell to synthesize enzymes and other necessary proteins • The ability of the cell to grow and reproduce (genetic integrity)



Processing of information and matter


Inadequate cellular oxygenation (hypoxia) interferes with the cell’s ability to transform energy. Hypoxia may be caused by a decrease in blood supply to an area, a decrease in the oxygen-carrying capacity of the blood (decreased hemoglobin), a ventilation/perfusion or respiratory problem that reduces the amount of arterial oxygen available, or a problem in the cell’s enzyme system that makes it unable to use oxygen. The usual cause of hypoxia is ischemia, or deficient blood supply. Ischemia is commonly seen in myocardial cell injury in which arterial blood flow is decreased because of atherosclerotic narrowing of blood vessels. Ischemia also results from intravascular clots (thrombi or emboli) that may form and interfere with blood supply. Thrombi and emboli are common causes of cerebrovascular accidents (strokes, brain attacks). The length of time different tissues can survive without oxygen varies. For example, brain cells most often succumb in 3 to 6 minutes. If the condition leading to hypoxia is slow and progressive, collateral circulation may develop, whereby blood is supplied by other blood vessels in the area. However, this mechanism is not highly reliable.

Nutritional Imbalance Nutritional imbalance refers to a relative or absolute deficiency or excess of one or more essential nutrients. This may be manifested as undernutrition (inadequate consumption of food or calories) or overnutrition (caloric excess). Caloric excess to the point of obesity overloads cells in the body with lipids. By requiring more energy to maintain the extra tissue, obesity places a strain on the body and has been associated with the development of disease, especially pulmonary and cardiovascular disease. Specific deficiencies arise when an essential nutrient is deficient or when there is an imbalance of nutrients. Protein deficiencies and avitaminosis (deficiency of vitamins) are typical examples. An energy deficit leading to cell injury can occur if there is insufficient glucose, or insufficient oxygen to transform the glucose into energy. A lack of insulin, or the inability to use insulin, may also prevent glucose from entering the cell from the blood. This occurs in diabetes mellitus, a metabolic disorder that can lead to nutritional deficiency, as well as a host of short-term and long-term life-threatening complications.

Physical Agents Physical agents, including temperature extremes, radiation, electrical shock, and mechanical trauma, can cause injury to the cells or to the entire body. The duration of exposure and the intensity of the stressor determine the severity of damage.

Temperature Environment FIGURE 7-4. Influences leading to disorder may arise from the internal

environment and the external environment of the system. Excesses or deficits of information and matter may occur, or there may be faulty regulation of processing.

When a person’s temperature is elevated, hypermetabolism occurs and the respiratory rate, heart rate, and basal metabolic rate all increase. With fever induced by infections, the hypothalamic thermostat may be reset at a higher temperature and then return to normal when the fever abates. The increase in body temperature is achieved


through physiologic mechanisms. Body temperatures greater than 41°C (106°F) indicate hyperthermia, because the physiologic function of the thermoregulatory centre breaks down and the temperature soars. This physiologic condition occurs in people who have heat stroke. Eventually, the high temperature causes coagulation of cell proteins, and cells die. The body must be cooled rapidly to prevent brain damage. The local response to burn injury is similar. There is an increase in metabolic activity, and, as heat increases, proteins coagulate and enzyme systems are destroyed. In extreme situations, charring or carbonization occurs. For more information about burn injuries, see Chapter 58. Extremes of low temperature, or cold, cause vasoconstriction. Blood flow becomes sluggish and clots form, leading to ischemic damage in the involved tissues. With still lower temperatures, ice crystals may form, and cells may burst.

Radiation and Electrical Shock Radiation is used for diagnosis and treatment of diseases. Ionizing forms of radiation may cause injury by their destructive action. Radiation decreases the protective inflammatory response of the cell, creating a favourable environment for opportunistic infections. Electrical shock produces burns as a result of the heat generated when electrical current travels through the body. It may also unexpectedly stimulate nerves, leading, for example, to fibrillation of the heart.

Mechanical Trauma Mechanical trauma can result in wounds that disrupt the cells and tissues of the body. The severity of the wound, the amount of blood loss, and the extent of nerve damage are significant factors in the outcome.

Chemical Agents Chemical injuries are caused by poisons, such as lye, which have a corrosive action on epithelial tissue, or by heavy metals, such as mercury, arsenic, and lead, each of which has its own specific destructive action. Many other chemicals are toxic in certain amounts, in certain people, and in specific tissues. For example, excessive secretion of hydrochloric acid can damage the stomach lining; large amounts of glucose can cause osmotic shifts, affecting the fluid and electrolyte balance; and too much insulin can cause unusual levels of glucose in the blood (hypoglycemia) and can lead to coma. Drugs, including prescribed medications, can also cause chemical poisoning. Some people are less tolerant of medications than others and manifest toxic reactions at the usual or customary dosages. Aging tends to decrease tolerance to medications. Polypharmacy (taking many medications at one time) also occurs frequently in the aging population and is a problem because of the unpredictable effects of the resulting medication interactions. Alcohol (ethanol) is also a chemical irritant. In the body, alcohol is broken down into acetaldehyde, which has a direct toxic effect on liver cells that leads to a variety of liver abnormalities, including cirrhosis in susceptible people. Disordered liver cell function leads to complications in other organs of the body.

Homeostasis, Stress, and Adaptation


Infectious Agents Biologic agents known to cause disease in humans are viruses, bacteria, rickettsiae, mycoplasmas, fungi, protozoa, and nematodes. The severity of the infectious disease depends on the number of microorganisms entering the body, their virulence, and the host’s defenses (e.g., health, age, immune responses). Some bacteria, such as those that cause tetanus and diphtheria, produce exotoxins that circulate and create cell damage. Others, such as gram-negative bacteria, produce endotoxins when they die. Tubercle bacilli induce an immune reaction. Viruses, the smallest living organisms known, survive as parasites of the living cells they invade. Viruses infect specific cells. Through a complex mechanism, viruses replicate within cells and then invade other cells, where they continue to replicate. An immune response is mounted by the body to eliminate the viruses, and the cells harbouring the viruses can be injured in the process. Typically, an inflammatory response and immune reaction are the physiologic responses of the body to viral infection.

Disordered Immune Responses The immune system is an exceedingly complex system, the purpose of which is to defend the body from invasion by any foreign object or foreign cell type, such as cancerous cells. This is a steady-state mechanism, but like other adjustment processes it can become disordered, and cellular injury results. The immune response detects foreign bodies by distinguishing non self substances from self substances and destroying the non self entities. The entrance of an antigen (foreign substance) into the body evokes the production of antibodies that attack and destroy the antigen (antigen–antibody reaction). The immune system may function as expected or it may be hypoactive or hyperactive. When it is hypoactive, immunodeficiency diseases occur; when it is hyperactive, hypersensitivity disorders occur. A disorder of the immune system itself can result in damage to the body’s own tissues. Such disorders are labelled autoimmune diseases (see Unit 11).

Genetic Disorders There is intense research interest in genetic defects as causes of disease and modifiers of genetic structure. Many of these defects produce mutations that have no recognizable effect, such as lack of a single enzyme; others contribute to more obvious congenital abnormalities, such as Down syndrome. People can be assessed for many genetic conditions (or the risk for such conditions) such as sickle cell disease, cystic fibrosis, hemophilia A and B, breast cancer, obesity, cardiovascular disease, phenylketonuria, and Alzheimer’s disease. The availability of genetic information and technology enables health care providers to perform screening, testing, and counselling for people with genetics concerns. Knowledge obtained from the Human Genome Project has also created opportunities for assessing a person’s genetic profile and preventing or treating diseases. Diagnostic genetics and gene therapy have the potential to identify and modify genes before they begin to express traits that would lead to disease or disability. (For further information, see Chapter 10.)



Biophysical and Psychosocial Concepts in Nursing Practice

Cellular Response to Injury: Inflammation Cells or tissues of the body may be injured or killed by any of the agents (physical, chemical, infectious) described earlier. When this happens, an inflammatory response (or inflammation) naturally occurs in the healthy tissues adjacent to the site of injury. Inflammation is a defensive reaction intended to neutralize, control, or eliminate the offending agent and to prepare the site for repair. It is a nonspecific response (not dependent on a particular cause) that is meant to serve a protective function. For example, inflammation may be observed at the site of a bee sting, in a sore throat, in a surgical incision, and at the site of a burn. Inflammation also occurs in cell injury events, such as strokes and myocardial infarctions. Inflammation is not the same as infection. An infectious agent is only one of several agents that may trigger an inflammatory response. An infection exists when the infectious agent is living, growing, and multiplying in the tissues and is able to overcome the body’s usual defenses. Regardless of the cause, a general sequence of events occurs in the local inflammatory response. This sequence involves changes in the microcirculation, including vasodilation, increased vascular permeability, and leukocytic cellular infiltration (Fig. 7-5). As these changes take place, five cardinal signs of inflammation are produced: redness, heat, swelling, pain, and loss of function. The transient vasoconstriction that occurs immediately after injury is followed by vasodilation and an increased rate of blood flow through the microcirculation to the area of tissue damage. Local heat and redness result. Next, the structure of the microvascular system changes to accommodate the movement of plasma protein from the blood into the tissues. Following this increase in vascular permeability, plasma fluids (including proteins and solutes) leak into the inflamed tissues, producing swelling. Leukocytes migrate through the endothelium and accumulate in the tissue at the site of the injury. The pain that occurs is attributed to the pressure of fluids or swelling on nerve endings and to the irritation of nerve endings by chemical mediators released at the site. Bradykinin is one of the chemical mediators suspected of causing pain. Loss of function is most likely related to the pain and swelling, but the exact mechanism is not completely known. As blood flow increases and fluid leaks into the surrounding tissues, the formed elements (red blood cells, white blood cells, and platelets) remain in the blood, causing it to become more viscous. Leukocytes (white blood cells) collect in the vessels, exit, and migrate to the site of injury to engulf offending organisms and to remove cellular debris in a process called phagocytosis. Fibrinogen in the leaked plasma fluid coagulates, forming fibrin for clot formation, which serves to wall off the injured area and prevent the spread of infection.

Chemical Mediators of Inflammation Injury initiates the inflammatory response, but chemical substances released at the site induce vascular changes.

Physiology/Pathophysiology Disruption of tissue integrity


Ischemic damage

Immune reaction

Inflammatory response

Vascular changes: Vasodilation ↑Capillary permeability ↑Blood flow Local tissue congestion

Cellular changes: Phagocytosis ↑ Leukocytes (granulocytes and monocytes) Release of chemical mediators (mast cells and macrophages)

Body responses

Local effects: Erythema Warmth Edema Pain Impaired functioning

Systemic effects: Fever Leukocytosis Malaise Anorexia Sepsis

FIGURE 7-5. Inflammatory response.

Foremost among these chemicals are histamine and kinins. Histamine is present in many tissues of the body but is concentrated in the mast cells. It is released when injury occurs and is responsible for the early changes in vasodilation and vascular permeability. Kinins increase vascular dilations and permeability and attract neutrophils to the area. Prostaglandins, another group of chemical substances, are also suspected of causing increased vascular permeability (Kunert, 2010).

Systemic Response to Inflammation The inflammatory response is often confined to the site, causing only local signs and symptoms. However, systemic responses can also occur. Fever is the most common sign of a systemic response to injury, and it is most likely caused by endogenous pyrogens (internal substances that cause fever) released from neutrophils and macrophages (specialized forms of leukocytes). These substances reset the hypothalamic thermostat, which controls body temperature, and produce fever. Leukocytosis, an increase in the synthesis and release of neutrophils from bone marrow, may occur to provide the body with greater ability to fight infection. During this process, general, nonspecific symptoms develop, including malaise, loss of appetite, aching, and weakness.


Types of Inflammation Inflammation is categorized primarily by its duration and the type of exudate produced. It may be acute, subacute, or chronic. Acute inflammation is characterized by the local vascular and exudative changes described previously and usually lasts less than 2 weeks. An acute inflammatory response is immediate and serves a protective function. After the causative agent is removed, the inflammation subsides and healing takes place with the return of usual or near-usual structure and function. Chronic inflammation develops if the injurious agent persists and the acute response is perpetuated. Symptoms are present for many months or years. Chronic inflammation may also begin insidiously and never have an acute phase. The chronic response does not serve a beneficial and protective function; on the contrary, it is debilitating and can produce long-lasting effects. As the inflammation becomes chronic, changes occur at the site of injury and the nature of the exudate becomes proliferative. A cycle of cellular infiltration, necrosis, and fibrosis begins, with repair and breakdown occurring simultaneously. Considerable scarring may occur, resulting in permanent tissue damage. Subacute inflammation falls between acute and chronic inflammation. It includes elements of the active exudative phase of the acute response as well as elements of repair, as in the chronic phase. The term subacute inflammation is not widely used.

Cellular Healing The reparative process begins at approximately the same time as the injury. Healing proceeds after the inflammatory debris has been removed. Healing may occur by regeneration, in which gradual repair of the defect occurs by proliferation of cells of the same type as those destroyed, or by replacement, in which cells of another type, usually connective tissue, fill in the tissue defect and result in scar formation.

Regeneration The ability of cells to regenerate depends on whether they are labile, permanent, or stable. Labile cells multiply constantly to replace cells worn out by usual physiologic processes; these include epithelial cells of the skin and those lining the gastrointestinal tract. Permanent cells include neurons—the nerve cell bodies, not their axons. Destruction of neurons is permanent, but axons may regenerate. If usual activity is to return, tissue regeneration must occur in a functional pattern, especially in the growth of several axons. Stable cells in some organ systems have a latent ability to regenerate. Under usual physiologic processes, they are not shed and do not need replacement, but if they are damaged or destroyed, they are able to regenerate. Examples include functional cells of the kidney, liver, and pancreas. Cells in other organs, such as the brain, for example, do not regenerate.

Replacement The condition of the host, the environment, and the nature and severity of the injury affect the processes of

Homeostasis, Stress, and Adaptation


inflammation, repair, and replacement. Depending on the extent of damage, repair and replacement may occur by first-, second-, or third-intention healing. In first-intention healing, the wound edges are approximated, as in a surgical wound. Little scar formation occurs, and the wound healing occurs without granulation. In secondintention healing, the edges are not approximated and the wound fills with granulation tissue. The process of repair takes longer and may result in scar formation, with loss of specialized function. For example, people who have recovered from myocardial infarction have abnormal electrocardiographic tracings because the electrical signal cannot be conducted through the connective tissue that has replaced the infarcted area. In third-intention healing, the wound edges are not approximated and healing is delayed. For more information about wound healing see Chapter 52.

Nursing Implications In the assessment of people who seek health care, both objective signs and subjective symptoms are the primary indicators of existing physiologic processes. The following questions are addressed: • Are the heart rate, respiratory rate, and temperature normal? • What emotional distress may be contributing to the patient’s health issues? • Are there other indicators of steady-state deviation? • What are the patient’s blood pressure, height, and weight? • Are there any problems in movement or sensation? • Are there any problems with affect, behaviour, speech, cognitive ability, orientation, or memory? • Are there obvious impairments, lesions, or deformities? Objective evidence can be obtained from laboratory data, such as electrolytes, blood urea nitrogen, blood glucose, and urinalysis results. Further signs of change are seen in diagnostic studies such as computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). Further information on diagnostic studies can be found in assessment chapters of each unit of the book. In making a nursing diagnosis, the nurse must relate the symptoms or problems reported by the patient to the existing physical signs. Management of specific biologic disorders is discussed in subsequent chapters; however, nurses can assist any patient to respond to stress-inducing biologic or psychological disorders with stress management interventions.

STRESS MANAGEMENT: NURSING INTERVENTIONS Stress or the potential for stress is ubiquitous; that is, it is both everywhere and anywhere (Kunert, 2010). Anxiety, frustration, anger, and feelings of inadequacy, helplessness, or powerlessness are emotions often associated with stress. In the presence of these emotions, the customary



Biophysical and Psychosocial Concepts in Nursing Practice

activities of daily living may be disrupted; for example, a sleep disturbance may occur, eating and activity patterns may be altered and family processes or role performance may be disrupted. Many nursing diagnoses are possible for patients suffering from stress. One nursing diagnosis related to stress is “Anxiety,” which is defined as a vague, uneasy feeling, the source of which may be nonspecific or not known to the person. Stress may also be manifested as ineffective coping patterns, impaired thought processes, or disrupted relationships. These human responses are reflected in the nursing diagnoses of “Risk-prone health behaviour,” “Ineffective coping,” “Defensive coping,” and “Ineffective denial,” all of which indicate poor adaptive responses (Herdman, 2012). Other possible nursing diagnoses include “Social isolation,” “Risk for impaired parenting,” “Risk for spiritual distress,” “Readiness for enhanced family coping,” “Decisional conflict,” “Situational low self-esteem,” and “Risk for powerlessness,” among others. Because human responses to stress are varied, as are the sources of stress, arriving at an accurate diagnosis allows interventions and goals to be more specific and leads to improved outcomes. Stress management is directed toward reducing and controlling stress and improving coping. The need to prevent illness, improve the quality of life, and decrease the cost of health care makes efforts to promote health essential, and stress control is a significant health promotion goal. Stress reduction methods and coping enhancements can derive from either internal or external sources. For example, healthy eating habits and relaxation techniques are internal resources that help reduce stress, and a broad social network is an external resource that helps reduce stress. Goods and services that can be purchased are also external resources for stress management. It may be easier for people with adequate financial resources to cope with constraints in the environment, because their sense of vulnerability to threat is decreased compared to those without adequate financial resources.

Promoting a Healthy Lifestyle A health-promoting lifestyle provides internal resources that aid in coping, and it buffers or cushions the impact of stressors. Lifestyles or habits that contribute to the risk of illness can be identified through a health risk appraisal, an assessment method designed to promote health by examining a person’s habits, and recommending changes when a health risk is identified. Health risk appraisals involve the use of health risk questionnaires to estimate the likelihood that people with a given set of characteristics will become ill. It is hoped that if people are provided with this information, they will adopt healthy behaviours (e.g., stop smoking, have periodic screening examinations) to improve their health. Questionnaires typically address the information presented in Chart 7-2. The personal information is compared with average population risk data, and the risk factors are identified and weighed. From this analysis, a person’s risks and major health hazards are identified. Further comparisons with population data can estimate how many years will


Information Addressed in Health Risk Questionnaires Demographic data: age, gender, race, ethnic background Personal and family history of diseases and health problems Lifestyle choices • Eating, sleeping, exercise, smoking, drinking, sexual activity, and driving habits • Stressors at home and on the job • Role relationships and associated stressors Physical measurements • Blood pressure • Height, weight, body mass index (BMI) • Laboratory analyses of blood and urine Participation in high-risk behaviours

be added to a person’s lifespan if the suggested changes are made. However, research has not yet demonstrated that providing people with such information ensures that they will change their behaviours. The single most important factor for determining health status is social class, and within a social class the research suggests that the major factor influencing health is level of education (Bastable, 2008).

Enhancing Coping Strategies Bulechek, et al. (2013, p. 228) identified “coping enhancement” as a nursing intervention and defined it as “assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles” (Chart 7-3). The nurse can build on the patient’s existing coping strategies, as identified in the health appraisal, or teach new strategies for coping if necessary. The five predominant ways of coping with illness identified in a review of 57 nursing research studies were as follows (Jalowiec, 1993): • • • •

Trying to be optimistic about the outcome Using social support Using spiritual resources (Skillen, 2012) Trying to maintain control either over the situation or over feelings • Trying to accept the situation Other ways of coping included seeking information, reprioritizing needs and roles, lowering expectations, making compromises, comparing oneself to others, planning activities to conserve energy, taking things one step at a time, listening to one’s body, and using self-talk for encouragement.

Teaching Relaxation Techniques Relaxation techniques are a major method used to relieve stress. Commonly used techniques include progressive muscle relaxation, the Benson Relaxation Response, and relaxation with guided imagery. The goal of relaxation



Coping Enhancement: Nursing Interventions Definition Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles.

Selected Activities Use a calm, reassuring approach and provide an atmosphere of acceptance for patients and families. Assist the patient and family in developing an objective appraisal of the event. Provide factual information concerning diagnosis, treatment, and prognosis as needed. Encourage an attitude of realistic hope as a way of dealing with feelings of helplessness. Acknowledge the patient’s spiritual/cultural background and encourage the use of spiritual resources if desired. Foster constructive methods of dealing with life problems for patients and families. Assist the patient and family to identify appropriate shortand long-term goals. Appraise the needs and desires for social support and assist the patient and family to identify available support systems. Assist the patient to identify positive strategies to deal with limitations, manage needed lifestyle or role changes, and work through the losses of chronic illness and/or disability if appropriate. Adapted from Bulechek, G. M., Butcher, H. K., & Dochterman, J. C. (Eds.). (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Mosby.

training is to produce a response that counters the stress response. When this goal is achieved, the action of the hypothalamus adjusts and decreases the activity of the sympathetic and parasympathetic nervous systems. The sequence of physiologic effects and their signs and symptoms are interrupted, and psychological stress is reduced. This is a learned response and requires practice to achieve. The different relaxation techniques share four similar elements: (1) a quiet environment, (2) a comfortable position, (3) a passive attitude, and (4) a mental device (something on which to focus one’s attention, such as a word, phrase, or sound).

Progressive Muscle Relaxation Progressive muscle relaxation involves tensing and releasing the muscles of the body in sequence and sensing the difference in feeling. It is best if the person lies on a soft cushion, in a quiet room, breathing easily. Someone usually reads the instructions in a low tone in a slow and relaxed manner, or a recording of the instructions may be played. The person tenses the muscles in the entire body (one muscle group at a time), holds, senses the tension, and then relaxes. As each muscle group is tensed, the person keeps the rest of the body relaxed. Each time the focus is on feeling the tension and relaxation. When the exercise is completed, the entire body should be relaxed (Benson, 1993; Benson & Stark, 1996).

Homeostasis, Stress, and Adaptation


Benson’s Relaxation Response Benson (1993) described the following steps of the Benson Relaxation Response: 1. Pick a brief phrase or word that reflects your basic belief system. 2. Choose a comfortable position. 3. Close your eyes. 4. Relax your muscles progressing from feet to head/neck. 5. Become aware of your breathing, and start using your selected focus word. 6. Maintain a passive demeanor saying “oh well” when other thoughts emerge. 7. Continue for a set period of time (10 to 15 minutes). 8. Open eyes and continue to sit for another minute. 9. Practice the technique twice daily. This response combines meditation with relaxation. Along with the repeated word or phrase, a passive demeanor is essential. If other thoughts or distractions (noises, pain) occur, Benson recommends not fighting the distraction but simply continuing to repeat the focus phrase. Time of day is not important, but the exercise works best on an empty stomach.

Relaxation With Guided Imagery Simple guided imagery is the mindful use of a word, phrase, or visual image for the purpose of distracting oneself from distressing situations or consciously taking time to relax or reenergize. A nurse can help a person select a pleasant scene or experience, such as watching the ocean or dabbling the feet in a cool stream. This image serves as the mental device in this technique. As the person sits comfortably and quietly, the nurse guides the person to review the scene, trying to feel and relive the imagery with all of the senses. A recording may be made of the description of the image, or commercial recordings for guided imagery and relaxation can be used. Other relaxation techniques include meditation, breathing techniques, massage, Reiki, music therapy, biofeedback, and the use of humour.

Educating About Stress Management Two commonly prescribed nursing educational interventions—providing sensory information and providing procedural information (e.g., preoperative teaching)—have the goal of reducing stress and improving the patient’s coping ability. This preparatory education includes giving structured content, such as a lesson in childbirth preparation to expectant parents, a review of cardiovascular anatomy to a cardiac patient, or a description of sensations a patient will experience during cardiac catheterization. These techniques may alter the person–environment relationship such that something that might have been viewed as harmful or a threat will now be perceived more positively. Giving patients information also reduces the emotional response so that they can concentrate and solve problems more effectively (Eggenberger & Nelms, 2007; Kasper, Köpke, Mühlhauser, et al., 2006).



Biophysical and Psychosocial Concepts in Nursing Practice

Enhancing Social Support The nature of social support and its influence on coping have been studied extensively. Social support has been demonstrated to be an effective moderator of life stress. Social support has been found to provide people with several different types of emotional information (Glass, Perrin, Campbell, et al., 2007; Wilsey & Shear, 2007). The first type of information leads people to believe that they are cared for and loved. This emotional support appears most often in a relationship between two people in which mutual trust and attachment are expressed by helping one another meet their emotional needs. The second type of information leads people to believe that they are esteemed and valued. This is most effective when there is recognition demonstrating a person’s favourable position in the group. Known as esteem support, this elevates the person’s sense of self-worth. The third type of information leads people to feel that they belong to a network of communication and mutual obligation. Members of this network share information and make goods and services available to the members as needed. Social support also facilitates a person’s coping behaviours; however, this depends on the nature of the social support. People can have extensive relationships and interact frequently, but the necessary support comes only when there is a deep level of involvement and concern, not when people merely touch the surface of each other’s lives. The critical qualities within a social network are the exchange of intimate communications and the presence of solidarity and trust. Emotional support from family and significant others provides love and a sense of sharing the burden. The emotions that accompany stress are unpleasant and often increase in a spiraling fashion if relief is not provided. Being able to talk with someone and express feelings openly may help a person gain mastery of the situation. Nurses can provide this support; however, it is important to identify the person’s social support system and encourage its use. People who are “loners,” who are isolated, or who withdraw in times of stress have a high risk of coping failure. Because anxiety can also distort a person’s ability to process information, it helps to seek information and advice from others who can assist with analyzing the threat and developing a strategy to manage it. Again, this use of others helps people maintain mastery of a situation and self-esteem. Thus, social networks assist with management of stress by providing people with: • • • • •

A positive social identity Emotional support Material aid and tangible services Access to information Access to new social contacts and new social roles

Recommending Support and Therapy Groups Support groups exist especially for people in similar stressful situations. Groups have been formed by parents of children with leukemia; people with ostomies; women who have had mastectomies; and people with other kinds

of cancer or other serious diseases, chronic illnesses, and disabilities. There are groups for single parents, who abuse substances and their family members, and victims of child abuse. Professional, civic, and religious support groups are active in many communities. There are also encounter groups, assertiveness training programs, and consciousness-raising groups to help people modify their usual behaviours in their transactions with their environment. Being a member of a group with similar issues or goals has a releasing effect on a person that promotes freedom of expression and exchange of ideas. As previously noted, a person’s psychological and biologic health, internal and external sources of stress management, and relationships with the environment are predictors of health outcomes. These factors are directly related to the person’s health patterns. The nurse has a significant role and responsibility in identifying the health patterns of the patient receiving care. If those patterns are not achieving physiologic, psychological, and social balance, the nurse is obligated, with the assistance and agreement of the patient, to seek ways to promote balance. Although this chapter has presented some physiologic mechanisms and perspectives on health and disease, the way that one copes with stress, the way one relates to others, and the values and goals held are also interwoven into those physiologic patterns. To evaluate a patient’s health patterns and to intervene if a disorder exists requires a total assessment of the person. Specific disorders and their nursing management are addressed in greater depth in other chapters.

Critical Thinking Exercises 1 A woman was carjacked, raped, and left on the shoulder of the road, where she was hit by a car. She is hospitalized with injuries related to her sexual assault and the hit-andrun vehicle crash. Describe the physiologic and psychological trauma she has experienced. Discuss the parameters that should be assessed. Identify appropriate nursing interventions used to alleviate the patient’s physiologic and emotional stressors. Address the need for emotional support from both the nursing staff and the family. 2 A 50-year-old woman had a successful kidney transplant 18 months ago. She developed an intimate relationship with a man in her neighbourhood. Several months later she was diagnosed with genital herpes. The woman verbalized to the nurse that this new illness only added to her health problems as well as to her financial, personal, and relational stressors. Discuss the methods the nurse would use to help this patient effectively cope with the multitude of stressors that she is experiencing. Address health care referrals to support groups or social networks that are appropriate for this patient. 3 A patient experiences burns to the upper extremities after being involved in a kitchen fire. Describe the manner in which homeostasis has been disrupted and the compensatory mechanisms that are evident. How does the patient’s medical treatment support the body’s compensatory mechanisms? Determine the evidence-based nursing interventions that are appropriate for promoting the healing process.



A 70-year-old woman recently moved to a retirement community where she lives independently. A nurse practitioner assesses this patient’s health promotion needs. The family’s health history reveals that her mother had type 2 diabetes and thyroid disease, and that her father had hypertension and coronary artery disease. This patient has limited resources and support networks for making necessary lifestyle changes. What evidence exists to support the nurse practitioner’s initiating strategies to promote a healthy lifestyle? What is the evidence that supports intervention to limit or prevent maladaptive responses from occurring with this woman? Describe the strength of the evidence regarding the effectiveness of lifestyle changes in promoting health in older adults.

REFERENCES AND SELECTED READINGS *Asterisks indicate nursing research articles. **Double asterisks indicate classic reference.

BOOKS Bastable, S. B. (Ed.). (2008). Nurse as educator: Principles of teaching and learning (3rd ed.). Boston, MA: Jones & Bartlett. **Benson, H. (1993). The relaxation response. In D. Goleman & J. Gurin (Eds.), Mind-body medicine: How to use your mind for better health. Yonkers, NY: Consumer Reports Books. **Benson, H., & Stark, M. (1996). Timeless healing. New York, NY: Scribner. Bulechek, G. M., Butcher, H. K., Dochterman, J. C. (Eds.). (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Mosby. Fauci, A. (Ed.). (2006). Harrison’s principles of internal medicine (16th ed.). New York: McGraw-Hill. Herdman, T. H. (2012). NANDA Interventions and Nursing Diagnosis: Definitions and Classifications, 2012–2014. Oxford, UK: Wiley-Blackwell **Jalowiec, A. (1993). Coping with illness: Synthesis and critique of the nursing literature from 1980–1990. In J. D. Barnfather & B. L. Lyon (Eds.). Stress and coping: State of the science and implications for nursing theory, research, and practice. Indianapolis, IN: Sigma Theta Tau International. Kunert, M. P. (2010). Stress and adaptation. In R. A. Hannon, C. Pooler, & C. M. Porth (Eds.), Porth pathophysiology: Concepts of altered health states. (1st Canadian ed.), pp. 190–205. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. **Lazarus, R. S. (1991). Emotion and adaptation. New York, NA: Oxford University Press. **Lazarus, R. S. (1993). Why we should think of stress as a subset of emotion. In L. Goldberger & S. Breznitz (Eds.). Handbook of stress: Theoretical and clinical aspects (2nd ed.). New York, NY: The Free Press. **Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer Publishing Co. McPhee, S. J., Lingappa, V. R., Ganong, W. F. (2005). Pathophysiology of disease: An introduction to clinical medicine (5th ed.). New York, NY: McGraw-Hill. *Rice, V. H. (Ed.). (2005). Handbook of stress, coping, and health: Implications for theory, research, and practice. Bern, Germany: Huber Publishing. **Selye, H. (1976). The stress of life (Rev. ed.). New York, NY: McGraw-Hill. Skillen, D. L. (2012). Assessment of social, cultural, & spiritual health. In T. C. Stephen, D. L. Skillen, R. A. Day, et al. (Eds.), Jensen’s Canadian Health Assessment for Nurses: A best practice approach (First Canadian ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Thibodeau, G. A., & Patton, K. T. (2005). The human body in health and disease (4th ed.). Philadelphia, PA: Elsevier.

JOURNALS Austin, W., Gable, E., Leier, B., et al. (2009). Compassion fatigue: the experience of nurses. Ethics and Social Welfare, 3(2), 192–214.

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*Ayalon, L., & Covinsky, K. (2007). Late-life mortality in older Jews exposed to the Nazi regime. Journal of the American Geriatrics Society, 55(9), 1380–1386. *Barnard, D., Street, A., Love, A. (2006). Relationships between stressors, work supports, and burnout among cancer nurses. Cancer Nursing, 29 (4), 338–345. Baumann, S. (2007). Recovering from abuse: A comparison of three paths. Nursing Science Quarterly, 20 (4), 342–348. *Baumgartner, L. (2007). The incorporation of the HIV/AIDS identity into the self over time. Qualitative Health Research, 17 (7), 919–931. *Ben-Ari, A. (2004). Sources of social support and attachment styles among Israeli-Arab students. International Social Work, 47 (2), 187–201. Bradshaw, B., Richardson, G., Kumpfer, K., et al. (2007). Determining the efficacy of a resiliency training approach in adults with type 2 diabetes. Diabetes Educator, 33(4), 650–659. *Brewer, M., & Melnyk, B. (2007). Evidence-based practice. Effective coping/mental health interventions for critically ill adolescents: an evidence review. Pediatric Nursing, 33(4), 361. Briones, T. (2007). Psychoneuroimmunology and related mechanisms in understanding health disparities in vulnerable populations. Annual Review of Nursing Research, 25, 219–256. *Caetano, R., Ramisetty-Mikler, S., Caetano-Vaeth, P., et al. (2007). Acculturation stress, drinking, and intimate partner violence among Hispanic couples in the U.S. Journal of Interpersonal Violence, 22(11), 1431–1447. Chung, M. C., Berger, Z., Jones, R., et al. (2008). Posttraumatic stress and comorbidity following myocardial infarction among older patients. Aging and Mental Health, 12(1), 125–133. Cukrowicz, K. C., Ekblad, A. G., Cheavens, J. S., et al. (2008). Coping and thought suppression as predictors of suicidal ideation in depressed older adults with personality disorders. Aging and Mental Health, 12(1), 149–157. *Dilworth-Anderson, P., Boswell, G., & Cohen, M. (2007). Spiritual and religious coping values and beliefs among African American caregivers: A qualitative study. Journal of Applied Gerontology, 26(4), 355–369. *Dolbier, C. L. (2007). Relationships of protective factors to stress and symptoms of illness. American Journal of Health Behaviour, 31(4), 423–433. Dolbier, C. L., Smith, S. E., Steinhardt, M. A. (2007). Relationships of protective factors to stress and symptoms of illness. American Journal of Health Behaviour, 31(4), 423–433. *Eggenberger, S., & Nelms, T. (2007). Being family: The family experience when an adult member is hospitalized with a critical illness. Journal of Clinical Nursing, 16(9), 1618–1628. *Flanagan, N. (2006). Testing the relationship between job stress and satisfaction in correctional nurses. Nursing Research, 55(5), 316–327. Forbes, D. A., & Neufeld, A. (2008). Looming dementia care crisis: Canada needs an integrated model of continuing care now! Canadian Journal of Nursing Research, 40(1), 9–10. Jansen, L., Forbes, D., Markle-Reid, M., et al. (2009). Formal care providers’ perceptions on home and community based services: Informing dementia care quality. Home Health Care Services Quarterly, 28, 1–23. *Glass, N., Perrin, N., Campbell, J. et al. (2007). The protective role of tangible support on post-traumatic stress disorder symptoms in urban women survivors of violence. Research in Nursing & Health, 30 (5), 558–568. Graham, J., Christian, L., & Kiecolt-Glaser, J. (2006). Stress, age, and immune function: Toward a lifespan approach. Journal of Behavioural Medicine, 29 (4), 389–400. *Greeff, A., & Holtzkamp, J. (2007). The prevalence of resilience in migrant families. Family & Community Health, 30 (3), 189–200. *Haight, W. L. (2007). Mothers’ strategies for protecting children from batterers: The perspectives of battered women involved in child protective services. Child Welfare, 86(4), 41–62. Herdman, T. H. (2012). (Ed). NANDA International Nursing Diagnoses: Definition and Classification, 2012–2014. Oxford, UK: Wiley-Blackwell. **Holmes, T. H., & Rahe, R. H. (1967). The social readjustment rating scale. Journal of Psychosomatic Research, 11, 213–218. Hurlbert, R. (2006). Strategies of medical intervention in the management of acute spinal cord injury. Spine, 31(11S), S16. Jackson, D., Firtko, A., Edenborough, M. (2007). Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: A literature review. Journal of Advanced Nursing, 60 (1), 1–9. Jillings, C. (2007). Patients with recently diagnosed hypertension described risk in terms of acceptance and denial narratives, which served as personal frameworks of coping. Evidence-Based Nursing, 10(3), 96–96.



Biophysical and Psychosocial Concepts in Nursing Practice

Kasper, J., Köpke, S., Mühlhauser, I., et al. (2006). Evidence-based patient information about treatment of multiple sclerosis—a phase one study on comprehension and emotional responses. Patient Education & Counseling, 62(1), 56–63. *Kendall-Tackett, K. (2007). Inflammation, cardiovascular disease, and metabolic syndrome as sequelae of violence against women: The role of depression, hostility, and sleep disturbance. Trauma, Violence & Abuse, 8(2), 117–126. Kleinpell, R. (2007). Supporting independence in hospitalized elders in acute care. Critical Care Nursing Clinics of North America, 19(3), 247–252. Krucoff, C. (2007). Mind/body. Active coping for chronic pain: Simple steps to make the shift from patient to person. Alternative Medicine Magazine, 8(1), 37–38. Langley, P., Fonseca, J., Iphofen, R. (2006). Holistic care: Psychoneuroimmunology and health from a nursing perspective. British Journal of Nursing, 15(20), 1126–1129. **Lazarus, R. S. (1991b). Cognition and motivation in emotion. American Psychologist, 46(4), 352–367. **Lazarus, R. S. (1991c). Progress on a cognitive-motivational-relational theory of emotion. American Psychologist, 46(8), 819–834. *Leserman, J., & Drossman, D. (2007). Relationship of abuse history to functional gastrointestinal disorders and symptoms. Trauma, Violence & Abuse, 8(3), 331–343. *Lunney, M. (2006). Stress overload: A new diagnosis. International Journal of Nursing Terminologies & Classifications, 17 (4), 165–175. Lusk, B., & Lash, A. A. (2005). The stress response, psychoneuroimmunology, and stress among ICU patients. Dimensions of Critical Care Nursing, 24(1), 25–31. Maldonado, M., Murillo-Cabezas, F., Calvo, J., et al. (2007). Melatonin as pharmacologic support in burn patients: A proposed solution to thermal injury-related lymphocytopenia and oxidative damage. Critical Care Medicine, 35(4), 1177–1185. Mertin, S., Sawatzky, J., Diehl-Jones, W. L., et al. (2007). Roadblock to recovery: The surgical stress response. Canadian Association of Critical Care Nurses, 18(1), 14–22. Pace, T., Mletzko, T., Alagbe, O., et al. (2006). Increased stress-induced inflammatory responses in male patients with major depression and increased early life stress. American Journal of Psychiatry, 163(9), 1630–1633. *Park, N., & Kang, D. (2006). Breast cancer risk and immune responses in healthy women. Oncology Nursing Forum, 33(6), 1151–1159. Richter, R. (2007). Gender matters: Female-specific relief efforts during disasters are key. JEMS: Journal of Emergency Medical Services, 32(5), 58.

*Salick, E., & Auerbach, C. (2006). From devastation to integration: Adjusting to and growing from medical trauma. Qualitative Health Research, 16(8), 1021–1037. *Strickland, O., Giger, J., Nelson, M., et al. (2007). The relationships among stress, coping, social support, and weight class in premenopausal African American women at risk for coronary heart disease. Journal of Cardiovascular Nursing, 22(4), 272–278. *Tak, S. H. (2006). An insider perspective of daily stress and coping in elders with arthritis. Orthopaedic Nursing, 25(2), 127–132. **Tausig, M. (1982). Measuring life events. Journal of Health and Social Behaviour, 23(1), 52–64. *Travis, W. J. (2007). Resilient parenting: Overcoming poor parental bonding. Social Work Research, 31(3), 135–149. Verhaeghe, S., van Zuuren, F., Defloor, T., et al. (2007). How does information influence hope in family members of traumatic coma patients in intensive care unit? Journal of Clinical Nursing, 16(8), 1488–1497. Walsh, F. (2007). Traumatic loss and major disasters: strengthening family and community resilience. Family Process, 46(2), 207–227. Warbah, L., Sathiyaseelan, M., Vijaya-Kumar, C., et al. (2007). Psychological distress, personality, and adjustment among nursing students. Nurse Education Today, 27 (6), 597–560. *Weisel, A., Most, T., Michael, R. (2007). Mothers’ stress and expectations as a function of time since child’s cochlear implantation. Journal of Deaf Studies & Deaf Education, 12(1), 55–64. *Wilsey, S., & Shear, M. (2007). Descriptions of social support in treatment narratives of complicated grievers. Death Studies, 31(9), 801–819.

RESOURCES A.D.A.M. Inc., Stress: Centre for Stress Management: definition.htm Inflammation—The Key to Chronic Disease: www.womentowomen. com/inflammation/default.aspx Institute of HeartMath: Empowering Heart-Based Living: www. Stress: The Silent Killer: htm The Psychology of Stress:


8 Individual and Family Considerations Related to Illness Adapted by Pauline Paul and Rene A. Day

Learning Objectives On completion of this chapter, the learner will be able to: 1. Describe the holistic approach to maintaining health and well-being. 2. Discuss the concepts of emotional well-being and emotional distress. 3. Describe recovery-oriented practice. 4. Explain the concepts of anxiety, posttraumatic stress disorder, depression, loss, and grief. 5. Determine the role of the nurse in identifying substance abuse problems and in helping families to cope. 6. Assess the impact of illness on the patient’s family and on family functioning. 7. Explore the concept of spirituality and address the spiritual needs of patients. 8. Identify nursing actions that promote effective coping for both patients and their families.




Biophysical and Psychosocial Concepts in Nursing Practice

When people experience threats to their health, they seek out various care providers for the purpose of maintaining or restoring health. In recent years, both patients and families have become increasingly involved in health care and health promotion activities. This chapter discusses the holistic approach to health and wellness, how a person’s emotional state contributes to health and illness, and how nurses can help individuals and families prevent the recurrence or exacerbation of health problems, and develop strategies to improve their future health status.

HOLISTIC APPROACH TO HEALTH AND HEALTH CARE Since the 1980s, holistic therapies often accompany traditional health care. According to the Public Health Agency of Canada (PHAC) (2008) approximately 70% of consumers in Canada follow holistic health practices. In ambulatory care settings, more consumers request these therapies, and increasing numbers of clinicians integrate them into their clinical practice (Hardy-Pickering, Adams, Sim, et al., 2007; Sood, 2007; van Tulder, 2007). In all settings, it is imperative that during clinical assessments the use of complementary and alternative therapies be assessed. Complementary and alternative therapies are discussed in Chapter 10. For some people, the holistic approach is viewed as a way to capitalize on personal strengths and recultivate the values and beliefs about health that were common before the age of technologic innovations and the sophistication of biomedical science. A lack of focus on individuals, families, and their environments by some health care providers has created feelings of disillusionment and depersonalization. Active participation by individuals and families in health promotion supports the self-care model historically embraced by the nursing profession. This model is congruent with the philosophy that seeks to balance and integrate the use of traditional medicine and advanced technology with the influence of the mind and spirit on

healing. A holistic approach to health reconnects the traditionally separate approaches to mind and body. Factors such as the physical environment, economic conditions, sociocultural issues, emotional state, interpersonal relationships, and support systems can influence health. The connections among physical health, emotional health, and spiritual well-being must be understood and considered when providing health care. It is the nurse’s conceptual integration of the physiologic health condition within the emotional and social context, along with the patient’s developmental life stage, that allows for the development of a holistic plan of nursing care.

THE BRAIN AND PHYSICAL AND EMOTIONAL HEALTH Research findings suggest fundamental relationships between the brain’s environment and mood, behaviour, and resistance to disease. One focus of brain research has been the biologic basis of mental disturbances and the relationship between mental disorders and changes in the brain. The field of psychoneuroimmunology examines connections between the emotions and the central nervous, neuroendocrine, and immune systems and has established compelling evidence that psychosocial variables can affect the functioning of the immune system. As neuroscientific research continues, data about neurotransmitters and brain functioning contribute to increased understanding of emotions, intelligence, memory, and many aspects of physical functioning. Increased knowledge about the brain and nervous system has led to breakthroughs in the treatment of both symptoms and illnesses. These findings suggest the need for health care professionals to recognize how biologic, emotional, and societal problems combine to affect individuals, families, and communities. Some problems that nurses and other health care providers must address include substance abuse, homelessness, family violence, eating disorders, trauma, and chronic mental health conditions such as anxiety and depression.

Glossary anxiety: an emotional state characterized by feelings of apprehension, discomfort, restlessness, or worry bereavement: feelings, thoughts, and responses that occur after a loss depression: state in which a person feels sad, distressed, and hopeless, with little to no energy for usual activities faith: belief and trust in God or a higher power family: a group whose members are related by reciprocal caring, mutual responsibilities, and loyalties grief: a universal response to any loss holistic health: promotion of the total health of mind, body, and spirit mental disorder: a state in which a person has deficits in functioning, has a distorted sense of self or the world, is unable to sustain relationships, or cannot handle stress or conflict effectively

mental health: a state in which a person can meet basic needs, assume responsibilities, sustain relationships, resolve conflicts, and grow throughout life posttraumatic stress disorder (PTSD): the development of severe anxiety-type symptoms after the experience of a traumatic life event recovery: a process in which people living with mental health problems and illnesses are actively engaged in their own journey of well-being (Mental Health Commission of Canada, 2014). spirituality: connectedness with self, others, a life force, or God that allows people to find meaning in life substance abuse: a maladaptive pattern of drug use that causes physical and emotional harm with the potential for disruption of daily life


MENTAL HEALTH AND EMOTIONAL DISTRESS Emotional health involves the ability to function as comfortably and productively as possible. Typically, people who are mentally healthy are satisfied with themselves and their life situations. In the usual course of living, emotionally healthy people focus on activities geared to meet their needs and attempt to accomplish personal goals while managing everyday challenges and issues. Often, people must work hard to balance their feelings, thoughts (Pasch, 2010), and behaviours to alleviate emotional distress, and much energy is used to change, adapt, or manage the obstacles inherent in daily living. A mentally healthy person accepts reality and has a positive sense of self. Emotional health is also manifested by having moral and humanistic values and beliefs, having satisfying interpersonal relationships, doing productive work, and maintaining a realistic sense of hope. See the Mental Health Commission of Canada’s goals on helping Canadians achieve positive mental health and well-being in Chart 8-1. The Mental Health Commission of Canada (2014a) is promoting a new approach: ‘Recovery-Oriented Practice’. Recovery is a process in which people living with mental health problems and illnesses are actively involved in their own journey’s of well being”. Recovery principles, including hope, self-determination, and responsibility can be adapted to the realities of different life stages, and to the full range of mental health problems and illnesses.” When people have unmet emotional needs or distress, they experience an overall feeling of unhappiness. As tension escalates, security and survival are threatened. How different people respond to these troublesome situations reflect their level of coping and maturity. Emotionally healthy people endeavour to meet the demands of distressCHART 8-1

Individual and Family Considerations Related to Illness

ing situations while still coping with the typical issues that emerge in their lives. The ways in which people respond to uncomfortable stimuli reflect their exposure to various biologic, emotional, and sociocultural experiences. When stress interferes with a person’s ability to function comfortably and inhibits the effective management of personal needs, that person is at risk for emotional problems. The use of ineffective and unhealthy methods of coping is manifested by dysfunctional behaviours, thoughts, and feelings. These behaviours are aimed at relieving the overwhelming stress, even though they may cause further problems. Coping ability is strongly influenced by biologic or genetic factors, physical and emotional growth and development, family and childhood experiences, and learning. Typically, people revert to the strategies observed early in life that were modelled by family members, caregivers, and others to resolve conflicts. If these strategies were not adaptive, the person exhibits a range of unproductive behaviours. Dysfunctional behaviour in one person not only seriously affects that person’s emotional health but can also put others at risk for injury or death. As these destructive behaviours are repeated, a cyclic pattern becomes evident: impaired thinking, negative feelings, and more dysfunctional actions that prevent the person from meeting the demands of daily living. No universally accepted definition of what constitutes an emotional disorder exists, but many views and theories share the idea that a number of variables can interfere with emotional growth and development and impede successful adaptation to the environment. Most clinicians have adopted the statement from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM- 5-TR), which defines the term mental disorder as a group of behavioural or psychological symptoms or a pattern that manifests itself in significant distress, impaired functioning, or accentuated risk of enduring severe suffering or possible death (American Psychiatric Association, 2013). Risk factors for mental health problems are listed in Chart 8-2.

Canada’s National Mental Health Strategy Toward Recovery and Well-Being The Mental Health Commission of Canada is a nonprofit corporation created by the Federal Government to promote mental health. In 2009, after an extensive national consultation process, the commission declared the following goals to help all Canadians achieve the highest level of mental health and well-being possible: 1. People of all ages living with mental health problems and illnesses are actively engaged and supported in their journey of recovery and well-being. 2. Mental health is promoted, and mental health problems and illnesses are prevented whenever possible. 3. The mental health system responds to the diverse needs of all people in Canada. 4. The role of families in promoting well-being and providing care is recognized, and their needs are supported. 5. People have equitable and timely access to appropriate and effective programs, treatments, services, and supports that are seamlessly integrated around their needs. 6. Actions are informed by the best evidence based on multiple sources of knowledge, outcomes are measured, and research is advanced. 7. People living with mental health problems and illnesses are fully included as valued members of society.



Risk Factors for Mental Health Problems Nonmodifiable Risk Factors • • • •

Age Gender Genetic background Family history

Modifiable Risk Factors • • • • • • • • • • • •

Marital status Family environment Housing problems Poverty or economic difficulties Physical health Nutritional status Stress level Social environment and activities Exposure to trauma Alcohol and drug misuse Environmental toxins or other pollutants Availability, accessibility, and cost of health services



Biophysical and Psychosocial Concepts in Nursing Practice

Patients seen in medical-surgical settings often struggle with psychosocial issues of anxiety, depression, loss, and grief. Abuse, addiction, chemical dependency, body image disturbances, and eating disorders are a few examples of issues that require extensive physical and emotional care to restore optimal functioning. The dual challenge for the health care team is to understand how the patient’s emotions influence physical conditions and to identify the best care for the patient experiencing underlying emotional and spiritual distress (Skillen, 2012).

Anxiety All people experience some degree of anxiety (a tense emotional state) as they face new, challenging, or threatening life situations. In clinical settings, fear of the unknown, unexpected news about one’s health, and impairment of bodily functions engenders anxiety. Although a mild level of anxiety can mobilize a person to take a position, act on the task that needs to be done, or learn to alter lifestyle habits, more severe anxiety can be paralyzing. Anxiety that escalates to a near panic state can be incapacitating. When patients receive unwelcome news about results of diagnostic studies, they are certain to experience anxiety. Different patients manifest physiologic, emotional, and behavioural signs and symptoms of anxiety in different ways.

Nursing Implications Early clinical observations of anxiety are essential components of nursing care (Chart 8-3). A high level of anxiety in a patient probably exacerbates physiologic distress. For example, a postoperative patient who is in pain may discover that anxiety intensifies the sensation of pain. A patient newly diagnosed with type 1 diabetes mellitus may be worried and fearful and therefore unable to focus on or complete essential self-care activities. Many medical conditions (e.g., a breast lump or heart condition) cause anxiety. Many assessment findings alert the nurse to patients with moderate to severe anxiety. All nurses must be vigilant about patients who worry excessively and deteriorate in emotional, social, or occupational functioning. If participation in the therapeutic regimen (e.g., administration of insulin) becomes a problem because of extreme anxiety, nursing interventions must be immediately initiated. Caring strategies emphasize ways for the patient to verbalize feelings and fears and to identify sources of anxiety. The need to teach and promote effective coping abilities and the use of relaxation techniques are the priorities of care. In some cases, antianxiety medication may be prescribed. Chart 8-4 provides a list of basic nursing principles that are useful to assist patients in managing severe anxiety. Chapter 9 presents additional information about stress and the relaxation response.


Assessing for Anxiety Be on the alert for the following assessment findings:

Physiologic Indicators • • • • • • • • • • • • • • •

Appetite change Headaches Muscle tension Fatigue or lethargy Weight change Cold and flu symptoms Digestive upsets Grinding teeth Palpitations Hypertension Restlessness Difficulty sleeping Skin irritations Injury prone Increased use of any alcohol or drugs

Emotional Indicators • • • • • • • • • • •

Forgetfulness Low productivity Feeling dull Poor concentration Negative attitude Confusion Whirling mind No new ideas Boredom Negative self-talk Anxiety

• • • • • • •

Frustration Depression Crying periods Irritability Worrying Feeling discouraged Nervous laughter

Relational Indicators • • • • • • • • • • •

Isolation Intolerance Resentment Loneliness Lashing out “Clamming up” Nagging Distrust Few friends No intimacy Using people

Spiritual Indicators • • • • • • • •

Emptiness Loss of meaning Doubt Unforgiving attitude Martyrdom Loss of direction Cynicism Apathy

human experience. Patients can suffer from posttraumatic stress disorder (PTSD), a condition that generates waves of anxiety, anger, aggression, depression, and suspicion; threatens a person’s sense of self; and interferes with daily functioning (Lasiuk & Hegadorn, 2006a,b). Specific examples of events that place people at risk for PTSD are rape, family violence, torture, terrorist attacks, fire, earthquake, CHART 8-4

Managing Anxiety • Listen actively and focus on having the patient discuss personal feelings.

• Use positive remarks and focus on the positive aspects of life in the “here and now.”

• Use appropriate touch (with patient permission) to demonstrate support.

• Discuss the importance of safety and the patient’s overall sense of well-being.

Posttraumatic Stress Disorder In medical-surgical settings, especially in emergency departments, burn units, and rehabilitation centres, nurses care for extremely anxious patients who have experienced overwhelming events that may be outside the range of usual

• Explain all procedures, policies, diagnostic studies, medications, treatments, or protocols for care.

• Explore coping strategies and work with the patient to

practice and use them effectively (e.g., breathing, progressive relaxation, visualization, imagery). • Use distraction as indicated to relax and prevent self from being overwhelmed.


and military combat. Patients who have experienced a traumatic event are often frequent users of the health care system, seeking treatment for the overall emotional and physical trauma that they experienced. The physiologic responses of people who have been severely traumatized include increased activity of the sympathetic nervous system, increased plasma catecholamine levels, and increased urinary epinephrine and norepinephrine levels. People with PTSD may lose the ability to control their response to stimuli (Loseke, Gelles & Cavanaugh, 2005). The resulting excessive arousal can increase overall body metabolism and trigger emotional reactivity. In this situation, patients have difficulty sleeping, have an exaggerated startle response, and are excessively vigilant. Symptoms of PTSD can occur hours to years after the trauma is experienced. Acute PTSD is defined as the experience of symptoms for less than a 3-month period. Chronic PTSD is defined as the experience of symptoms lasting longer than 3 months. In the case of delayed PTSD, up to 6 months may elapse between the trauma and the manifestation of symptoms (American Psychiatric Association, 2013). For more information, see Chart 8-5.

Nursing Implications It is often thought that the incidence of PTSD is very low in the overall population. However, when high-risk groups are studied, the results indicate that more than 50% of study participants have PTSD (McKenny & Price, 2005). Therefore, it is important that nurses consider which of their patients are at risk for PTSD and be knowledgeable about the common symptoms associated with it. Older people are more susceptible to the physical effects of trauma and the effects of PTSD because of the neural inactivation associated with aging. One study reported that people with strong support networks were less likely to experience PTSD after a natural disaster than people without a strong support system (Acierno, Ruggiero, Kilpatrick, et al., 2006). The sensitivity and caring of the nurse creates the interpersonal relationship necessary to work with patients who have PTSD. These patients are physically compromised and are struggling emotionally with situations that are not considered part of normal human experience, situations that violate the commonly held perceptions of human social justice. Retired General Romeo D’Allaire (now Senator D’Allaire) was the Forces Commander of the United Nations troops in Rwanda. Despite his pleas for more troops to avert disaster, he was ignored by the international community, and a genocide occurred in which over 800,000 people were killed. In his book Shake Hands with the Devil: The Failure of Humanity in Rwanda, he describes how upon returning to Canada his mental health deteriorated, culminating in suicide attempts, a diagnosis of PTSD, a medical discharge from the Canadian Armed Forces, and dozens of therapy sessions and medications. He became the “public face” of PTSD when he was found inebriated on a park bench in Ottawa. He publically talks about this episode to help people understand more about PTSD.

Treatment of patients with PTSD includes several essential components: establishing a trusting relationship, addressing and working through the trauma experience, and teaching the coping skills needed for recovery and self-care. The patient’s progress can be influenced by the

Individual and Family Considerations Related to Illness



Assessing for Posttraumatic Stress Disorder (PTSD) Be on the alert for the following assessment findings:

Physiologic Indicators • • • • • • • • • • • • • • • •

Dilated pupils Headaches Sleep pattern disturbances Tremors Elevated blood pressure Tachycardia or palpitations Diaphoresis with cold, clammy skin Hyperventilation Dyspnea Smothering or choking sensation Nausea, vomiting, or diarrhea Stomach ulcers Dry mouth Abdominal pain Muscle tension or soreness Exhaustion

Psychological Indicators • • • • • • • • • • • • • • • • • • • • • • • • • •

Anxiety Anger Depression Fears or phobias Survivor guilt Hypervigilance Nightmares or flashbacks Intrusive thoughts about the trauma Impaired memory Dissociative states Restlessness or irritability Strong startle response Substance abuse Self-hatred Feelings of estrangement Feelings of helplessness, hopelessness, or powerlessness Lack of interest in life Inability to concentrate Difficulty communicating, caring, and expressing love Problems with relationships Sexual problems ranging from acting out to impotence Difficulty with intimacy Inability to trust Lack of impulse control Aggressive, abusive, or violent behaviour, including suicide Thrill-seeking behaviours

Copel, L. C. (2000). Nurse’s clinical guide: Psychiatric and mental health care (2nd ed.). Springhouse, PA: Springhouse.

ability to cope with the various aspects of both the physical and the emotional distress.

Depression Depression is a common response to health issues and is an underdiagnosed condition, particularly in hospitalized patients (Seelig & Katon, 2008). People may become depressed as a result of injury or illness; may be suffering from an earlier loss that is compounded by a new health



Biophysical and Psychosocial Concepts in Nursing Practice

issue; or may seek health care for somatic manifestations of depression. The cause of depression is unknown but it includes the interaction of genetic, biological, social, and psychological factors (Lasiuk & Bickley, 2010). Clinical depression is distinguished from everyday feelings of sadness by its duration and severity (Lasiuk, 2012). Most people occasionally feel down or depressed, but these feelings are short-lived and do not result in impaired functioning. People who are clinically depressed usually have had signs of a depressed mood or a decreased interest in pleasurable activities for at least a 2-week period. An obvious impairment in social, occupational, and overall daily functioning occurs in some people. Others function appropriately in their interactions with the outside world by exerting great effort and forcing themselves to mask their distress. Sometimes they are successful at hiding their depression for months or years and astonish family members and others when they finally admit that they are seriously depressed. Many people experience depression but seek treatment for somatic concerns. The leading somatic concerns of patients struggling with depression are headache, backache, abdominal pain, fatigue, malaise, anxiety, and decreased desire or issues with sexual functioning (Varcarolis, Carson, & Shoemaker, 2006). It is estimated that depression is undiagnosed about half of the time, and masquerades as physical health problems (Townsend, 2005). People with depression also exhibit poor functioning with frequent absences from work and school. MacMillan, Patterson, & Wathen (2005) found that two questions can be used to assess for depression and may be as useful as longer questionnaires: “Over the past 2 weeks, have you felt down? Depressed? Or hopeless?” and “Over the past 2 weeks have you felt little interest or pleasure in doing things?” Specific symptoms of clinical depression include feelings of sadness, worthlessness, fatigue, guilt, and difficulty concentrating or making decisions. Changes in appetite, weight gain or loss, sleep disturbances, and psychomotor retardation or agitation are also common. Often, patients have recurrent thoughts about death or suicide or have made suicide attempts. A diagnosis of clinical depression is made when a person presents with at least five of nine diagnostic criteria for depression (Chart 8-6). Unfortunately, only one of three people who are depressed is properly diagnosed and appropriately treated (American Psychiatric Association, 2013).


Diagnostic Criteria for Depression Based on the DSM-5-TR A person experiences at least five out of nine characteristics, with one of the first two symptoms present most of the time: 1. Depressed mood 2. Loss of pleasure or interest 3. Weight gain or loss 4. Sleeping difficulties 5. Psychomotor agitation or retardation 6. Fatigue 7. Feeling worthless 8. Inability to concentrate 9. Thoughts of suicide or death American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5-TR) (5th ed.). Washington, DC: Author.

Talking with the patient about his or her fears, frustration, anger, and despair can help alleviate a sense of helplessness and lead to necessary treatment. Helping the patient learn to cope effectively with conflict, interpersonal issues, and grief and encouraging the patient to discuss actual and potential losses may hasten his or her recovery from depression. It may also be possible to help the patient identify and decrease negative self-talk and unrealistic expectations and show how these contribute to depression. The nurse monitors the patient for the onset of new concerns because depression adversely affects physical health and self-care activities (Chart 8-8). All patients with depression should be evaluated to determine if they would benefit from antidepressant therapy. In addition to the measures previously listed, psychoeducational programs, establishment of support systems, and counselling can reduce anxiety- and depressionrelated distress. Psychoeducational programs can help patients and their families understand depression, treatment options, and coping strategies. (In crisis situations, it is imperative that patients be referred to psychiatrists, psychiatric nurse specialists, advanced practice psychiatric mental health nurses, or crisis centres.) Explaining to

Nursing Implications Because any loss in function, change in role, or alteration in body image is a possible antecedent to depression, nurses in all settings encounter patients who are depressed or who have thought about suicide. Depression is suspected if changes in the patient’s thoughts or feelings and a loss of self-esteem are noted. Chart 8-7 lists risk factors for depression. Depression can occur at any age, and it is diagnosed more frequently in women than in men. In older patients, nurses should be aware that decreased mental alertness or withdrawal-type responses may be indicative of depression. Consultation with an advanced practice psychiatric mental health nurse to assess and differentiate between dementia-like symptoms (Haase, 2010), and depression is often helpful.


Risk Factors for Depression • • • • • • • • • •

Family history Stressful situations Female gender Prior episodes of depression Onset before age 40 years Medical comorbidity Past suicide attempts Lack of support systems History of physical or sexual abuse Current substance abuse


Individual and Family Considerations Related to Illness



Chart 8-8. Loneliness and Social Support in MS Beal, C. C. & Stuifbergen, A. (2007). Loneliness in women with multiple sclerosis. Rehabilitation Nursing, 32 (4), 165–171. Purpose Women diagnosed with multiple sclerosis (MS) are at risk for loneliness due to the changes that frequently occur in their social activities and networks. This study was designed to (1) examine the relationship between loneliness, social support, functional limitations, self-rated health status, social responses to illness, and marital status, as well as to (2) determine the extent that the previously mentioned variables could predict loneliness. Design A secondary analysis examined data collected from 659 women in 1996. Participants, from the southwest region of the United States, were members of the National Multiple Sclerosis Society. The women provided information on age, gender, ethnicity, education, employment, marital status, and type of MS. The participants completed a longitudinal survey concerning health promotion behaviours and quality of life for people with MS. The researchers used descriptive statistics to describe the subjects. Pearson correlations and regression analysis were used to identify the variables that explained the variance for loneliness. Findings The subjects reported few problems with activities of daily living. Ninety-eight of the women (approximately 15%) revealed that they experienced fatigue, with 48% indicating that the fatigue was frequent or disabling. The majority of the participants reported that they were less social as a result of the MS because it was difficult to plan social activities. These women believed that other people did not

patients that depression is a medical illness and not a sign of personal weakness, and that effective treatment will allow them to feel better and stay emotionally healthy, is an important aspect of care (Varcarolis et al., 2006).

Suicide In Canada, 2% of all deaths are due to suicide, and screening in primary care settings may help to reduce mortality (Stephen et al., 2010). It is estimated that 90% of those who died by suicide had a mental health illness (Langille, 2014). See Table 8-1 for number of suicide deaths by age group.

TABLE 8-1 Age Group Number of Deaths

Numbers of Suicide Deaths by Age Groups in Canada, 2009

15–24 25–44 45–64 ≥65 Total 60 yrs: 8–20 mg/dL About 10:1

Bladder Ultrasonography Bladder ultrasonography is a noninvasive method of measuring urine volume in the bladder. It may be indicated for urinary frequency, inability to void after removal of an indwelling urinary catheter, measurement of postvoiding residual urine volume, inability to void postoperatively, or assessment of the need for catheterization during the initial stages of an intermittent catheterization training program. Portable, battery-operated devices are available for bedside use. The scan head is placed on the patient’s abdomen and directed toward the bladder. The device automatically calculates and displays urine volume.

Computed Tomography and Magnetic Resonance Imaging Computed tomography (CT) scans and magnetic resonance imaging (MRI) are noninvasive techniques that provide excellent cross-sectional views of the kidney and urinary tract. They are used to evaluate genitourinary masses, nephrolithiasis, chronic renal infections, renal or urinary tract trauma, metastatic disease, and soft tissue abnormalities. The nurse should explain to the patient that a sedative may be prescribed. Claustrophobia is often a problem, especially with MRI. Patient preparation for the MRI includes removal of any metallic objects, such as jewelry or clothing with metallic clasps. Credit cards should be kept away from the MRI area because of their magnetic strips. MRI is contraindicated in patients with pacemakers, surgical clips, or any metallic objects anywhere in the body. Occasionally, an oral or intravenous radiopaque contrast material is used in CT scanning to



Urinary Tract Function

CHART 44-6

Patient Care During Urologic Testing With Contrast Agents For some patients, contrast agents are nephrotoxic and allergenic. The following guidelines can help the nurse and other health care providers respond quickly in the event of a problem.

Nursing Actions for Room Preparation • Have emergency equipment and medications available in

case the patient has an anaphylactic reaction to the contrast agent. Emergency supplies include epinephrine, corticosteroids, vasopressors, oxygen, and airway and suction equipment.

Nursing Actions for Patient Preparation • Obtain the patient’s allergy history with emphasis on • •

allergy to iodine, shellfish, and other seafood, because many contrast agents contain iodine. Notify physician and radiologist if the patient is allergic or suspected to be allergic to iodine. Obtain health history. Contrast agents should be used with caution in older patients and patients who have diabetes mellitus, multiple myeloma, renal insufficiency, or volume depletion. Inform the patient that he or she may experience a temporary feeling of warmth, flushing of the face, and an unusual flavour (similar to that of seafood) in the mouth when the contrast agent is infused. Monitor patient closely for allergic reaction and monitor urine output.

enhance visualization. Nursing care guidelines for patient preparation and test precautions for any imaging procedure requiring a contrast agent (also called contrast medium) are explained in Chart 44-6.

Nuclear Scans Nuclear scans require injection of a radioisotope (a technetium 99m–labelled compound or iodine 123 [123I] hippurate) into the circulatory system; the isotope is then monitored as it moves through the blood vessels of the kidneys. A scintillation camera is placed behind the kidney with the patient in a supine, prone, or seated position. Hypersensitivity to the radioisotope is rare. The technetium scan provides information about kidney perfusion. The 123I-hippurate renal scan provides information about kidney function, such as GFR. Nuclear scans are used to evaluate acute and chronic renal failure, renal masses, and blood flow before and after kidney transplantation. The radioisotope is injected at a specified time to achieve the proper concentration in the kidneys. After the procedure is completed, the patient is encouraged to drink fluids to promote excretion of the radioisotope by the kidneys.

Intravenous Urography IV urography includes various tests such as excretory urography, intravenous pyelography (IVP), and infusion drip pyelography. A radiopaque contrast agent is adminis-

tered by IV. An IVP shows the kidneys, ureter, and bladder via x-ray imaging as the dye moves through the upper and then the lower urinary system. A nephrotomogram may be carried out as part of the study to visualize different layers of the kidney and the diffuse structures within each layer and to differentiate solid masses or lesions from cysts in the kidneys or urinary tract. IV urography may be used as the initial assessment of many suspected urologic conditions, especially lesions in the kidneys and ureters. It also provides an approximate estimate of renal function. After the contrast agent (sodium diatrizoate or meglumine diatrizoate) is administered by IV, multiple x-rays are obtained to visualize drainage structures in the upper and lower urinary systems. Infusion drip pyelography requires IV infusion of a large volume of a dilute contrast agent to opacify the renal parenchyma and fill the urinary tract. This examination method is useful when prolonged opacification of the drainage structures is desired so that tomograms (body-section radiography) can be made. Images are obtained at specified intervals after the start of the infusion. These images show the filled and distended collecting system. The patient preparation is the same as for excretory urography, except that fluids are not restricted.

Retrograde Pyelography In retrograde pyelography, catheters are advanced through the ureters into the renal pelvis by means of cystoscopy. A contrast agent is then injected. Retrograde pyelography is usually performed if IV urography provides inadequate visualization of the collecting systems. It may also be used before extracorporeal shock wave lithotripsy and in patients with urologic cancer who need follow-up and have an allergy to IV contrast agents. Possible complications include infection, hematuria, and perforation of the ureter. Retrograde pyelography is used infrequently because of improved techniques in excretory urography.

Cystography Cystography aids in evaluating vesicoureteral reflux (backflow of urine from the bladder into one or both ureters) and in assessing for bladder injury. A catheter is inserted into the bladder, and a contrast agent is instilled to outline the bladder wall. The contrast agent may leak through a small bladder perforation stemming from bladder injury, but such leakage is usually harmless. Cystography can also be performed with simultaneous pressure recordings inside the bladder.

Voiding Cystourethrography Voiding cystourethrography uses fluoroscopy to visualize the lower urinary tract and assess urine storage in the bladder. It is commonly used as a diagnostic tool to identify vesicoureteral reflux. A urethral catheter is inserted, and a contrast agent is instilled into the bladder. When the bladder is full and the patient feels the urge to void, the catheter is removed, and the patient voids.


Renal Angiography A renal angiogram, or renal arteriogram, provides an image of the renal arteries. The femoral (or axillary) artery is pierced with a needle, and a catheter is threaded up through the femoral and iliac arteries into the aorta or renal artery. A contrast agent is injected to opacify the renal arterial supply. Angiography is used to evaluate renal blood flow in suspected renal trauma, to differentiate renal cysts from tumours, and to evaluate hypertension. It is used preoperatively for renal transplantation. Before the procedure, a laxative may be prescribed to evacuate the colon so that unobstructed x-rays can be obtained. Injection sites (groin for femoral approach or axilla for axillary approach) may be shaved. The peripheral pulse sites (radial, femoral, and dorsalis pedis) are marked for easy access during postprocedural assessment. The patient is informed that there may be a brief sensation of warmth along the course of the vessel when the contrast agent is injected. After the procedure, vital signs are monitored until stable. If the axillary artery was the injection site, blood pressure measurements are taken on the opposite arm. The injection site is examined for swelling and hematoma. Peripheral pulses are palpated, and the colour and temperature of the involved extremity are noted and compared with those of the uninvolved extremity. Cold compresses may be applied to the injection site to decrease edema and pain. Possible complications include hematoma formation, arterial thrombosis or dissection, false aneurysm formation, and altered renal function.

Urologic Endoscopic Procedures Endourology, or urologic endoscopic procedures, can be performed in one of two ways: using a cystoscope inserted into the urethra, or percutaneously, through a small incision. The cystoscopic examination is used to directly visualize the urethra and bladder. The cystoscope, which is inserted through the urethra into the bladder, has an optical lens system that provides a magnified, illuminated view of the bladder (Fig. 44-8). The use of a high-intensity light and interchangeable lenses allows excellent visualization and permits still and motion pictures to be taken. The cystoscope is manipulated to allow complete visualization of the urethra and bladder as well as the ureteral orifices and prostatic urethra. Small ureteral catheters can be passed through the cystoscope for assessment of the ureters and the pelvis of each kidney. The cystoscope also allows the urologist to obtain a urine specimen from each kidney to evaluate its function. Cup forceps can be inserted through the cystoscope for biopsy. Calculi may be removed from the urethra, bladder, and ureter using cystoscopy. If a lower tract cystoscopy is performed, the patient is usually conscious, and the procedure is usually no more uncomfortable than a catheterization. To minimize post-test urethral discomfort, viscous lidocaine is administered several minutes before the study. If the cystoscopy includes examination of the upper tracts, a sedative may be administered before the procedure.


Assessment of Renal and Urinary Tract Function

To light source



Irrigant Ureteral orifice

FIGURE 44-8. Cystoscopic examination. A rigid or semirigid cysto-

scope is introduced into the bladder. The upper cord is an electric line for the light at the distal end of the cystoscope. The lower tubing leads from a reservoir of sterile irrigant that is used to inflate the bladder.

General anesthesia is usually administered to ensure that there are no involuntary muscle spasms when the scope is being passed through the ureters or kidney. The nurse describes the procedure to the patient and family to prepare them and to allay their fears. If an upper cystoscopy is to be performed, the patient is usually restricted to nothing by mouth (NPO) for several hours beforehand. Postprocedural management is directed at relieving any discomfort resulting from the examination. Some burning on voiding, blood-tinged urine, and urinary frequency from trauma to the mucous membranes can be expected. Moist heat to the lower abdomen and warm sitz baths are helpful in relieving pain and relaxing the muscles. After a cystoscopic examination, the patient with obstructive pathology may experience urine retention if the instruments used during the examination caused edema. The nurse carefully monitors the patient with prostatic hyperplasia for urine retention. Warm sitz baths and antispasmodic medication, such as flavoxate or flavoxate hydrochloride may be prescribed to relieve temporary urine retention caused by poor relaxation of the urinary sphincter; however, intermittent catheterization may be necessary for a few hours after the examination. The nurse monitors the patient for signs and symptoms of urinary tract infection. Because edema of the urethra secondary to local trauma may obstruct urine flow, the patient is also monitored for signs and symptoms of obstruction.

Biopsy Renal and Ureteral Brush Biopsy Brush biopsy techniques provide specific information when abnormal x-ray findings of the ureter or renal pelvis raise questions about whether a defect is a tumour, a



Urinary Tract Function

stone, a blood clot, or an artefact. First, a cystoscopic examination is conducted. Then, a ureteral catheter is introduced, followed by a biopsy brush that is passed through the catheter. The suspected lesion is brushed back and forth to obtain cells and surface tissue fragments for histologic analysis. After the procedure, IV fluids may be administered to help clear the kidneys and prevent clot formation. Urine may contain blood (usually clearing in 24 to 48 hours) from oozing at the brushing site. Postoperative renal colic occasionally occurs and responds to analgesic agents.

Kidney Biopsy Biopsy of the kidney is used to help diagnose and evaluate the extent of kidney disease. Indications for biopsy include unexplained acute renal failure, persistent proteinuria or hematuria, transplant rejection, and glomerulopathies. A small section of renal cortex is obtained either percutaneously (needle biopsy) or by open biopsy through a small flank incision. Before the biopsy is carried out, coagulation studies are conducted to identify any risk of postbiopsy bleeding. Contraindications to kidney biopsy include bleeding tendencies, uncontrolled hypertension, a solitary kidney, and morbid obesity (Salama & Cook, 2012).

Procedure The patient may be prescribed a fasting regimen 6 to 8 hours before the test. An IV line is established. A urine specimen is obtained and saved for comparison with the postbiopsy specimen. If a needle biopsy is to be performed, the patient is instructed to breathe in and hold that breath (to prevent the kidney from moving) while the needle is being inserted. The sedated patient is placed in a prone position with a sandbag under the abdomen. The skin at the biopsy site is infiltrated with a local anesthetic agent. The biopsy needle is introduced just inside the renal capsule of the outer quadrant of the kidney. The location of the needle may be confirmed by fluoroscopy or by ultrasound, in which case a special probe is used. With open biopsy, a small incision is made over the kidney, allowing direct visualization. Preparation for an open biopsy is similar to that for any major abdominal surgery.

Critical Thinking Exercises 1

Two days after major surgery your patient reports lower abdominal pain. Describe the assessment techniques appropriate to evaluate the pain. Review the possible causes, describe the actions you would take and the rationale for each action, and identify the evidence base that supports the actions. What criteria would you use to evaluate the strength of the evidence?

2 A 46-year-old patient with a history of smoking is admitted to the hospital for evaluation of urinary dysfunction and is scheduled for a urinary system MRI. Explain why the MRI is indicated for this patient and what, if any, precautions must be taken because the patient is trying to

stop smoking. What nursing observations and assessments are indicated because of the history of smoking? What patient teaching is appropriate before the MRI? 3 You make a home visit to an older female patient who is incontinent. Identify assessments and possible interventions you would use to evaluate and manage the incontinence. Identify the evidence for the assessments and nursing interventions you chose and the strength of that evidence.

REFERENCES AND SELECTED READINGS *Asterisk indicates nursing research article.

BOOKS Boswell, W. D., Jadvar, H., & Palmer, S. L. (2012). Diagnostic kidney imaging. In M. W. Taal, G. M. Chertow, P. A. Marsden, et al. (Eds.), Brenner & Rector’s The Kidney (9th ed., pp. 930–1005). Philadelphia, PA: Elsevier. Eliopoulos, C. (2014). Gerontological Nursing (8th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Hannon, R. A., Pooler, C., & Porth, C. M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Holcombe, D. M., & Kern Feeley, N. (2013). Renal failure. In P. G. Morton, & D. K. Fontaine, (Eds.), Critical Care Nursing A Holistic Approach (10th ed., pp. 663–690). Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins. Israni, A. K., & Kasiske, B. L. (2012). Laboratory assessment of kidney disease: Glomerular filtration rate, urinalysis, and proteinuria. In M. W. Taal, G. M. Chertow, P. A. Marsden, et al. (Eds.), Brenner & Rector’s The Kidney (9th ed., pp. 868–896). Philadelphia, PA: Elsevier. Miller, C. A. (2012). Nursing for wellness in older adults (6th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Salama, A. D., & Cook, H. T. (2012). The renal biopsy. In M. W. Taal, G. M. Chertow, P. A. Marsden, et al. (Eds.), Brenner & Rector’s The Kidney (9th ed., pp. 1006–1015). Philadelphia, PA: Elsevier. Snyder, K. A., & Crusius, K. C. (2013). Patient assessment: Renal system. In P. G. Morton, & D. K. Fontaine, (Eds.), Critical Care Nursing A Holistic Approach (10th ed., pp. 618–636). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Snyder, K. A., & Haas, K. (2013). Anatomy and physiology of the renal system. In P. G. Morton, & D. K. Fontaine, (Eds.), Critical Care Nursing A Holistic Approach (10th ed., pp. 607–636). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (2010). Canadian Bates’ guide to health assessment for nurses (1st ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (2012). Canadian Jensen’s nursing health assessment: A best practice approach (1st ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

JOURNALS AND ELECTRONIC DOCUMENTS *Alexaitis, I., & Broome, B. (2013). Implementation of a nurse-driven protocol to prevent catheter associated urinary tract infections. Journal of Nursing Care Quality, 29 (3), 245–252. Castner, D. (2010). Understanding the stages of chronic kidney disease. Nursing, 40 (5), 25–31. Collins, M., & Claros, E. (2011). Recognizing the face of dehydration. Nursing, 41(8), 26–31. Keyock, K. L., & Newman, D. K. (2011). Understanding stress urinary incontinence. The Nurse Practitioner, 36 (10), 24–36. Larsen, B., & Post, G. J. (2013). LUTS: A practical guide to alleviating lower urinary tract symptoms. Journal of the American Academy of Physician Assistants, 26 (3), 26–30.

CHAPTER 44 Menaker, J., & Scalea, T. M. (2010). Geriatric Care in the surgical intensive care unit. Critical Care Medicine, 38 (9), S452–459. Mentes, J. C. (2013). The complexities of hydration issues in the elderly. Nutrition Today, 48 (4S), S10–S12. National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) (2014). High blood pressure and kidney disease. Retrieved from #howcan O’Leary, M., & Dierich, M. (2010). Urinary tract dysfunction in neurological disorders: The nurses’ role in assessment and management. Journal of Neuroscience in Nursing, 42(2), E8–E23. Robinson, J. P., Bradway, C. W., Bunting-Perry, L., et al. (2013). Lower urinary tract symptoms in men with parkinson disease. Journal of Neuroscience Nursing, 45 (6), 382–392. Scemons, D. (2013). Urinary incontinence in adults. Nursing, 43(11), 52–60. Shultz, J. M. (2012). Rethink urinary incontinence in older women. Nursing, 42(11), 32–40.

Assessment of Renal and Urinary Tract Function


Sullivan, J. M. (2011). Caring for older adults after surgery. Nursing, 41(4), 48–51. Wilde, M. H., Bliss, D. A., Booth, J., et al. (2014). Self-management of urinary & fecal incontinence. American Journal of Nursing, 114(1), 38–45. Zuber, K., Liles, A. M., & Davies, J. (2013). Medication dosing in patients with chronic kidney disease. Journal of American Academy of Physician Assistants, 26 (10), 19–25.

RESOURCES American Association of Kidney Patients, American Urological Association, National Kidney Foundation, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, The Kidney Foundation of Canada Kidney Cancer Research Network of Canada entrez/query.fcgi?db=OMIM


45 Management of Patients With Renal Disorders Adapted by Lisa Rock

Learning Objectives On completion of this chapter, the learner will be able to: 1. Describe the key factors associated with the development of renal disorders. 2. Differentiate between the causes of chronic kidney disease and acute and chronic renal failure. 3. Compare and contrast the pathophysiology, clinical manifestations, medical management, and nursing management for patients with renal disorders. 4. Describe the nursing management of patients with acute and chronic renal failure. 5. Compare and contrast the renal replacement therapies including hemodialysis, peritoneal dialysis, and kidney transplantation. 6. Describe the nursing management of the hospitalized patient on dialysis. 7. Develop a postoperative plan of nursing care and teaching plan for the patient undergoing kidney surgery and transplantation.



The renal system helps regulate the body’s internal environment and is essential for the maintenance of life. Nurses working in any clinical setting may encounter patients with various renal disorders and thus need to be knowledgeable about these disorders. This chapter provides an overview of electrolyte imbalances that are common in patients with renal disorders. The main causes of kidney disease are discussed, together with management strategies to prevent damage and preserve renal function. Chronic kidney disease (CKD) and acute and chronic renal failure (CRF) are discussed, as is the care of patients with other renal conditions who require dialysis, transplantation, and kidney surgery.

FLUID AND ELECTROLYTE IMBALANCES IN RENAL DISORDERS Patients with renal disorders commonly experience fluid and electrolyte imbalances and require careful assessment

Management of Patients With Renal Disorders


and close monitoring for signs of potential problems. The patient whose fluid intake exceeds the ability of the kidneys to excrete fluid is said to have fluid overload. If fluid intake is inadequate, the patient is said to be volume depleted and may show signs and symptoms of fluid volume deficit. The fluid intake and output (I&O) record, a key monitoring tool, is used to document important fluid parameters, including the amount of fluid taken in (orally or parenterally), the volume of urine excreted, and other fluid losses (diarrhea, vomiting, diaphoresis). Patient weight is also important, and documenting trends in weight is a key assessment strategy essential for determining the daily fluid allowance and indicating signs of fluid overload or deficit.



The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded. A 1-kg weight gain is equal to 1,000 mL of retained fluid.

Glossary acute nephritic syndrome: type of renal failure with glomerular inflammation acute renal failure: sudden rapid deterioration of kidney function that is sometimes reversible acute tubular necrosis: type of acute renal failure in which there is actual damage to the kidney tubules anuria: total urine output less than 50 mL in 24 hours arteriovenous fistula: type of vascular access for dialysis; created by surgically connecting an artery to a vein arteriovenous graft: type of surgically created vascular access for dialysis by which a piece of biologic, semibiologic, or synthetic graft material connects the patient’s artery to a vein azotemia: abnormal concentration of nitrogenous wastes in the blood chronic kidney disease: chronic progressive and irreversible diseases of the kidneys continuous ambulatory peritoneal dialysis: method of peritoneal dialysis whereby a patient manually performs four or five complete exchanges or cycles throughout the day continuous cyclic peritoneal dialysis: method of peritoneal dialysis in which a peritoneal dialysis machine (cycler) automatically performs exchanges, usually while the patient sleeps continuous renal replacement therapy: variety of methods used to replace normal kidney function by circulating the patient’s blood through a filter and returning it to the patient dialysate: solution that circulates through the dialyzer in hemodialysis and through the peritoneal membrane in peritoneal dialysis dialyzer: “artificial kidney” or dialysis machine; contains a semipermeable membrane through which particles of a certain size can pass

diffusion: movement of solutes (waste products) from an area of higher concentration to an area of lower concentration effluent: term used to describe the drained fluid from a peritoneal dialysis exchange end-stage renal disease: final stage of renal failure that results in retention of uremic waste products and the need for renal replacement therapies exchange (peritoneal dialysis): complete cycle of peritoneal dialysis includes fill, dwell, and drain phases glomerulonephritis: inflammation of the glomerular capillaries hemodialysis: procedure during which a patient’s blood is circulated through a dialyzer to remove waste products and excess fluid interstitial nephritis: inflammation within the renal tissue nephrosclerosis: hardening of the renal arteries nephrotic syndrome: type of renal failure with increased glomerular permeability and massive proteinuria nephrotoxic: any substance, medication, or action that destroys kidney tissue osmosis: movement of water through a semipermeable membrane from an area of lower solute concentration to an area of higher solute concentration peritoneal dialysis: procedure that uses the lining of the patient’s peritoneal cavity as the semipermeable membrane for exchange of fluid and solutes peritonitis: inflammation of the peritoneal membrane (lining of the peritoneal cavity) pyelonephritis: inflammation of the renal pelvis ultrafiltration: process whereby water is removed from the blood by means of a pressure gradient between the patient’s blood and the dialysate uremia: an excess of urea and other nitrogenous wastes in the blood urinary casts: proteins secreted by damaged kidney tubules



Urinary Tract Function

Clinical Manifestations The signs and symptoms of common fluid and electrolyte disturbances that can occur in patients with renal disorders and their general management strategies are listed in Table 45-1. The nurse continually assesses, monitors, and informs appropriate members of the health care team if the patient exhibits any of these signs. Management strategies for fluid and electrolyte disturbances in renal disease are discussed in greater depth later in this chapter (see also Chapter 15).

Gerontologic Considerations Changes in kidney function with normal aging increase the susceptibility of older adults to kidney dysfunction and renal failure (Perico, Remuzzi, & Benigni, 2011). In addition, the incidence of systemic diseases, such as atherosclerosis, hypertension, heart failure, diabetes, and cancer, increases with advancing age, predisposing older adults to renal disease associated with these

TABLE 45-1

disorders. Therefore, acute problems need to be prevented, if possible, or recognized and treated quickly to avoid kidney damage, and nurses in all settings need to be alert for signs and symptoms of renal dysfunction in older adults. Older adults frequently take multiple prescription and over-the-counter medications. Because alterations in renal blood flow, glomerular filtration, and renal clearance increase the risk for medication-associated changes in renal function, precautions are indicated with all medications. When older adults undergo extensive diagnostic tests or when new medications (e.g., diuretic agents) are added, precautions must be taken to prevent dehydration, which can compromise marginal renal function and lead to renal failure (Mentes, 2013). With aging, the kidney is less able to respond to acute fluid and electrolyte changes. Older adults may develop atypical and nonspecific signs and symptoms of disturbed renal function and fluid and electrolyte imbalances. Recognition of these problems is further hampered by their association with pre-existing disorders and the misconception that they are normal changes of aging.

Common Fluid and Electrolyte Disturbances in Renal Disorders



General Management Strategies

Fluid volume deficit

Acute weight loss ≥5%, decreased skin turgor, dry mucous membranes, oliguria or anuria, increased hematocrit, blood urea nitrogen (BUN) level increased out of proportion to creatinine level, hypothermia Acute weight gain ≥5%, edema, crackles, shortness of breath, decreased BUN, decreased hematocrit, distended neck veins Nausea, malaise, lethargy, headache, abdominal cramps, apprehension, seizures Dry, sticky mucous membranes, thirst, rough dry tongue, fever, restlessness, weakness, disorientation Anorexia, abdominal distention, paralytic ileus, muscle weakness, ECG changes, dysrhythmias Diarrhea, colic, nausea, irritability, muscle weakness, ECG changes

Fluid challenge, fluid replacement orally or parenterally

Fluid volume excess

Sodium deficit Sodium excess Potassium deficit Potassium excess

Calcium deficit

Calcium excess

Bicarbonate deficit Bicarbonate excess Protein deficit Magnesium deficit

Magnesium excess

Phosphorus deficit Phosphorus excess

Abdominal and muscle cramps, stridor, carpopedal spasm, hyperactive reflexes, tetany, positive Chvostek’s or Trousseau’s sign, tingling of fingers and around mouth, ECG changes Deep bone pain, flank pain, muscle weakness, depressed deep tendon reflexes, constipation, nausea and vomiting, confusion, impaired memory, polyuria, polydipsia, ECG changes Headache, confusion, drowsiness, increased respiratory rate and depth, nausea and vomiting, warm flushed skin Depressed respirations, muscle hypertonicity, dizziness, tingling of fingers and toes Chronic weight loss, emotional depression, pallor, fatigue, soft flabby muscles Dysphagia, muscle cramps, hyperactive reflexes, tetany, positive Chvostek’s or Trousseau’s sign, tingling of fingers, dysrhythmias, vertigo Facial flushing, nausea and vomiting, sensation of warmth, drowsiness, depressed deep tendon reflexes, muscle weakness, respiratory depression, cardiac arrest Deep bone pain, flank pain, muscle weakness and pain, paresthesia, apprehension, confusion, seizures Tetany, tingling of fingers and around mouth, muscle spasms, soft tissue calcification

Fluid and sodium restriction, diuretics, dialysis

Diet, normal saline or hypertonic saline solutions Fluids, diuretics, dietary restriction Diet, oral or parenteral potassium replacement therapy Dietary restriction, diuretics, IV glucose, insulin and sodium bicarbonate, cation-exchange resin, calcium gluconate, dialysis Diet, oral or parenteral calcium salt replacement

Fluid replacement, etidronate, pamidronate, mithramycin, calcitonin, glucocorticoids, phosphate salts Bicarbonate replacement, dialysis Fluid replacement if volume depleted; ensure adequate chloride Diet, dietary supplements, hyperalimentation, albumin Diet, oral or parenteral magnesium replacement therapy Calcium gluconate, mechanical ventilation, dialysis

Diet, oral or parenteral phosphorus supplementation therapy Diet restriction, phosphate binders, normal saline solution, IV dextrose solution, and insulin


RENAL DISORDERS Chronic Kidney Disease Chronic kidney disease (CKD) is an abnormality of kidney structure or function for 3 months or more and is identified by the glomerular filtration rate (GFR) and other markers that indicate kidney damage (Kidney Disease Improving Global Outcomes [KDIGO], 2012). CKD is associated with decreased quality of life, increased health care expenditures, and premature death. Untreated CKD can result in end-stage renal disease (ESRD) and necessitate renal replacement therapy (dialysis or kidney transplantation). Risk factors include cardiovascular disease, diabetes, hypertension, and obesity (KDIGO, 2012). At the end of 2010, there were an estimated 39,352 people in Canada living with ESRD (Canadian Organ Replacement Register/Canadian Institute for Health Information, 2014). Diabetes is the primary cause of ESRD in Canada. The second leading cause is hypertension, followed by glomerulonephritis; polycystic kidney disease, hereditary, or congenital disorders; and systemic lupus erythematosus (Hannon, Pooler, & Porth, 2010).

Pathophysiology In the early stages of CKD there can be significant damage to the kidneys without signs or symptoms. The pathophysiology of CKD is not yet clearly understood, but the damage to the kidneys is thought to be caused by prolonged acute inflammation that is not organ specific and thus has subtle systemic manifestations.

Stages of Chronic Kidney Disease CKD has been classified into five stages by the National Kidney Foundation (NKF) (Chart 45-1). Stage 5 results when the kidneys cannot remove the body’s metabolic wastes or perform their regulatory functions and renal replacement therapies are required to sustain life. Screening and early intervention are important, as not all patients progress to stage 5 CKD. Patients with CKD are at increased risk for cardiovascular disease, the leading cause of morbidity and mortality (Holcombe & Kern Feeley, 2013). Treatment of hypertension, anemia, and hyperglycemia and detection of proteinuria all help to slow disease progression and improve patient outcomes (Castner, 2010).

Clinical Manifestations Elevated serum creatinine levels indicate underlying kidney disease; as the creatinine level increases, symptoms of CKD begin. Anemia, due to decreased erythropoietin production by the kidney; metabolic acidosis; and abnormalities in calcium and phosphorus herald the development of CKD. Fluid retention, evidenced by both edema and congestive heart failure, develops. As the disease progresses, abnormalities in electrolytes occur, heart failure worsens, and hypertension becomes more difficult to control.

Management of Patients With Renal Disorders


CHART 45-1

Stages of Chronic Kidney Disease Stages are based on the glomerular filtration rate (GFR). The normal GFR is 125 mL/min/1.73 m2.

Stage 1

GFR ≥ 90 mL/min/1.73 m2 Kidney damage with normal or increased GFR

Stage 2

GFR = 60–89 mL/min/1.73 m2 Mild decrease in GFR

Stage 3

GFR = 30–59 mL/min/1.73 m2 Moderate decrease in GFR

Stage 4

GFR = 15–29 mL/min/1.73 m2 Severe decrease in GFR

Stage 5

GFR < 15 mL/min/1.73 m2 Kidney failure (end-stage renal disease [ESRD])

Assessment and Diagnostic Findings The GFR is the amount of plasma filtered through the glomeruli per unit of time. Creatinine clearance is a measure of the amount of creatinine the kidneys are able to clear in a 24-hour period. Normal values differ in men and women. Calculation of GFR, an important assessment perimeter in CKD, is discussed in Chapter 44.

Medical Management The management of patients with CKD includes treatment of the underlying causes. Regular clinical and laboratory assessment is important to keep the blood pressure (BP) below 130/80 mm Hg. Medical management also includes early referral for initiation of renal replacement therapies as indicated by the patient’s renal status. Prevention of complications is accomplished by controlling cardiovascular risk factors; treating hyperglycemia; treating anemia; smoking cessation, weight loss, and exercise programs as needed; and reduction in salt and alcohol intake.

Nephrosclerosis Nephrosclerosis (hardening of the renal arteries) is most often due to prolonged hypertension and diabetes. Nephrosclerosis is a major cause of CKD and ESRD secondary to many disorders.

Pathophysiology There are two forms of nephrosclerosis: malignant (accelerated) and benign. Malignant nephrosclerosis is often associated with significant hypertension (diastolic blood pressure



Urinary Tract Function

higher than 130 mm Hg). It usually occurs in young adults and twice as often in men compared to women. Damage is caused by decreased blood flow to the kidney resulting in patchy necrosis of the renal parenchyma. Over time, fibrosis occurs and glomeruli are destroyed. The disease process progresses rapidly. Without dialysis, more than half of patients die from uremia (an excess of urea and other nitrogenous wastes in the blood) in a few years. Benign nephrosclerosis can be found in older adults, associated with atherosclerosis and hypertension.

Assessment and Diagnostic Findings Symptoms are rare early in the disease, even though the urine usually contains protein and occasional casts. Renal insufficiency and associated signs and symptoms occur late in the disease.

Medical Management Treatment of nephrosclerosis is aggressive antihypertensive therapy. An angiotensin-converting enzyme (ACE) inhibitor, alone or in combination with other antihypertensive medications, significantly reduces its incidence (Castner, 2010). See Chapter 33 for additional information on hypertension.

PRIMARY GLOMERULAR DISEASES Diseases that destroy the glomerulus of the kidney are the third most common cause of stage 5 CKD. In these disorders, the glomerular capillaries are primarily involved. Antigen–antibody complexes form in the blood and become trapped in the glomerular capillaries (the filtering portion of the kidney), inducing an inflammatory response. Immunoglobulin G (IgG), the major immunoglobulin (antibody) found in the blood, can be detected in the glomerular capillary walls. The major clinical manifestations of glomerular injury include proteinuria, hematuria, decreased GFR, decreased excretion of sodium, edema, and hypertension (Chart 45-2).

CHART 45-2

Terms Typically Used When Describing Glomerular Disease Primary: Disease is mainly in glomeruli Secondary: Glomerular diseases that are the consequence of systemic disease Idiopathic: Cause is unknown Acute: Occurs over days or weeks Chronic: Occurs over months or years Rapidly progressing: Constant loss of renal function with minimal chance of recovery Diffuse: Involves all glomeruli Focal: Involves some glomeruli Segmental: Involves portions of individual glomeruli Membranous: Evidence of thickened glomerular capillary walls Proliferative: Number of glomerular cells involved is increasing

skin) and acute viral infections (upper respiratory tract infections, mumps, varicella zoster virus, Epstein–Barr virus, hepatitis B, and human immunodeficiency virus [HIV] infection). In some patients, antigens outside the body (e.g., medications, foreign serum) initiate the process, resulting in antigen–antibody complexes being deposited in the glomeruli. In other patients, the kidney tissue itself serves as the inciting antigen.

Physiology/Pathophysiology Antigen (group A beta-hemolytic streptococcus)

Antigen–antibody product

Deposition of antigen–antibody complex in glomerulus

Increased production of epithelial cells lining the glomerulus

Acute Nephritic Syndrome The acute nephritic syndrome is the clinical manifestation of glomerular inflammation (Hannon et al., 2010). Glomerulonephritis is an inflammation of the glomerular capillaries that can occur in acute and chronic forms.

Leukocyte infiltration of the glomerulus

Thickening of the glomerular filtration membrane

Pathophysiology Primary glomerular diseases include postinfectious glomerulonephritis, rapidly progressive glomerulonephritis, membrane proliferative glomerulonephritis, and membranous glomerulonephritis. Postinfectious causes are group A beta-hemolytic streptococcal infection of the throat that precedes the onset of glomerulonephritis by 2 to 3 weeks (Fig. 45-1). It may also follow impetigo (infection of the

Scarring and loss of glomerular filtration membrane

Decreased glomerular filtration rate (GFR) FIGURE 45-1. Sequence of events in acute nephritic syndrome.


Clinical Manifestations The primary presenting features of an acute glomerular inflammation are hematuria, oliguria, edema, azotemia, an abnormal concentration of nitrogenous wastes in the blood, and proteinuria decreased GFR (Hannon et al., 2010). The hematuria may be microscopic (identifiable only through microscopic examination) or macroscopic (visible to the eye). The urine may appear cola-coloured because of red blood cells (RBCs) and protein plugs or casts; RBC casts indicate glomerular injury. Glomerulonephritis may be mild and the hematuria discovered incidentally through a routine urinalysis, or the disease may be severe, with acute renal failure (ARF) and oliguria. Some degree of edema and hypertension is present in most patients. Marked proteinuria due to the increased permeability of the glomerular membrane may also occur, with associated pitting edema, hypoalbuminemia, hyperlipidemia, and fatty casts in the urine. Blood urea nitrogen (BUN) and serum creatinine levels may increase as urine output decreases. In addition, anemia may be present. In the more severe form of the disease, patients also complain of headache, malaise, and flank pain. Older adults may experience circulatory overload with dyspnea, engorged neck veins, cardiomegaly, and pulmonary edema. Atypical symptoms include confusion, somnolence, and seizures, which are often confused with the symptoms of a primary neurologic disorder.

Assessment and Diagnostic Findings In acute nephritic syndrome, the kidneys become large, edematous, and congested. All renal tissues including the glomeruli, tubules, and blood vessels are affected to varying degrees. Patients with an IgA nephropathy have an elevated serum IgA and low to normal complement levels. Electron microscopy and immunofluorescent analysis help identify the nature of the lesion; however, a kidney biopsy may be needed for definitive diagnosis. (See Chapter 44 for discussion of kidney biopsy.) If the patient improves, the amount of urine increases and the urinary protein and sediment diminish. The percentage of adults who recover is unknown. Some patients develop severe uremia (an excess of urea and other nitrogenous wastes in the blood) within weeks and require dialysis for survival. Others, after a period of apparent recovery, insidiously develop chronic glomerulonephritis.

Complications Complications of acute glomerulonephritis include hypertensive encephalopathy, heart failure, and pulmonary edema. Hypertensive encephalopathy is a medical emergency, and therapy is directed toward reducing the blood pressure without impairing renal function. This can occur in acute nephritic syndrome or preeclampsia with chronic hypertension of greater than 140/90 mm Hg. Rapidly progressive glomerulonephritis is characterized by a rapid decline in renal function. Without treatment, ESRD develops in a matter of weeks or months. Signs and symptoms are similar to those of acute glomerulonephritis (hematuria and proteinuria), but the course of the disease is more

Management of Patients With Renal Disorders


severe and rapid. Crescent-shaped cells accumulate in Bowman’s space, disrupting the filtering surface. Plasma exchange (plasmapheresis) and treatment with high-dose corticosteroids and cytotoxic agents have been used to reduce the inflammatory response. Dialysis is initiated in acute glomerulonephritis if signs and symptoms of uremia are severe. The prognosis for patients with acute nephritic syndrome is excellent and rarely causes CKD (Hannon et al., 2010).

Medical Management Management consists primarily of treating symptoms, attempting to preserve kidney function, and treating complications promptly. Treatment may include corticosteroids, antihypertensives, and controlling proteinuria. Pharmacologic therapy depends on the cause of acute glomerulonephritis. If residual streptococcal infection is suspected, penicillin is the agent of choice; however, other antibiotic agents may be prescribed. Dietary protein is restricted when renal insufficiency and nitrogen retention (elevated BUN) develop. Sodium is restricted when the patient has hypertension, edema, and heart failure.

Nursing Management Although most patients with acute uncomplicated glomerulonephritis are cared for as outpatients, nursing care is important in every setting.

Providing Care in the Hospital In a hospital setting, carbohydrates are given liberally to provide energy and reduce the catabolism of protein. I&O are carefully measured and recorded. Fluids are given based on the patient’s fluid losses and daily body weight. Insensible fluid loss through the lungs (300 mL) and skin (600 mL) is considered when estimating fluid loss (see Chapter 15). If treatment is effective, diuresis will begin, resulting in decreased edema and blood pressure. Proteinuria and microscopic hematuria may persist for many months; in fact, 20% of patients have some degree of persistent proteinuria or decreased GFR 1 year after presentation (Hannon et al., 2010). Other nursing interventions focus on patient education about the disease process, explanations of laboratory and other diagnostic tests, and preparation for safe and effective self-care at home (Castner, 2010).

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Patient education is directed toward symptom management and monitoring for complications. Fluid and diet restrictions must be reviewed with the patient to avoid worsening of edema and hypertension. The patient is instructed verbally and in writing to notify the physician if symptoms of renal failure occur (e.g., fatigue, nausea, vomiting, diminishing urine output) or at the first sign of any infection. CONTINUING CARE. The importance of follow-up evaluations of blood pressure, urinalysis for protein, and BUN and serum creatinine levels to determine if the disease has progressed is stressed to the patient. A referral for home care may be indicated; a visit from a home care



Urinary Tract Function

nurse provides an opportunity for careful assessment of the patient’s progress and detection of early signs and symptoms of renal insufficiency. If corticosteroids, immunosuppressant agents, or antibiotic medications are prescribed, the home care nurse or nurse in the outpatient setting uses the opportunity to review the dosage, desired actions, and adverse effects of medications and the precautions to be taken.

Chronic Glomerulonephritis Chronic glomerulonephritis may be due to repeated episodes of acute nephritic syndrome, hypertensive nephrosclerosis, hyperlipidemia, chronic tubulointerstitial injury, or hemodynamically mediated glomerular sclerosis. Secondary glomerular diseases that can have systemic effects include lupus erythematosus, Goodpasture’s syndrome (caused by antibodies to the glomerular basement membrane), diabetic glomerulosclerosis, and amyloidosis.

Pathophysiology The kidneys are reduced to as little as one fifth their normal size (consisting largely of fibrous tissue). The cortex layer shrinks to 1 to 2 mm in thickness or less. Bands of scar tissue distort the remaining cortex, making the surface of the kidney rough and irregular. Numerous glomeruli and their tubules become scarred, and the branches of the renal artery are thickened. The resulting severe glomerular damage can progress to stage 5 CKD and require renal replacement therapies.

Clinical Manifestations The symptoms of chronic glomerulonephritis vary. Some patients with severe disease have no symptoms at all for many years (Hannon et al., 2010). The condition may be discovered when hypertension or elevated BUN and serum creatinine levels are detected. Most patients report general symptoms, such as loss of weight and strength, increasing irritability, and an increased need to urinate at night (nocturia). Headaches, dizziness, and digestive disturbances are also common. As chronic glomerulonephritis progresses, signs and symptoms of CKD and CRF may develop. The patient appears poorly nourished, with a yellow-grey pigmentation of the skin and periorbital and peripheral (dependent) edema. Blood pressure may be normal or severely elevated. Retinal findings include hemorrhage, exudate, narrowed tortuous arterioles, and papilledema. Anemia causes pale mucous membranes. Cardiomegaly, a gallop rhythm, distended neck veins, and other signs and symptoms of heart failure may be present (Stephen, Skillen, Day, et al., 2010). Crackles can be heard in the bases of the lungs. Peripheral neuropathy with diminished deep tendon reflexes and neurosensory changes occur late in the disease. The patient becomes confused and demonstrates a limited attention span. An additional late finding includes evidence of pericarditis with a pericardial friction rub and pulsus paradoxus (difference in blood pressure during inspiration and expiration of greater than 10 mm Hg).

Assessment and Diagnostic Findings A number of laboratory abnormalities occur. Urinalysis reveals a fixed specific gravity of about 1.010, variable proteinuria, and urinary casts (proteins secreted by damaged kidney tubules). As renal failure progresses and the GFR falls below 50 mL/min, the following changes occur: • Hyperkalemia due to decreased potassium excretion, acidosis, catabolism, and excessive potassium intake from food and medications • Metabolic acidosis from decreased acid secretion by the kidney and inability to regenerate bicarbonate • Anemia secondary to decreased erythropoiesis (production of RBCs) • Hypoalbuminemia with edema secondary to protein loss through the damaged glomerular membrane • Increased serum phosphorus level due to decreased renal excretion of phosphorus • Decreased serum calcium level (calcium binds to phosphorus to compensate for elevated serum phosphorus levels) • Mental status changes • Impaired nerve conduction due to electrolyte abnormalities and uremia Chest x-rays may show cardiac enlargement and pulmonary edema. The electrocardiogram (ECG) may be normal or may indicate left ventricular hypertrophy associated with hypertension and signs of electrolyte disturbances, such as tall, tented (or peaked) T waves associated with hyperkalemia. Computed tomography (CT) and magnetic resonance imaging (MRI) scans show a decrease in the size of the renal cortex.

Medical Management Management of symptoms guides the treatment. If the patient has hypertension, efforts are made to reduce the blood pressure with sodium and water restriction, antihypertensive agents, or both. Weight is monitored daily, and diuretic medications are prescribed to treat fluid overload. Proteins of high biologic value (dairy products, eggs, meats) are provided to promote good nutritional status. Adequate calories are provided to spare protein for tissue growth and repair. Urinary tract infections (UTIs) must be treated promptly to prevent further renal damage. Dialysis is initiated early in the course of the disease to keep the patient in optimal physical condition, prevent fluid and electrolyte imbalances, and minimize the risk of complications of renal failure. The course of dialysis is smoother if treatment begins before the patient develops complications.

Nursing Management Whether the patient is hospitalized or cared for in the home, the nurse observes the patient for common fluid and electrolyte disturbances in renal disease (Table 45-1). Changes in fluid and electrolyte status and in cardiac and neurologic status are reported promptly to the physician. Anxiety levels are often extremely high for both the patient and family. Throughout the course of the disease and treatment, the


nurse gives emotional support by providing opportunities for the patient and family to verbalize their concerns, have their questions answered, and explore their options.

Promoting Home and Community-Based Care


Management of Patients With Renal Disorders

Physiology/Pathophysiology Damaged glomerular capillary membrane

TEACHING PATIENTS SELF-CARE. The nurse has a major

role in teaching the patient and family about the prescribed treatment plan and the risks associated with noncompliance. Instructions to the patient include explanations and scheduling for follow-up evaluations: blood pressure, urinalysis for protein and casts, and laboratory studies of BUN and serum creatinine levels. If long-term dialysis is needed, the nurse teaches the patient and family about the procedure, how to care for the access site, dietary restrictions, and other necessary lifestyle modifications. These topics are discussed later in this chapter. Periodic hospitalization, visits to the outpatient clinic or office, and home care referrals provide the nurse in each setting with the opportunity for careful assessment of the patient’s progress and continued education about changes to report to the primary health care provider (worsening signs and symptoms of renal failure, such as nausea, vomiting, and diminished urine output). Specific teaching may include explanations about recommended diet and fluid modifications and medications (purpose, desired effects, adverse effects, dosage, and administration schedule). CONTINUING CARE. Periodic laboratory evaluations of creatinine clearance and BUN and serum creatinine levels are carried out to assess residual renal function and the need for dialysis or transplantation. If dialysis is initiated, the patient and family require considerable assistance and support in dealing with therapy and its long-term implications. The patient and family are reminded of the importance of participation in health promotion activities, including health screening. The patient is instructed to inform all health care providers about the diagnosis of glomerulonephritis so that all medical management, including pharmacologic therapy, is based on altered renal function.

Nephrotic Syndrome Nephrotic syndrome is a type of renal failure characterized by increased glomerular permeability and is manifested by massive proteinuria (Hannon et al., 2010). Clinical findings include a marked increase in protein (particularly albumin) in the urine (proteinuria), a decrease in albumin in the blood (hypoalbuminemia), diffuse edema, high serum cholesterol, and low-density lipoproteins (hyperlipidemia). The syndrome is apparent in any condition that seriously damages the glomerular capillary membrane and results in increased glomerular permeability to plasma proteins. Although the liver is capable of increasing the production of albumin, it cannot keep up with the daily loss of albumin through the kidneys. Thus, hypoalbuminemia results (Fig. 45-2).

Pathophysiology Nephrotic syndrome occurs with many intrinsic renal diseases and systemic diseases that cause glomerular damage.

Loss of plasma protein (albumin)

Stimulates synthesis of lipoproteins



Decreased oncotic pressure

Generalized edema (fluid moves from vascular space to extracellular compartment)

Activation of renin–angiotensin system

Sodium retention


FIGURE 45-2. Sequence of events in nephrotic syndrome.

It is not a specific glomerular disease but a constellation of clinical findings that result from the glomerular damage (Hannon et al., 2010).

Clinical Manifestations The major manifestation of nephrotic syndrome is edema. It is usually soft and pitting and commonly occurs around the eyes (periorbital), in dependent areas (sacrum, ankles, and hands), and in the abdomen (ascites). Patients may also exhibit irritability, headache, and malaise.

Assessment and Diagnostic Findings Proteinuria (predominately albumin) exceeding 3.5 g/day is the hallmark of the diagnosis of nephrotic syndrome (Hannon et al., 2010). Protein electrophoresis and immunoelectrophoresis may be performed on the urine to categorize the type of proteinuria. The urine may also contain increased white blood cells (WBCs) as well as granular and epithelial casts. A needle biopsy of the kidney may be performed for histologic examination of renal tissue to confirm the diagnosis.

Complications Complications of nephrotic syndrome include infection (due to a deficient immune response), thromboembolism (especially of the renal vein), pulmonary emboli, ARF (due to hypovolemia), and accelerated atherosclerosis (due to hyperlipidemia).



Urinary Tract Function

Medical Management Treatment is focused on treating the underlying disease state causing proteinuria, slowing progression of CKD, and relieving symptoms. Typical treatment includes diuretics for edema, ACE inhibitors to reduce proteinuria, and lipid-lowering agents for hyperlipidemia.

Nursing Management In the early stages of nephrotic syndrome, nursing management is similar to that of the patient with acute glomerulonephritis, but as the condition worsens, management is similar to that of the patient with ESRD (see the following section). Patients with nephrotic syndrome need adequate instruction about the importance of following all medication and dietary regimens so that their condition can remain stable as long as possible. Patients must be made aware of the importance of communicating any health-related change to their health care providers as soon as possible so that appropriate medication and dietary changes can be made before further changes occur within the glomeruli.

POLYCYSTIC KIDNEY DISEASE Pathophysiology Polycystic kidney disease (PKD) is a genetic disorder characterized by the growth of numerous cysts in the kidneys. When cysts form in the kidneys, they are filled with fluid, destroying the nephrons. PKD cysts can profoundly enlarge the kidneys while replacing much of the normal structure, resulting in reduced kidney function and leading to kidney failure. PKD can also cause cysts in the liver and problems in other organs, such as blood vessels in the brain and heart. The number of cysts as well as the complications they cause help distinguish PKD from the usually harmless “simple” cysts that can form in the kidneys in later years of life. In the United States, PKD and cystic diseases are the fifth leading cause of kidney failure. Two major inherited forms of PKD exist: • Autosomal dominant PKD is the most common inherited form. Symptoms usually develop between the ages of 30 and 40, but they can begin earlier, even in childhood. About 90% of all PKD cases are autosomal dominant PKD. • Autosomal recessive PKD is a rare inherited form. Symptoms of autosomal recessive PKD begin in the earliest months of life or in utero. When autosomal dominant PKD causes kidneys to fail, which usually happens after many years, the patient requires dialysis or kidney transplantation. About one half of people with the most common type of PKD progress to CKD stage 5, requiring renal replacement.

Clinical Manifestations Signs and symptoms of PKD result from loss of renal function and the increasing size of the kidneys as the cysts

grow. Renal damage can result in hematuria, polyuria (large amounts of urine), hypertension, development of renal calculi and associated UTIs, and proteinuria. The growing cysts are noted with reports of abdominal fullness and flank pain (back and lower sides).

Assessment and Diagnostic Findings Since PKD is a genetic disease, careful evaluation of family history is necessary. Palpation of the abdomen will often reveal enlarged cystic kidneys. Diagnosis is usually made with ultrasound imaging of the kidney (Hannon et al., 2010).

Medical Management PKD has no cure and treatment is largely supportive including blood pressure control, pain control, and antibiotics to resolve infections. Once the kidneys fail, renal replacement therapy is indicated. Genetic testing and counselling may be indicated.

RENAL CANCER Cancer of the kidney accounts for 3,656 new cases (3.8%) in men and 2,285 new cases (2.5%) in women in Canada in 2013. (Canadian Cancer Society’s Steering Committee, 2013). The incidence of all stages of kidney cancer has increased in the last two decades in Canada. Tobacco use continues to be a significant risk factor for renal carcinoma (Chart 45-3). The most common type of renal carcinoma arises from the renal epithelium and accounts for more than 85% of all kidney tumours. These tumours may metastasize early to the lungs, bone, liver, brain, and contralateral kidney. One quarter of patients have metastatic disease at the time of diagnosis. Although enhanced imaging techniques account for improved detection of early-stage kidney cancer, symptoms may not be present until the tumour reaches a considerable size (Hannon et al., 2010).

Clinical Manifestations Many renal tumours produce no symptoms and are discovered on a routine physical examination as a palpable abdominal mass. The classic signs and symptoms, which occur in only 10% of patients, include hematuria, pain, CHART 45-3

Risk Factors for Renal Cancer • Gender: Affects men more than women • Tobacco use • Occupational exposure to industrial chemicals, such as petroleum products, heavy metals, and asbestos

• Obesity • Unopposed estrogen therapy • Polycystic kidney disease


and a mass in the flank (Canadian Cancer Society, 2014). The usual sign that first calls attention to the tumour is painless hematuria, which may be either intermittent and microscopic or continuous and gross. There may be a dull pain in the back from the pressure produced by compression of the ureter, extension of the tumour into the perirenal area, or hemorrhage into the kidney tissue. Colicky pains occur if a clot or mass of tumour cells passes down the ureter. Symptoms from metastasis may be the first manifestations of renal tumour and may include unexplained weight loss, increasing weakness, and anemia.

Assessment and Diagnostic Findings The diagnosis of a renal tumour may require intravenous (IV) urography, cystoscopic examination, nephrotomograms, renal angiograms, ultrasonography, or a CT scan. These tests may be exhausting for patients already debilitated by the systemic effects of a tumour as well as for older patients and those who are anxious about the diagnosis and outcome. The nurse assists the patient to prepare physically and psychologically for these procedures and monitors carefully for signs and symptoms of dehydration and exhaustion.

Medical Management The goal of management is to eradicate the tumour before metastasis occurs.

Surgical Management NEPHRECTOMY. A radical nephrectomy is the preferred treatment if the tumour can be removed. This includes removal of the kidney (and tumour), adrenal gland, surrounding perinephric fat and Gerota’s fascia, and lymph nodes. Laparoscopic nephrectomy can be performed for removal of the kidney with a small tumour. This procedure incurs less morbidity and a shorter recovery time. Radiation therapy, hormonal therapy, or chemotherapy may be used along with surgery. Immunotherapy may also be helpful. For patients with bilateral tumour or cancer of a functional single kidney, nephron-sparing surgery (partial nephrectomy) may be considered. Nephron-sparing surgery is increasingly being used to treat patients with solid renal lesions. The technical success rate of nephron-sparing surgery is excellent, and operative morbidity and mortality are low. Patients with upper tract transitional cell carcinoma may benefit from laparoscopic nephroureterectomy. Although it is a lengthier surgical procedure, it has the same efficacy and is better tolerated by patients than open nephroureterectomy. RENAL ARTERY EMBOLIZATION. In patients with metastatic renal carcinoma, the renal artery may be occluded to impede the blood supply to the tumour and thus kill the tumour cells. After angiographic studies are completed, a catheter is advanced into the renal artery, and embolizing materials (e.g., Gelfoam, autologous blood clot, steel coils) are injected into the artery and carried with the arterial blood flow to occlude the tumour vessels mechanically. This decreases the local blood supply, making removal of

Management of Patients With Renal Disorders


the kidney (nephrectomy) easier. It also stimulates an immune response because infarction of the renal cell carcinoma releases tumour-associated antigens that enhance the patient’s response to metastatic lesions. The procedure may also reduce the number of tumour cells entering the venous circulation during surgical manipulation. After renal artery embolization and tumour infarction, a characteristic symptom complex called postinfarction syndrome occurs, lasting 2 to 3 days. The patient has pain localized to the flank and abdomen, elevated temperature, and gastrointestinal (GI) symptoms. Pain is treated with parenteral analgesic agents, and acetaminophen (Tylenol) is administered to control fever. Antiemetic medications, restriction of oral intake, and IV fluids are used to treat the GI symptoms.

Pharmacologic Therapy Currently, no pharmacologic agents are in widespread use for treatment of renal cell carcinoma, which is refractory to most chemotherapeutic agents. However, depending on the stage of the tumour, percutaneous partial or radical nephrectomy may be followed by treatment with chemotherapeutic agents. Radiation therapy may be used for palliation in patients who are not candidates for surgery. Treatment with biologic response modifiers such as interleukin-2 (IL-2) is effective. IL-2, a protein that regulates cell growth, is used alone or in combination with lymphokineactivated killer cells (WBCs that have been stimulated by IL-2 to increase their ability to kill cancer cells). Interferon, another biologic response modifier, appears to have a direct antiproliferative effect on renal tumours. Temsirolimus (Torisel) is administered by IV infusion on a weekly basis to treat advanced renal cell carcinoma (Wood, 2010).

Nursing Management The patient with a renal tumour usually undergoes extensive diagnostic and therapeutic procedures. Treatment includes surgery, radiation therapy, and medications. After surgery, the patient usually has catheters and drains in place to maintain a patent urinary tract, to remove drainage, and to permit accurate measurement of urine output. Because of the location of the surgical incision, the patient’s position during surgery, and the nature of the surgical procedure, pain and muscle soreness are common. Pharmacologic management often includes immunosuppressant agents; therefore, patients are monitored for infection (Aschenbrenner, 2007). The patient requires frequent analgesia during the postoperative period and assistance with turning, coughing, use of incentive spirometry, and deep breathing to prevent atelectasis and other pulmonary complications. The patient and family require assistance and support to cope with the diagnosis and uncertain prognosis. (See this chapter for discussion of postoperative care of the patient undergoing kidney surgery and Chapter 17 for discussion of care of the patient with cancer.)

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. The nurse teaches the patient to inspect and care for the incision and perform other general postoperative care including activity and



Urinary Tract Function

lifting restrictions, driving, and pain management. Instructions are provided about when to notify the physician about problems (e.g., fever, breathing difficulty, wound drainage, blood in the urine, pain or swelling of the legs). The nurse encourages the patient to eat a healthy diet and to drink adequate liquids to avoid constipation and to maintain an adequate urine volume. Education and emotional support are provided related to the diagnosis, treatment, and continuing care because many patients are concerned about the loss of the other kidney, the possible need for dialysis, or the recurrence of cancer. CONTINUING CARE. Follow-up care is essential to detect signs of metastases and to reassure the patient and family about the patient’s status and well-being. The patient who has had surgery for renal carcinoma should have a yearly physical examination and chest x-ray, because late metastases are not uncommon. All subsequent symptoms should be evaluated with possible metastases in mind. If follow-up chemotherapy is necessary, the patient and family are informed about the treatment plan or chemotherapy protocol, what to expect with each visit, and when to notify the physician. Evaluation of remaining renal function (creatinine clearance, BUN and serum creatinine levels) may also be carried out periodically. A home care nurse may monitor the patient’s physical status and psychological well-being and coordinate other indicated services and resources.

RENAL FAILURE Renal failure results when the kidneys cannot remove the body’s metabolic wastes or perform their regulatory functions. The substances normally eliminated in the urine accumulate in the body fluids as a result of impaired renal excretion, affecting endocrine and metabolic functions as well as fluid, electrolyte, and acid–base disturbances. Renal failure is a systemic disease and is a final common pathway of many different kidney and urinary tract diseases. In 2012, 5,431 patients were diagnosed with endstage kidney diseases. This is more than double what was found in 1993 (Canadian Institute for Health Information [CIHI], 2013).

Acute Renal Failure Acute renal failure (ARF) is a rapid loss of renal function due to damage to the kidneys. Depending on the duration and severity of ARF, a wide range of potentially lifethreatening metabolic complications can occur, including metabolic acidosis as well as fluid and electrolyte imbalances. Treatment is aimed at replacing renal function temporarily to minimize potentially lethal complications and reduce potential causes of increased renal injury with the goal of minimizing long-term loss of renal function. ARF is a problem seen in hospitalized patients and those in outpatient settings. A widely accepted criterion for ARF is a decreased GFR and accumulation of BUN and serum creatinine. Further classification can be made using the Risk, Injury, Failure, Loss, End stage (RIFLE) classification system (Holcombe & Kern Feeley, 2013; Yaklin, 2011).

Pathophysiology Although the pathogenesis of ARF and oliguria is not always known, many times there is a specific underlying problem. Some of the factors may be reversible if identified and treated promptly, before kidney function is impaired. This is true of the following conditions that reduce blood flow to the kidney and impair kidney function: (1) hypovolemia; (2) hypotension; (3) reduced cardiac output and heart failure; (4) obstruction of the kidney or lower urinary tract by tumour, blood clot, or kidney stone; and (5) bilateral obstruction of the renal arteries or veins. If these conditions are treated and corrected before the kidneys are permanently damaged, the increased BUN and creatinine levels, oliguria, and other signs may be reversed. Although renal stones are not a common cause of ARF, some types may increase the risk for ARF. Some hereditary stone diseases (see Chapter 46), primary struvite stones, and infection-related urolithiasis associated with anatomic and functional urinary tract anomalies and spinal cord injury may cause recurrent bouts of obstruction as well as crystal-specific damage to tubular epithelial cells and interstitial renal cells.

Categories of Acute Renal Failure The major categories of ARF are prerenal (hypoperfusion of kidney), intrarenal (actual damage to kidney tissue), and postrenal (obstruction to urine flow). Prerenal ARF, which occurs in 60% to 70% of cases, is the result of impaired blood flow that leads to hypoperfusion of the kidney and a decrease in the GFR. Intrarenal ARF is the result of actual parenchymal damage to the glomeruli or kidney tubules. Acute tubular necrosis (ATN) is the most common type of intrinsic ARF. Characteristics of ATN are intratubular obstruction, tubular back leak (abnormal reabsorption of filtrate and decreased urine flow through the tubule), vasoconstriction, and changes in glomerular permeability. These processes result in a decrease of GFR, progressive azotemia, and fluid and electrolyte imbalances. CKD, diabetes, heart failure, hypertension, and cirrhosis can lead to ATN (Ali & Gray-Vickrey, 2011; Holcombe & Kern Feeley, 2013). Postrenal ARF usually results from obstruction distal to the kidney. Pressure rises in the kidney tubules and eventually, the GFR decreases. Common causes of each type of ARF are summarized in Chart 45-4.

Phases of Acute Renal Failure There are four phases of ARF: initiation, oliguria, diuresis, and recovery. • The initiation period begins with the initial insult and ends when oliguria develops. • The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). The minimum amount of urine needed to rid the body of normal metabolic waste products is 400 mL. In this phase uremic symptoms first appear and life-threatening conditions such as hyperkalemia develop.


Management of Patients With Renal Disorders


CHART 45-4

Causes of Acute Renal Failure Prerenal Failure

Myoglobinuria (trauma, crush injuries, burns) Hemoglobinuria (transfusion reaction, hemolytic anemia) • Nephrotoxic agents such as: Aminoglycoside antibiotics (gentamicin, tobramycin) Radiopaque contrast agents Heavy metals (lead, mercury) Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic) Nonsteroidal anti-inflammatory drugs (NSAIDs) Angiotensin-converting enzyme inhibitors (ACE inhibitors) • Infectious processes such as: Acute pyelonephritis Acute glomerulonephritis

• Volume depletion resulting from:

Hemorrhage Renal losses (diuretics, osmotic diuresis) Gastrointestinal losses (vomiting, diarrhea, nasogastric suction) • Impaired cardiac efficiency resulting from: Myocardial infarction Heart failure Dysrhythmias Cardiogenic shock • Vasodilation resulting from: Sepsis Anaphylaxis Antihypertensive medications or other medications that cause vasodilation

Postrenal Failure • Urinary tract obstruction, including: Calculi (stones) Tumours Benign prostatic hyperplasia Strictures Blood clots

Intrarenal Failure • Prolonged renal ischemia resulting from:

Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures)

Some patients have decreased renal function with increasing nitrogen retention, yet actually excrete normal amounts of urine (2 L/day or more). This is the nonoliguric form of renal failure and occurs predominantly after exposure of the patient to nephrotoxic agents, burns, traumatic injury, and the use of halogenated anesthetic agents. • The diuresis period is marked by a gradual increase in urine output, which signals that glomerular filtration has started to recover. Laboratory values stabilize and eventually decrease. Although the volume of urinary output may reach normal or elevated levels, renal function may still be markedly abnormal. Because uremic symptoms may still be present, the need for expert medical and nursing management continues. The patient must be observed closely for dehydration during this phase; if dehydration occurs, the uremic symptoms are likely to increase. • The recovery period signals the improvement of renal function and may take 3 to 12 months. Laboratory valTABLE 45-2

ues return to the patient’s normal level. Although a permanent 1% to 3% reduction in the GFR is common, it is not clinically significant.

Clinical Manifestations Almost every system of the body is affected with failure of the normal renal regulatory mechanisms. The patient may appear critically ill and lethargic. The skin and mucous membranes are dry from dehydration. Central nervous system signs and symptoms include drowsiness, headache, muscle twitching, and seizures. Table 45-2 summarizes common clinical characteristics in all three categories of ARF.

Assessment and Diagnostic Findings Assessment of the patient with ARF includes evaluation for changes in the urine, diagnostic tests that evaluate the

Comparing Clinical Characteristics of Acute Renal Failure Categories





Etiology Blood urea nitrogen value

Parenchymal damage Increased

Obstruction Increased

Creatinine Urine output

Hypoperfusion Increased (out of normal 20:1 proportion to creatinine) Increased Decreased

Increased Varies, often decreased

Urine sodium

Decreased to 40 mEq/L

Urinary sediment Urine osmolality Urine specific gravity

Normal, few hyaline casts Increased to 500 mOsm Increased

Abnormal casts and debris About 350 mOsm similar to serum Low normal

Increased Varies, may be decreased, or sudden anuria Varies, often decreased to 20 mEq/L or less Usually normal Varies, increased or equal to serum Varies



Urinary Tract Function

kidney contour, and a variety of laboratory values. See Chapter 44 for information about the normal characteristics of urine, diagnostic findings, and laboratory values in the renal system. In ARF, urine output varies from scanty to a normal volume, hematuria may be present, and the urine has a low specific gravity (compared with a normal value of 1.010 to 1.025). One of the earliest manifestations of tubular damage is the inability to concentrate the urine (Hannon et al., 2010). Patients with prerenal azotemia have a decreased amount of sodium in the urine (less than 20 mEq/L) and normal urinary sediment. Patients with intrarenal azotemia usually have urinary sodium levels greater than 40 mEq/L with urinary casts and other cellular debris. Ultrasonography is a critical component of the evaluation of patients with renal failure. A renal sonogram or a CT or MRI scan may show evidence of anatomic changes. The BUN level increases steadily at a rate dependent on the degree of catabolism (breakdown of protein), renal perfusion, and protein intake. Serum creatinine levels are useful in monitoring kidney function and disease progression and increase with glomerular damage. With a decline in the GFR, oliguria, and anuria, patients are at high risk for hyperkalemia. Protein catabolism results in the release of cellular potassium into the body fluids, causing severe hyperkalemia (high serum potassium levels). Hyperkalemia may lead to dysrhythmias, such as ventricular tachycardia and cardiac arrest. Sources of potassium include normal tissue catabolism, dietary intake, blood in the GI tract, or blood transfusion and other sources (e.g., IV infusions, potassium penicillin, and extracellular shift in response to metabolic acidosis). Progressive metabolic acidosis occurs in renal failure because patients cannot eliminate the daily metabolic load of acid-type substances produced by the normal metabolic processes. In addition, normal renal buffering mechanisms fail. This is reflected by a decrease in the serum CO2-combining power and blood pH. There may be an increase in blood phosphate concentrations; calcium levels may be low due to decreased absorption of calcium from the intestine and as a compensatory mechanism for the elevated blood phosphate levels. Anemia is another common laboratory finding in ARF, as a result of reduced erythropoietin production, uremic GI lesions, reduced RBC lifespan, and blood loss from the GI tract.

Prevention ARF has a high mortality rate that ranges from 25% to 90%. Factors that influence mortality include increased age, comorbid conditions, and pre-existing renal and vascular diseases (Dirkes, 2011). Therefore, prevention of ARF is essential (Chart 45-5). A careful history is obtained to identify exposure to nephrotoxic agents or environmental toxins. The kidneys are susceptible to the adverse effects of medications because the kidneys are repeatedly exposed to substances in the blood. Patients taking nephrotoxic medications (e.g., aminoglycosides, gentamicin, tobramycin, colistimethate, polymyxin B, amphotericin B, vancomycin, amikacin, cyclosporine) should be monitored closely for changes in renal function. BUN and serum creatinine levels should be obtained at baseline within 24 hours after

CHART 45-5

Preventing Acute Renal Failure 1. Provide adequate hydration to patients at risk for dehydration including: Before, during, and after surgery Patients undergoing intensive diagnostic studies requiring fluid restriction and contrast agents (e.g., barium enema, intravenous pyelograms), especially older patients who may have marginal renal reserve Patients with neoplastic disorders or disorders of metabolism (e.g., gout) and those receiving chemotherapy 2. Prevent and treat shock promptly with blood and fluid replacement. 3. Monitor central venous and arterial pressures and hourly urine output of critically ill patients to detect the onset of renal failure as early as possible. 4. Treat hypotension promptly. 5. Continually assess renal function (urine output, laboratory values) when appropriate. 6. Take precautions to ensure that the appropriate blood is administered to the correct patient in order to avoid severe transfusion reactions, which can precipitate renal failure. 7. Prevent and treat infections promptly. Infections can produce progressive renal damage. 8. Pay special attention to wounds, burns, and other precursors of sepsis. 9. To prevent infections from ascending in the urinary tract, give meticulous care to patients with indwelling catheters. Remove catheters as soon as possible. 10. To prevent toxic drug effects, closely monitor dosage, duration of use, and blood levels of all medications metabolized or excreted by the kidneys.

initiation of these medications and at least twice a week while the patient is receiving them. Any agent that reduces renal blood flow (e.g., long-term analgesic use) may cause renal insufficiency. Chronic use of analgesic agents, particularly nonsteroidal anti-inflammatory drugs (NSAIDs), may cause interstitial nephritis (inflammation within the renal tissue) and papillary necrosis. Patients with heart failure or cirrhosis with ascites are at particular risk for NSAID-induced renal failure. Increased age, pre-existing renal disease, and the simultaneous administration of several nephrotoxic agents increase the risk for kidney damage. Radiocontrast-induced nephropathy (RIN) is a major cause of hospital-acquired ARF. Patients undergo more than 1 million radiocontrast studies in the United States annually; of these approximately 150,000 will experience RIN, and at least 1% of these will require dialysis and experience a prolonged hospital stay (Barreto, 2007). This is a potentially preventable condition. Baseline levels of creatinine greater than 2 mg/dL identify patients at high risk. Limiting the patient’s exposure to contrast agents and nephrotoxic medications will reduce the risk of RIN (Jorgensen, 2013). Administration of N-acetylcysteine and sodium bicarbonate before and during procedures reduces risk, but prehydration with saline is considered the most effective method to prevent RIN (Isaac, 2012).


Gerontologic Considerations About half of all patients who develop ARF during hospitalization are older than 60 years. The etiology of ARF in older adults includes prerenal causes such as dehydration, intrarenal causes such as nephrotoxic agents (e.g., medications, contrast agents), and complications of major surgery (Holcombe & Kern Feeely, 2013). Suppression of thirst, enforced bed rest, lack of access to drinking water, and confusion all contribute to the older patient’s failure to consume adequate fluids and may lead to dehydration, further compromising already decreased renal function. ARF in older adults is also often seen in the community setting. Nurses in the ambulatory setting need to be aware of the risk. All medications need to be monitored for potential side effects that could result in damage to the kidney either through reduced circulation or nephrotoxicity. Outpatient procedures that require fasting or a bowel preparation may cause dehydration and therefore require careful monitoring.

Medical Management The kidneys have a remarkable ability to recover from insult. The objectives of treatment of ARF are to restore normal chemical balance and prevent complications until repair of renal tissue and restoration of renal function can occur. Management includes eliminating the underlying cause; maintaining fluid balance; avoiding fluid excesses; and, when indicated, providing renal replacement therapy. Prerenal azotemia is treated by optimizing renal perfusion, whereas postrenal failure is treated by relieving the obstruction. Intrarenal azotemia is treated with supportive therapy, with removal of causative agents, aggressive management of prerenal and postrenal failure, and avoidance of associated risk factors. Shock and infection, if present, are treated promptly (see Chapter 16). Maintenance of fluid balance is based on daily body weight, serial measurements of central venous pressure, serum and urine concentrations, fluid losses, blood pressure, and the clinical status of the patient. The parenteral and oral intake and the output of urine, gastric drainage, stools, wound drainage, and perspiration are calculated and are used as the basis for fluid replacement. The insensible fluid produced through the normal metabolic processes and lost through the skin and lungs is also considered in fluid management. Fluid excesses can be detected by the clinical findings of dyspnea, tachycardia, and distended neck veins. The patient’s lungs are auscultated for moist crackles. Because pulmonary edema may be caused by excessive administration of parenteral fluids, extreme caution must be used to prevent fluid overload. The development of generalized edema is assessed by examining the presacral and pretibial areas several times daily. Mannitol (Osmitrol), furosemide (Lasix), or ethacrynic acid (Edecrin) may be prescribed to initiate diuresis. Adequate renal blood flow in patients with prerenal causes of ARF may be restored by IV fluids or transfusions of blood products. If ARF is caused by hypovolemia secondary to hypoproteinemia, an infusion of albumin may be prescribed. Dialysis may be initiated to prevent complications of ARF, such as hyperkalemia, metabolic acidosis,

Management of Patients With Renal Disorders


pericarditis, and pulmonary edema. Dialysis corrects many biochemical abnormalities; allows for liberalization of fluid, protein, and sodium intake; diminishes bleeding tendencies; and promotes wound healing. Hemodialysis (a procedure that circulates the patient’s blood through a dialyzer to remove waste products and excess fluid), peritoneal dialysis (PD) (a procedure that uses the patient’s peritoneal membrane [the lining of the peritoneal cavity] as the semipermeable membrane to exchange fluid and solutes), or a variety of continuous renal replacement therapies (CRRTs) (methods used to replace normal kidney function by circulating the patient’s blood through a hemofilter) may be performed. These and other treatment modalities for patients with renal dysfunction are discussed later in this chapter.

Pharmacologic Therapy Hyperkalemia is the most life-threatening of the fluid and electrolyte changes that occur in patients with renal disturbances. Therefore, the patient is monitored for hyperkalemia through serial serum electrolyte levels (potassium value greater than 5.5 mmol/L), ECG changes (tall, tented, or peaked T waves), and changes in clinical status (see Chapter 15). Other symptoms of hyperkalemia include irritability, abdominal cramping, diarrhea, paresthesia, and generalized muscle weakness. Muscle weakness may present as slurred speech, difficulty breathing, paresthesia, and paralysis. As the potassium level increases, both cardiac and other muscular function declines, making this a true medical emergency (Mount & Zandi-Nejad, 2012). The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract. Sorbitol may be administered in combination with Kayexalate to induce a diarrhea-type effect (it induces water loss in the GI tract). If a Kayexalate retention enema is administered (the colon is the major site of potassium exchange), a rectal catheter with a balloon may be used to facilitate retention if necessary. The patient should retain the Kayexalate for 30 to 45 minutes to promote potassium removal. Afterward, a cleansing enema may be prescribed to remove remaining medication as a precaution against fecal impaction. If the patient is hemodynamically unstable (low blood pressure, changes in mental status, dysrhythmia), IV dextrose 50%, insulin, and calcium replacement may be administered to shift potassium back into the cells. Salbutamol sulfate (Ventolin HFA) by nebulizer can lower plasma potassium concentration by 0.3 to 0.85 mmol/L (Elliot, Ronksley, Clase, et al., 2010). The shift of potassium into the intracellular space is temporary, so arrangements for dialysis need to be made on an emergent basis. Since many medications are eliminated through the kidneys, dosages must be reduced when a patient has ARF. Examples of commonly used agents that require adjustment are antibiotic medications (especially aminoglycosides), digoxin, ACE inhibitors, and magnesium-containing agents. In addition, many medications have been used in patients with ARF in an attempt to improve patient outcomes. Diuretic agents are often used to control fluid volume, but they have not been shown to improve recovery from ARF (Dirkes, 2011).



Urinary Tract Function

In patients with severe acidosis, the arterial blood gases and serum bicarbonate levels (CO2-combining power) must be monitored because the patient may require sodium bicarbonate therapy or dialysis. If respiratory problems develop, appropriate ventilatory measures must be instituted. The elevated serum phosphate level may be controlled with phosphate-binding agents (e.g., calcium or lanthanum carbonate) that help prevent a continuing rise in serum phosphate levels by decreasing the absorption of phosphate from the intestinal tract.

Nutritional Therapy ARF causes severe nutritional imbalances (because nausea and vomiting contribute to inadequate dietary intake), impaired glucose use and protein synthesis, and increased tissue catabolism. The patient is weighed daily and loses 0.2 to 0.5 kg daily if the nitrogen balance is negative (i.e., caloric intake falls below caloric requirements). If the patient gains or does not lose weight or develops hypertension, fluid retention should be suspected. Nutritional support is based on the underlying cause of ARF, the catabolic response, the type and frequency of renal replacement therapy, comorbidities, and nutritional status. Replacement of dietary proteins is individualized to provide the maximum benefit and minimize uremic symptoms. Caloric requirements are met with highcarbohydrate meals, because carbohydrates have a protein-sparing effect (i.e., in a high-carbohydrate diet, protein is not used for meeting energy requirements but is “spared” for growth and tissue healing). Foods and fluids containing potassium or phosphorus (e.g., bananas, citrus fruits and juices, coffee) are restricted. The oliguric phase of ARF may last 10 to 20 days and is followed by the diuretic phase, at which time urine output begins to increase, signalling that kidney function is returning. Results of blood chemistry tests are used to determine the amounts of sodium, potassium, and water needed for replacement, along with assessment for overhydration or underhydration. Following the diuretic phase, the patient is placed on a high-protein, high-calorie diet and is encouraged to resume activities gradually.

Nursing Management The nurse has an important role in caring for the patient with ARF. The nurse monitors for complications, participates in emergency treatment of fluid and electrolyte imbalances, assesses the patient’s progress and response to treatment, and provides physical and emotional support. In addition, the nurse keeps family members informed about the patient’s condition, helps them understand the treatments, and provides psychological support. Although the development of ARF may be the most serious problem, the nurse continues to provide nursing care indicated for the primary disorder (e.g., burns, shock, trauma, obstruction of the urinary tract).

Monitoring Fluid and Electrolyte Balance Because of the serious fluid and electrolyte imbalances that can occur with ARF, the nurse monitors the patient’s serum electrolyte levels and physical indicators of these complications during all phases of the disorder. Hyperka-

lemia is the most immediate life-threatening imbalance seen in ARF. Parenteral fluids, all oral intake, and all medications are screened carefully to ensure that hidden sources of potassium are not inadvertently administered or consumed. IV solutions must be carefully selected based on the patient’s fluid and electrolyte status. The patient’s cardiac function and musculoskeletal status are monitored closely for signs of hyperkalemia. The nurse monitors fluid status by paying careful attention to fluid intake (IV medications should be administered in the smallest volume possible), urine output, apparent edema, distention of the jugular veins, alterations in heart sounds and breath sounds, and increasing difficulty in breathing. Accurate daily weights, as well as I&O records, are essential. Indicators of deteriorating fluid and electrolyte status are reported immediately to the physician, and preparation is made for emergency treatment. Severe fluid and electrolyte disturbances may be treated with hemodialysis, PD, or CRRT.

Reducing Metabolic Rate The nurse takes steps to reduce the patient’s metabolic rate. Bed rest may be indicated to reduce exertion and the metabolic rate during the most acute stage of the disorder. Fever and infection, both of which increase the metabolic rate and catabolism, are prevented or treated promptly.

Promoting Pulmonary Function Attention is given to pulmonary function, and the patient is assisted to turn, cough, and take deep breaths frequently to prevent atelectasis and respiratory tract infection. Drowsiness and lethargy may prevent the patient from moving and turning without encouragement and assistance.

Preventing Infection Asepsis is essential with invasive lines and catheters to minimize the risk of infection and increased metabolism. An indwelling urinary catheter is avoided whenever possible due to the high risk of UTI associated with its use but may be required to provide ongoing data required to monitor fluid I&O.

Providing Skin Care The skin may be dry or susceptible to breakdown as a result of edema; therefore, meticulous skin care is important. In addition, excoriation and itching of the skin may result from the deposit of irritating toxins in the patient’s tissues. Bathing the patient with cool water, frequent turning, and keeping the skin clean and well moisturized and the fingernails trimmed to avoid excoriation are often comforting and prevent skin breakdown.

Providing Psychosocial Support The patient with ARF may require treatment with hemodialysis, PD, or CRRT. The length of time that these treatments are necessary varies with the cause and extent of damage to the kidneys. The patient and family need assistance, explanation, and support during this period. The purpose of the treatment is explained to the patient and family by the physician. However, high levels of anxiety and


fear may necessitate repeated explanation and clarification by the nurse. The family members may initially be afraid to touch and talk to the patient during these procedures but should be encouraged and assisted to do so. In an intensive care setting, many of the nurse’s functions are devoted to the technical aspects of patient care; however, it is essential that the psychological needs and other concerns of the patient and family be addressed. Continued assessment of the patient for complications of ARF and precipitating causes is essential.

Management of Patients With Renal Disorders


more sensitive indicator of renal function than BUN. The BUN is affected not only by renal disease but also by protein intake in the diet, catabolism (tissue and RBC breakdown), parenteral nutrition, and medications such as corticosteroids.

Sodium and Water Retention

When a patient has sustained enough kidney damage to require renal replacement therapy on a permanent basis, the patient has moved into the fifth or final stage of CKD, also referred to as CRF or ESRD.

The kidney cannot concentrate or dilute the urine normally in ESRD. Appropriate responses by the kidney to changes in the daily intake of water and electrolytes, therefore, do not occur. Some patients retain sodium and water, increasing the risk for edema, heart failure, and hypertension. Hypertension may also result from activation of the renin–angiotensin–aldosterone axis and the concomitant increased aldosterone secretion. Other patients have a tendency to lose sodium and run the risk of developing hypotension and hypovolemia. Vomiting and diarrhea may cause sodium and water depletion, which worsens the uremic state.



As renal function declines, the end products of protein metabolism (normally excreted in urine) accumulate in the blood. Uremia develops and adversely affects every system in the body. The greater the buildup of waste products, the more pronounced the symptoms are. The rate of decline in renal function and progression of ESRD is related to the underlying disorder, the urinary excretion of protein, and the presence of hypertension. The disease tends to progress more rapidly in patients who excrete significant amounts of protein or have elevated blood pressure than in those without these conditions.

Metabolic acidosis occurs in ESRD because the kidneys are unable to excrete increased loads of acid. Decreased acid secretion results from the inability of the kidney tubules to excrete ammonia (NH 3−) and to reabsorb sodium bicarbonate (HCO3−). There is also decreased excretion of phosphates and other organic acids.


Clinical Manifestations Because virtually every body system is affected in ESRD, patients exhibit a number of signs and symptoms (Broscious & Castagnola, 2006). The severity of these signs and symptoms depends in part on the degree of renal impairment, other underlying conditions, and the patient’s age. Cardiovascular disease is the predominant cause of death in patients with ESRD (Holcombe & Kern Feeley, 2013). Peripheral neuropathy, a disorder of the peripheral nervous system, is present in some patients. Patients complain of severe pain and discomfort. Restless leg syndrome and burning feet can occur in the early stage of uremic peripheral neuropathy (Holcombe & Kern Feeley, 2013). The precise mechanisms for many of these systemic signs and symptoms have not been identified. However, it is generally thought that the accumulation of uremic waste products is the probable cause. Chart 45-6 summarizes the systemic signs and symptoms. Cardiovascular disease is the predominant cause of death in patients with ESRD.

Assessment and Diagnostic Findings Glomerular Filtration Rate As the GFR decreases (due to nonfunctioning glomeruli), the creatinine clearance decreases, while the serum creatinine and BUN levels increase. Serum creatinine is a

Anemia Anemia develops as a result of inadequate erythropoietin production, the shortened lifespan of RBCs, nutritional deficiencies, and the patient’s tendency to bleed, particularly from the GI tract. Erythropoietin, a substance normally produced by the kidneys, stimulates bone marrow to produce RBCs (Muzzy & Snyder, 2013). In ESRD, erythropoietin production decreases and profound anemia results, producing fatigue, angina, and shortness of breath.

Calcium and Phosphorus Imbalance Another abnormality seen in ESRD is a disorder in calcium and phosphorus metabolism (Hannon et al., 2010). Serum calcium and phosphate levels have a reciprocal relationship in the body: As one increases, the other decreases. With a decrease in filtration through the glomerulus of the kidney, there is an increase in the serum phosphate level and a reciprocal or corresponding decrease in the serum calcium level. The decreased serum calcium level causes increased secretion of parathormone from the parathyroid glands. However, in renal failure, the body does not respond normally to the increased secretion of parathormone; as a result, calcium leaves the bone, often producing bone changes and bone disease as well as calcification of major blood vessels in the body. In addition, the active metabolite of vitamin D (1,25-dihydroxycholecalciferol) normally manufactured by the kidney decreases as renal failure progresses (Hannon et al., 2010). Uremic bone disease, often called renal osteodystrophy, develops from the complex changes in calcium, phosphate, and parathormone balance. There is also evidence of calcification of blood vessels.



Urinary Tract Function

CHART 45-6

Assessing for End-Stage Renal Disease Be alert for the following signs and symptoms:



• • • • • • • •

• • • • • • • • • •

Weakness and fatigue Confusion Inability to concentrate Disorientation Tremors Seizures Asterixis Restlessness of legs Burning of soles of feet Behaviour changes

Integumentary • • • • • • •

Grey-bronze skin colour Dry, flaky skin Pruritus Ecchymosis Purpura Thin, brittle nails Coarse, thinning hair

Cardiovascular • • • • • • • • • •

Hypertension Pitting edema (feet, hands, sacrum) Periorbital edema Pericardial friction rub Engorged neck veins Pericarditis Pericardial effusion Pericardial tamponade Hyperkalemia Hyperlipidemia

Crackles Thick, tenacious sputum Depressed cough reflex Pleuritic pain Shortness of breath Tachypnea Kussmaul-type respirations Uremic pneumonitis

Gastrointestinal • • • • • • •

Ammonia odour to breath (“uremic fetor”) Metallic taste Mouth ulcerations and bleeding Anorexia, nausea, and vomiting Hiccups Constipation or diarrhea Bleeding from gastrointestinal tract

Hematologic • Anemia • Thrombocytopenia

Reproductive • • • •

Amenorrhea Testicular atrophy Infertility Decreased libido

Musculoskeletal • • • • • •

Muscle cramps Loss of muscle strength Renal osteodystrophy Bone pain Bone fractures Foot drop


Medical Management

Potential complications of CRF that concern the nurse and necessitate a collaborative approach to care include the following:

The goal of management is to maintain kidney function and homeostasis for as long as possible. All factors that contribute to ESRD and all factors that are reversible (e.g., obstruction) are identified and treated. Management is accomplished primarily with medications and diet therapy, although dialysis may also be needed to decrease the level of uremic waste products in the blood and to control electrolyte balance.

• Hyperkalemia due to decreased excretion, metabolic acidosis, catabolism, and excessive intake (diet, medications, fluids) • Pericarditis, pericardial effusion, and pericardial tamponade due to retention of uremic waste products and inadequate dialysis • Hypertension due to sodium and water retention and malfunction of the renin–angiotensin–aldosterone system • Anemia due to decreased erythropoietin production, decreased RBC lifespan, bleeding in the GI tract from irritating toxins and ulcer formation, and blood loss during hemodialysis • Bone disease and metastatic and vascular calcifications due to retention of phosphorus, low serum calcium levels, abnormal vitamin D metabolism, and elevated aluminum levels

Pharmacologic Therapy Complications can be prevented or delayed by administering prescribed phosphate-binding agents, calcium supplements, antihypertensive and cardiac medications, antiseizure medications, and erythropoietin Eprex. CALCIUM AND PHOSPHORUS BINDERS. Hyperphosphatemia and hypocalcemia are treated with medications that bind dietary phosphorus in the GI tract. Binders such as calcium carbonate (Os-Cal) or calcium acetate (PhosLo) are prescribed, but there is a risk of hypercalcemia. If calcium is high or the calcium–phosphorus product exceeds 55 mg/dL, a polymeric phosphate binder such as sevelamer


hydrochloride (Renagel) may be prescribed (Muzzy & Snyder, 2013). These medications bind dietary phosphorus in the intestinal tract. All binding agents must be administered with food to be effective. Magnesium-based antacids are avoided to prevent magnesium toxicity. ANTIHYPERTENSIVE AND CARDIOVASCULAR AGENTS.

Hypertension is managed by intravascular volume control and a variety of antihypertensive agents. Heart failure and pulmonary edema may also require treatment with fluid restriction, low-sodium diets, diuretic agents, inotropic agents such as digoxin (Lanoxin) or dobutamine (Dobutrex), and dialysis. The metabolic acidosis of ESRD usually produces no symptoms and requires no treatment; however, sodium bicarbonate supplements or dialysis may be needed to correct the acidosis if it causes symptoms (Holcombe & Kern Feeley, 2013). ANTISEIZURE AGENTS. Neurologic abnormalities may occur, so the patient must be observed for early evidence of slight twitching, headache, delirium, or seizure activity. If seizures occur, the onset of the seizure is recorded along with the type, duration, and general effect on the patient. The physician is notified immediately. IV diazepam (Valium) or phenytoin (Dilantin) is usually administered to control seizures. The side rails of the bed should be raised and padded to protect the patient. The nursing management of the patient with seizures is discussed in Chapter 62. ERYTHROPOIETIN. Anemia associated with ESRD is treated with recombinant human erythropoietin (Eprex). Patients with anemia (hemoglobin less than 110 g/L) present with nonspecific symptoms, such as malaise, general fatigability, and decreased activity tolerance. Erythropoietin therapy is initiated to achieve a hemoglobin level of 110 to 120 g/L. Erythropoietin is administered intravenously or subcutaneously three times a week in ESRD. It may take 2 to 6 weeks for the hematocrit to increase; therefore, the medication is not indicated for patients who need immediate correction of severe anemia. Management involves adjustment of heparin to prevent clotting of the lines during hemodialysis treatments, frequent monitoring of hemoglobin and periodic assessment of serum iron and transferrin levels. Because adequate stores of iron are necessary for an adequate response to erythropoietin, supplementary iron may be prescribed. The patient’s blood pressure and serum potassium level are monitored to detect hypertension and increasing serum potassium levels, which may occur with therapy and the increasing RBC mass. The occurrence of hypertension requires initiation or adjustment of the patient’s antihypertensive therapy. Hypertension that cannot be controlled is a contraindication to recombinant erythropoietin therapy. Patients who have received erythropoietin therapy have reported decreased levels of fatigue, increased feelings of well-being, better tolerance of dialysis, higher energy levels, and improved exercise tolerance. In addition, this therapy has decreased the need for transfusion and its associated risks, including bloodborne infectious disease, antibody formation, and iron overload.

Nutritional Therapy Dietary intervention is necessary with deterioration of renal function and includes careful regulation of protein

Management of Patients With Renal Disorders


intake, fluid intake to balance fluid losses, sodium intake to balance sodium losses, and some restriction of potassium. At the same time, adequate caloric intake and vitamin supplementation must be ensured. Protein is restricted because urea, uric acid, and organic acids—the breakdown products of dietary and tissue proteins—accumulate rapidly in the blood when there is impaired renal clearance. The allowed protein must be of high biologic value (dairy products, eggs, meats). High-biologic-value proteins are those that are complete proteins and supply the essential amino acids necessary for growth and cell repair. Usually, the fluid allowance per day is 500 to 600 mL more than the previous day’s 24-hour urine output. Calories are supplied by carbohydrates and fat to prevent wasting. Vitamin supplementation is necessary because a proteinrestricted diet does not provide the necessary complement of vitamins. In addition, the patient on dialysis may lose water-soluble vitamins during the dialysis treatment. Hyperkalemia is usually prevented by ensuring adequate dialysis treatments with potassium removal and careful monitoring of diet, medications, and fluids for their potassium content. Sodium polystyrene sulfonate (Kayexalate), a cation-exchange resin, may be needed for acute hyperkalemia.

Dialysis The patient with increasing symptoms of renal failure is referred to a dialysis and transplantation centre early in the course of progressive renal disease. Dialysis is usually initiated when the patient cannot maintain a reasonable lifestyle with conservative treatment. In Canada, for 2010, the number of patients receiving dialysis was 23,188 (Canadian Organ Replacement Register/Canadian Institute for Health Information, 2014).

Nursing Management The patient with ESRD requires astute nursing care to avoid the complications of reduced renal function and the stresses and anxieties of dealing with a life-threatening illness. Nursing care is directed toward assessing fluid status and identifying potential sources of imbalance, implementing a dietary program to ensure proper nutritional intake within the limits of the treatment regimen, and promoting positive feelings by encouraging increased self-care and greater independence. It is extremely important to provide explanations and information to the patient and family concerning ESRD, treatment options, and potential complications. A great deal of emotional support is needed by the patient and family because of the numerous changes experienced. Specific interventions, along with rationale and evaluation criteria, are presented in more detail in the plan of nursing care for the patient with CRF (Chart 45-7).

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. The nurse plays an important role in teaching the patient with ESRD. Because of the extensive teaching needed, the home care nurse, dialysis nurse, and nurses in the hospital and outpatient settings all provide ongoing education and reinforcement (text continued on page 1424)



Urinary Tract Function


Chart 45-7. The Patient With Chronic Renal Failure



Nursing Diagnosis: Excess fluid volume related to decreased urine output, dietary excesses, and retention of sodium and water Goal: Maintenance of ideal body weight without excess fluid 1. Assess fluid status: a. Daily weight b. Intake and output balance c. Skin turgor and presence of edema d. Distention of neck veins e. Blood pressure, pulse rate, and rhythm f. Respiratory rate and effort 2. Limit fluid intake to prescribed volume. 3. Identify potential sources of fluid: a. Medications and fluids used to take or administer medications: oral and intravenous b. Foods 4. Explain to patient and family rationale for fluid restriction. 5. Assist patient to cope with the discomforts resulting from fluid restriction. 6. Provide or encourage frequent oral hygiene.

1. Assessment provides baseline and ongoing database for monitoring changes and evaluating interventions.

• Demonstrates no rapid weight changes

• Maintains dietary and fluid restrictions

• Exhibits normal skin turgor without edema

2. Fluid restriction will be determined on basis of weight, urine output, and response to therapy. 3. Unrecognized sources of excess fluids may be identified.

• Exhibits normal vital signs • Exhibits no neck vein distention • Reports no difficulty breathing or shortness of breath

• Performs oral hygiene frequently • Reports decreased thirst • Reports decreased dryness of oral mucous membranes

4. Understanding promotes patient and family cooperation with fluid restriction. 5. Increasing patient comfort promotes compliance with dietary restrictions. 6. Oral hygiene minimizes dryness of oral mucous membranes.

Nursing Diagnosis: Imbalanced nutrition: less than body requirements related to anorexia, nausea, vomiting, dietary restrictions, and altered oral mucous membranes Goal: Maintenance of adequate nutritional intake 1. Assess nutritional status: a. Weight changes b. Laboratory values (serum electrolyte, BUN, creatinine, protein, transferrin, and iron levels) 2. Assess patient’s nutritional dietary patterns: a. Diet history b. Food preferences c. Calorie counts 3. Assess for factors contributing to altered nutritional intake: a. Anorexia, nausea, or vomiting b. Diet unpalatable to patient c. Depression d. Lack of understanding of dietary restrictions e. Stomatitis 4. Provide patient’s food preferences within dietary restrictions. 5. Promote intake of high-biologicvalue protein foods: eggs, dairy products, meats.

1. Baseline data allow for monitoring of changes and evaluating effectiveness of interventions. 2. Past and present dietary patterns are considered in planning meals.

3. Information about other factors that may be altered or eliminated to promote adequate dietary intake is provided.

4. Increased dietary intake is encouraged. 5. Complete proteins are provided for positive nitrogen balance needed for growth and healing.

• Consumes protein of high biologic value

• Chooses foods within dietary restrictions that are appealing

• Consumes high-calorie foods within dietary restrictions

• Explains in own words rationale for • • • • •

dietary restrictions and relationship to urea and creatinine levels Takes medications on schedule that does not produce anorexia or feeling of fullness Consults written lists of acceptable foods Reports increased appetite at meals Exhibits no rapid increases or decreases in weight Demonstrates normal skin turgor without edema; wound healing and acceptable plasma albumin levels


Plan of Nursing Care NURSING INTERVENTIONS 6. Encourage high-calorie, low-protein, low-sodium, and low-potassium snacks between meals. 7. Alter schedule of medications so that they are not given immediately before meals. 8. Explain rationale for dietary restrictions and relationship to kidney disease and increased urea and creatinine levels. 9. Provide written lists of foods allowed and suggestions for improving their taste without use of sodium or potassium. 10. Provide pleasant surroundings at meal-times. 11. Weigh patient daily. 12. Assess for evidence of inadequate protein intake: a. Edema formation b. Delayed wound healing c. Decreased serum albumin levels


Management of Patients With Renal Disorders

Chart 45-7. The Patient With Chronic Renal Failure, Continued



6. Reduces source of restricted foods and proteins and provides calories for energy, sparing protein for tissue growth and healing. 7. Ingestion of medications just before meals may produce anorexia and feeling of fullness. 8. Promotes patient understanding of relationships between diet and urea and creatinine levels to renal disease. 9. Lists provide a positive approach to dietary restrictions and a reference for patient and family to use when at home. 10. Unpleasant factors that contribute to patient’s anorexia are eliminated. 11. Allows monitoring of fluid and nutritional status. 12. Inadequate protein intake can lead to decreased albumin and other proteins, edema formation, and delay in wound healing.

Nursing Diagnosis: Deficient knowledge regarding condition and treatment Goal: Increased knowledge about condition and related treatment 1. Assess understanding of cause of renal failure, consequences of renal failure, and its treatment: a. Cause of patient’s renal failure b. Meaning of renal failure c. Understanding of renal function d. Relationship of fluid and dietary restrictions to renal failure e. Rationale for treatment (hemodialysis, peritoneal dialysis, transplantation) 2. Provide explanation of renal function and consequences of renal failure at patient’s level of understanding and guided by patient’s readiness to learn. 3. Assist patient to identify ways to incorporate changes related to illness and its treatment into lifestyle. 4. Provide oral and written information as appropriate about: a. Renal function and failure b. Fluid and dietary restrictions c. Medications d. Reportable problems, signs, and symptoms e. Follow-up schedule f. Community resources g. Treatment options

1. Provides baseline for further explanations and teaching.

• Verbalizes relationship of cause of renal failure to consequences

• Explains fluid and dietary restrictions • • •

2. Patient can learn about renal failure and treatment as he or she becomes ready to understand and accept the diagnosis and consequences. 3. Patient can see that his or her life does not have to revolve around the disease. 4. Provides patient with information that can be used for further clarification at home.

as they relate to failure of kidney’s regulatory functions States in own words relationship of renal failure and need for treatment Asks questions about treatment options, indicating readiness to learn Verbalizes plans to continue as normal a life as possible Uses written information and instructions to clarify questions and seek additional information

continued >



Urinary Tract Function


Chart 45-7. The Patient With Chronic Renal Failure, Continued



Nursing Diagnosis: Activity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure Goal: Participation in activity within tolerance 1. Assess factors contributing to activity intolerance: a. Fatigue b. Anemia c. Fluid and electrolyte imbalances d. Retention of waste products e. Depression 2. Promote independence in self-care activities as tolerated; assist if fatigued. 3. Encourage alternating activity with rest. 4. Encourage patient to rest after dialysis treatments.

1. Indicates factors contributing to severity of fatigue.

• Participates in increasing levels of activity and exercise

• Reports increased sense of well-being • Alternates rest and activity • Participates in selected self-care activities

2. Promotes improved self-esteem. 3. Promotes activity and exercise within limits and adequate rest. 4. Adequate rest is encouraged after dialysis treatments, which are exhausting to many patients.

Nursing Diagnosis: Risk for situational low self-esteem related to dependency, role changes, change in body image, and change in sexual function Goal: Improved self-esteem 1. Assess patient’s and family’s responses and reactions to illness and treatment. 2. Assess relationship of patient and significant family members. 3. Assess usual coping patterns of patient and family members. 4. Encourage open discussion of concerns about changes produced by disease and treatment: a. Role changes b. Changes in lifestyle c. Changes in occupation d. Sexual changes e. Dependence on health care team 5. Explore alternate ways of sexual expression other than sexual intercourse. 6. Discuss role of giving and receiving love, warmth, and affection.

1. Provides data about problems encountered by patient and family in coping with changes in life. 2. Identifies strengths and supports of patient and family. 3. Coping patterns that may have been effective in past may be harmful in view of restrictions imposed by disease and treatment. 4. Encourages patient to identify concerns and steps necessary to deal with them.

• Identifies previously used coping

styles that have been effective and those no longer possible due to disease and treatment (alcohol or drug use; extreme physical exertion) • Patient and family identify and verbalize feelings and reactions to disease and necessary changes in their lives • Seeks professional counselling, if necessary, to cope with changes resulting from renal failure • Reports satisfaction with method of sexual expression

5. Alternative forms of sexual expression may be acceptable. 6. Sexuality means different things to different people, depending on stage of maturity.

Collaborative Problems: Hyperkalemia; pericarditis, pericardial effusion, and pericardial tamponade; hypertension; anemia; bone disease and metastatic calcifications

Goal: Absence of complications

Hyperkalemia 1. Monitor serum potassium levels. Notify physician if level greater than 5.5 mEq/L, and prepare to treat hyperkalemia. 2. Assess patient for muscle weakness, diarrhea, ECG changes (tall-tented T waves and widened QRS).

1. Hyperkalemia causes potentially life-threatening changes in the body. 2. Cardiovascular signs and symptoms are characteristic of hyperkalemia.

• Patient has normal potassium level • Experiences no muscle weakness or diarrhea

• Exhibits normal ECG pattern • Vital signs are within normal limits



Chart 45-7. The Patient With Chronic Renal Failure, Continued


Pericarditis, Pericardial Effusion, and Pericardial Tamponade 1. About 30%–50% of patients with 1. Assess patient for fever, chest pain, chronic renal failure develop periand a pericardial friction rub (signs carditis due to uremia; fever, chest of pericarditis) and, if present, notify pain, and a pericardial friction rub physician. are classic signs. 2. Pericardial effusion is a common 2. If patient has pericarditis, assess for fatal sequela of pericarditis. Signs the following every 4 hours: of an effusion include a paradoxical a. Paradoxical pulse >10 mm Hg pulse (>10 mm Hg drop in blood b. Extreme hypotension pressure during inspiration) and c. Weak or absent peripheral pulses signs of shock due to compression d. Altered level of consciousness of the heart by a large effusion. Care. Bulging neck veins diac tamponade exists when the patient is severely compromised hemodynamically. 3. Cardiac ultrasound is useful in visu3. Prepare patient for cardiac ultraalizing pericardial effusions and sound to aid in diagnosis of pericarcardiac tamponade. dial effusion and cardiac tamponade. 4. Cardiac tamponade is a life-threat4. If cardiac tamponade develops, preening condition, with a high morpare patient for emergency pericartality rate. Immediate aspiration of diocentesis. fluid from the pericardial space is essential. Hypertension 1. Monitor and record blood pressure as indicated. 2. Administer antihypertensive medications as prescribed. 3. Encourage compliance with dietary and fluid restriction therapy. 4. Teach patient to report signs of fluid overload, vision changes, headaches, edema, or seizures. Anemia 1. Monitor RBC count, hemoglobin, and hematocrit levels as indicated. 2. Administer medications as prescribed, including iron and folic acid supplements, Epogen, and multivitamins. 3. Avoid drawing unnecessary blood specimens. 4. Teach patient to prevent bleeding: avoid vigorous nose blowing and contact sports, and use a soft toothbrush. 5. Administer blood component therapy as indicated.


Management of Patients With Renal Disorders


• Has strong and equal peripheral pulses

• Absence of a paradoxical pulse • Absence of pericardial effusion or

tamponade on cardiac ultrasound

• Patient has normal heart sounds

1. Provides objective data for monitoring. Elevated levels may indicate nonadherence to the treatment regimen. 2. Antihypertensive medications play a key role in treatment of hypertension associated with chronic renal failure. 3. Adherence to diet and fluid restrictions and dialysis schedule prevents excess fluid and sodium accumulation. 4. These are indications of inadequate control of hypertension and the need to alter therapy.

• Blood pressure within normal limits • Reports no headaches, visual prob-

1. Provides assessment of degree of anemia. 2. RBCs need iron, folic acid, and vitamins to be produced. Epogen stimulates the bone marrow to produce RBC. 3. Anemia is worsened by drawing numerous specimens. 4. Bleeding from anywhere in the body worsens anemia.

• Patient has a normal skin colour

lems, or seizures

• Edema is absent • Demonstrates compliance with dietary and fluid restrictions

without pallor

• Exhibits hematology values within acceptable limits

• Experiences no bleeding from any site

5. Blood component therapy may be needed if the patient has symptoms. continued >



Urinary Tract Function


Chart 45-7. The Patient With Chronic Renal Failure, Continued


Bone Disease and Metastatic Calcifications 1. 1. Administer the following medications as prescribed: phosphate binders, calcium supplements, vitamin D supplements. 2. 2. Monitor serum lab values as indicated (calcium, phosphorus, aluminum levels) and report abnormal findings to physician. 3. 3. Assist patient with an exercise program.


Chronic renal failure causes numerous physiologic changes affecting calcium, phosphorus, and vitamin D metabolism. Hyperphosphatemia, hypocalcemia, and excess aluminum accumulation are common in chronic renal failure. Bone demineralization increases with immobility.

while monitoring the patient’s progress and compliance with the treatment regimen. A referral to a nutritionist is made because of the dietary changes required. The patient is taught how to check the vascular access device for patency and appropriate precautions, such as avoiding venipuncture and blood pressure measurements on the arm with the access device. In addition, the patient and family need to know what problems to report to the health care provider. These include the following: • Worsening signs and symptoms of renal failure (nausea, vomiting, change in usual urine output [if any], ammonia odour on breath) • Signs and symptoms of hyperkalemia (muscle weakness, diarrhea, abdominal cramps) • Signs and symptoms of access problems (clotted fistula or graft, infection) These signs and symptoms of decreasing renal function, in addition to increasing BUN and serum creatinine levels, may indicate a need to alter the dialysis prescription. The dialysis nurses also provide ongoing education and support at each treatment visit. CONTINUING CARE. The importance of follow-up examinations and treatment is stressed to the patient and family because of changing physical status, renal function, and dialysis requirements. Referral for home care provides the home care nurse with the opportunity to assess the patient’s environment and emotional status and the coping strategies used by the patient and family to deal with the changes in family roles often associated with chronic illness. The home care nurse also assesses the patient for further deterioration of renal function and signs and symptoms of complications resulting from the primary renal disorder, the resulting renal failure, and effects of treatment strategies (e.g., dialysis, medications, dietary restrictions). Patients need education and reinforcement of the dietary restrictions required, including fluid, sodium, potassium, and protein restriction. Reminders about the need for health promotion activities and health screening are an important part of nursing care for the patient with renal failure.

• Exhibits serum calcium, phosphorus,

and aluminum levels within acceptable ranges • Exhibits no symptoms of hypocalcemia • Has no bone demineralization on bone scan • Discusses importance of maintaining activity level and exercise program

Gerontologic Considerations Diabetes, hypertension, chronic glomerulonephritis, interstitial nephritis, and urinary tract obstruction are the causes of ESRD in the older adult. The signs and symptoms of renal disease in the older adult are often nonspecific. The occurrence of symptoms of other disorders (heart failure, dementia) can mask the symptoms of renal disease and delay or prevent diagnosis and treatment. Patients often develop signs and symptoms of nephrotic syndrome, such as edema and proteinuria. Hemodialysis and PD are used effectively in treating older patients. The number of older patients initiating dialysis has dramatically increased in the past decade (Kurella, Covinsky, Collins, et al., 2007). Although there is no specific age limitation for renal transplantation, concomitant disorders (e.g., coronary artery disease, peripheral vascular disease) have made it a less common treatment for the older patients. However, the outcome is comparable to that of younger patients. Some older patients elect not to undergo dialysis or transplantation. Conservative management, including nutritional therapy, fluid control, and medications such as phosphate binders, may be considered in patients who are not suitable for or elect not to have dialysis or transplantation.

RENAL REPLACEMENT THERAPIES The use of renal replacement therapies becomes necessary when the kidneys can no longer remove wastes, maintain electrolytes, and regulate fluid balance. This can occur rapidly or over a long period of time and the need for replacement therapy can be acute (short term) or chronic (long term). The main renal replacement therapies include the various types of dialysis and kidney transplantation.

Dialysis Types of dialysis include hemodialysis, CRRT, and PD. Acute dialysis is indicated when there is a high and increasing level


of serum potassium, fluid overload, or impending pulmonary edema, increasing acidosis, pericarditis, and severe confusion. It may also be used to remove medications or toxins (poisoning or medication overdose) from the blood or for edema that does not respond to other treatment, hepatic coma, hyperkalemia, hypercalcemia, hypertension, and uremia (Mosenkis, Kirk, & Berns, 2006). Chronic or maintenance dialysis is indicated in advanced CKD and ESRD in the following instances: the presence of uremic signs and symptoms affecting all body systems (nausea and vomiting, severe anorexia, increasing lethargy, mental confusion), hyperkalemia, fluid overload not responsive to diuretics and fluid restriction, and a general lack of well-being. An urgent indication for dialysis in patients with renal failure is pericardial friction rub. The decision to initiate dialysis should be reached only after thoughtful discussion among the patient, family, physician, and others as appropriate. Many potentially life-threatening issues are associated with the need for dialysis. The nurse can assist the patient and family by answering their questions, clarifying the information provided, and supporting their decision. Successful kidney transplantation eliminates the need for dialysis. Not only is the quality of life much improved in patients with ESRD who undergo transplantation, but also physiologic function is improved as well. Patients who undergo renal transplantation from living donors before dialysis is initiated generally have longer survival of the transplanted kidney than patients who receive transplantation after dialysis treatment is initiated.

Hemodialysis Hemodialysis is used for patients who are acutely ill and require short-term dialysis (days to weeks) and for patients with advanced CKD and ESRD who require long-term or permanent renal replacement therapy. Hemodialysis prevents death but does not cure renal disease and does not compensate for the loss of endocrine or metabolic activities of the kidneys. Most patients receive intermittent hemodialysis that involves treatments three times a week with the average treatment duration of 3 to 4 hours in an outpatient setting. Hemodialysis can also be performed at home by the patient and a caregiver. With home dialysis, treatment time and frequency can be adjusted to meet optimal patient needs. The objectives of hemodialysis are to extract toxic nitrogenous substances from the blood and to remove excess water. A dialyzer (also referred to as an artificial kidney) serves as a synthetic semipermeable membrane, replacing the renal glomeruli and tubules as the filter for the impaired kidneys. In hemodialysis, the blood, laden with toxins and nitrogenous wastes, is diverted from the patient to a machine, a dialyzer, where toxins are filtered out and removed and the blood is returned to the patient. Diffusion, osmosis, and ultrafiltration are the principles on which hemodialysis is based (see Chapter 15). The toxins and wastes in the blood are removed by diffusion— that is, they move from an area of higher concentration in the blood to an area of lower concentration in the dialysate. The dialysate is a solution made up of all the important electrolytes in their ideal extracellular concentrations.

Management of Patients With Renal Disorders


The electrolyte level in the patient’s blood can be brought under control by properly adjusting the dialysate bath. The semipermeable membrane impedes the diffusion of large molecules, such as RBCs and proteins. Excess water is removed from the blood by osmosis, in which water moves from an area of low concentration potential (the blood) to an area of high concentration potential (the dialysate bath). In ultrafiltration, water moves under high pressure to an area of lower pressure. This process is much more efficient than osmosis at water removal and is accomplished by applying negative pressure or a suctioning force to the dialysis membrane. Because patients with renal disease usually cannot excrete water, this force is necessary to remove fluid to achieve fluid balance. The body’s buffer system is maintained using a dialysate bath made up of bicarbonate (most common) or acetate, which is metabolized to form bicarbonate. The anticoagulant heparin is administered to keep blood from clotting in the dialysis circuit. Cleansed blood is returned to the body. By the end of the dialysis treatment, many waste products have been removed, the electrolyte balance has been restored to normal, and the buffer system has been replenished.

Dialyzers Dialyzers are hollow-fibre devices containing thousands of tiny strawlike tubes that carry the blood through the dialyzer. The tubes are porous and act as a semipermeable membrane allowing toxins, fluid, and electrolytes to pass through. The constant flow of the solution maintains the concentration gradient to facilitate the exchange of wastes from the blood through the semipermeable membrane into the dialysate solution, where they are removed and discarded (Fig. 45-3). Dialyzers have undergone many technologic changes in performance and biocompatibility. High-flux dialysis uses highly permeable membranes to increase the clearance of low- and mid-molecular-weight molecules. These special membranes are used with higher than traditional rates of flow for the blood entering and exiting the dialyzer (500 to 550 mL/min). High-flux dialysis increases the efficiency of treatments while shortening their duration and reducing the need for heparin.

Vascular Access Access to the patient’s vascular system must be established to allow blood to be removed, cleansed, and returned to the patient’s vascular system at rates between 300 and 800 mL/min. Several types of access are available.

Vascular Access Devices Immediate access to the patient’s circulation for acute hemodialysis is achieved by inserting a double-lumen, noncuffed, large-bore catheter into the subclavian, internal jugular, or femoral vein by the physician (Fig. 45-4). This method of vascular access involves some risk (e.g., hematoma, pneumothorax, infection, thrombosis of the subclavian vein, inadequate flow). The catheter is removed when no longer needed (e.g., because the patient’s condition has



Urinary Tract Function

Vascular access to circulation

Arterial blood

Venous blood

Blood port

Blood pressure monitor

Semipermeable membrane

Dialysate fluid out

Blood pump

Clot and bubble trap

Dialysate fluid out

Dialysate fluid in


Blood port

Dialysate fluid in

A FIGURE 45-3. Hemodialysis system. A, Blood from an artery is pumped into (B) a dialyzer where it flows

through the cellophane tubes, which act as the semipermeable membrane (inset). The dialysate, which has the same chemical composition as the blood except for urea and waste products, flows in around the tubules. The waste products in the blood diffuse through the semipermeable membrane into the dialysate.

improved or another type of access has been established). Double-lumen, cuffed catheters may also be inserted, usually by either a surgeon or interventional radiologist, into the internal jugular vein of the patient. Since these catheters have cuffs under the skin, the insertion site heals, sealing the wound and reducing the risk for ascending infection. This feature makes these catheters safe for longer-term use. Infection rates, however, remain high and septicemia continues to be a common cause for hospital admission.

Arteriovenous Fistula The preferred method of permanent access is an arteriovenous fistula (AVF) that is created surgically (usually in the forearm) by joining (anastomosing) an artery to a vein, either side to side or end to side (Fig. 45-5A). Needles are inserted into the vessel to obtain blood flow adequate to pass through the dialyzer. The arterial segment of the fistula is used for arterial flow to the dialyzer and the venous segment for reinfusion of the dialyzed blood. This access will need time (2 to 3 months) to “mature” before it can be used. As the AVF matures, the venous segment dilates due to the increased blood flow coming directly from the artery. Once sufficiently dilated it will then accommodate two large-bore (14-, 15-, or 16-gauge) nee-

dles that are inserted for each dialysis treatment. The patient is encouraged to perform hand exercises to increase the size of these vessels (i.e., squeezing a rubber ball for forearm fistulas) to accommodate the large-bore needles. Once established, this access has the longest useful life and thus is the best option for vascular access for the chronic hemodialysis patient.

Arteriovenous Graft An arteriovenous graft can be created by subcutaneously interposing a biologic, semibiologic, or synthetic graft material between an artery and vein (Fig. 45-5B). Usually a graft is created when the patient’s vessels are not suitable for creation of an AVF. Patients with compromised vascular systems (e.g., from diabetes) will require a graft because their native vessels are not suitable for creation of an AVF. Grafts are usually placed in the arm but may be placed in the thigh or chest area. Stenosis, infection, and thrombosis are the most common complications that result in loss of this access. It is not at all uncommon to see a dialysis patient with numerous “old” or “nonfunctioning” accesses present on their arms. The patient is asked to identify which is the current access in use and it is checked carefully for the presence of a bruit and thrill.


Management of Patients With Renal Disorders



Internal jugular vein Subclavian vein

Catheter Catheter cuff

Aortic arch

Superior vena cava Left atrium

“Red” adapter

Right ventricle

“Blue” adapter FIGURE 45-4. Double-lumen, cuffed hemodialysis catheter used in acute hemodialysis. The red adapter is attached to a blood line through which blood is pumped from the patient to the dialyzer. After the blood passes through the dialyzer (artificial kidney), it returns to the patient through the blue adapter.



Failure of the permanent dialysis access (fistula or graft) accounts for most hospital admissions of patients undergoing chronic hemodialysis. Thus, protection of the access is of high priority.

Cephalic vein Radial artery


Median cubital vein Radial artery Graft


FIGURE 45-5. A, Arteriovenous fistulas are created by anastomosing a

patient’s vein to an artery. This illustrates a side-to-side anastomosis. B, Arteriovenous grafts are established by placing synthetic tubing between the artery and vein.

While hemodialysis can prolong life indefinitely, it does not alter the natural course of the underlying CKD, nor does it completely replace kidney function. The CKD complications previously discussed will continue to worsen and require more aggressive treatment. With the initiation of dialysis, disturbances of lipid metabolism (hypertriglyceridemia) are accentuated and contribute to cardiovascular complications. Heart failure, coronary heart disease, angina, stroke, and peripheral vascular insufficiency may occur and can incapacitate the patient. Cardiovascular disease remains the leading cause of death in patients receiving dialysis (Vasundhara, Kozman, Liu, et al., 2014). Anemia is compounded by blood lost during hemodialysis. Gastric ulcers may result from the physiologic stress of chronic illness, medication, and pre-existing medical conditions (e.g., diabetes). Patients with uremia report a metallic taste and nausea when they require dialysis. Vomiting may occur during the hemodialysis treatment when rapid fluid shifts and hypotension occur. These contribute to the malnutrition seen in patients on dialysis. Worsening calcium metabolism and renal osteodystrophy can result in bone pain and fractures, interfering with mobility. As time on dialysis continues, calcification of major blood vessels has been reported and linked to hypertension and other vascular complications. Phosphorus deposits in the skin can occur and cause itching. Many dialysis patients experience fatigue while undergoing hemodialysis. Up to 85% of people undergoing hemodialysis experience major sleep problems that further complicate their overall health status (Horigan, Rocchiccioli, & Trimm, 2012). Early-morning or lateafternoon dialysis may be a risk factor for developing sleep disturbances. Other complications of dialysis treatment may include the following: • Episodes of shortness of breath often occur as fluid accumulates between dialysis treatments. • Hypotension may occur during the treatment as fluid is removed. Nausea and vomiting, diaphoresis, tachycardia, and dizziness are common signs of hypotension. • Painful muscle cramping may occur, usually late in dialysis as fluid and electrolytes rapidly leave the extracellular space. • Exsanguination may occur if blood lines separate or dialysis needles become dislodged. • Dysrhythmias may result from electrolyte and pH changes or from removal of antiarrhythmic medications during dialysis. • Air embolism is rare but can occur if air enters the vascular system. • Chest pain may occur in patients with anemia or arteriosclerotic heart disease. • Dialysis disequilibrium results from cerebral fluid shifts. Signs and symptoms include headache, nausea and vomiting, restlessness, decreased level of consciousness, and seizures. It is more likely to occur in ARF or when BUN levels are very high, exceeding 54 mmol/L.



Urinary Tract Function

Nursing Management The nurse in the dialysis unit has an important role in monitoring, supporting, assessing, and educating the patient. During dialysis, the patient, the dialyzer, and the dialysate bath require constant monitoring because numerous complications are possible, including clotting of the circuit, air embolism, inadequate or excessive ultrafiltration hypotension, cramping, vomiting, blood leaks, contamination, and access complications. Nursing care of the patient and maintenance of the vascular access device are especially important and are discussed later in this chapter in the section titled Special Considerations: Nursing Management of the Hospitalized Patient on Dialysis.

Promoting Pharmacologic Therapy Many medications are removed from the blood during hemodialysis; therefore, dosage or timing of the medication administration may require adjustment. Medications that are water soluble are readily removed during hemodialysis treatment and those that are fat soluble or adhere to other substances (like albumin) are not dialyzed out very well. This is the reason some drug overdoses are treated with emergency hemodialysis and others are not. Patients undergoing hemodialysis who require medications (e.g., cardiac glycosides, antibiotic agents, antiarrhythmic medications, antihypertensive agents) are monitored closely to ensure that blood and tissue levels of these medications are maintained without toxic accumulation. Antihypertensive therapy, often part of the regimen of patients on dialysis, is one example when communication, teaching, and evaluation can make a difference in patient outcomes. The patient must know when and when not to take the medication. For example, if an antihypertensive agent is taken on a dialysis day, hypotension may occur during dialysis, causing dangerously low blood pressure. Many medications that are taken once daily can be held until after the dialysis treatment.

Promoting Nutritional and Fluid Therapy Diet is important for patients on hemodialysis because of the effects of uremia. Goals of nutritional therapy are to minimize uremic symptoms and fluid and electrolyte imbalances; to maintain good nutritional status through adequate protein, calorie, vitamin, and mineral intake; and to enable the patient to eat a palatable and enjoyable diet. Restricting dietary protein decreases the accumulation of nitrogenous wastes, reduces uremic symptoms, and may even postpone the initiation of dialysis for a few months. Restriction of fluid is also part of the dietary prescription because fluid accumulation may occur, leading to weight gain, heart failure, and pulmonary edema. With the initiation of hemodialysis, the patient usually requires some restriction of dietary protein, sodium, potassium, and fluid intake. Protein intake is restricted to about 1.2 to 1.3 g/kg ideal body weight per day; therefore, protein must be of high biologic quality. Sodium is usually restricted to 2 to 3 g/day; fluids are restricted to an amount equal to the daily urine output plus 500 mL/day. The goal for patients on hemodialysis is to keep their interdialytic (between dialysis treatments) weight gain under 1.5 kg (Welch & Perkins, 2006). Potassium restriction depends

on the amount of residual renal function and the frequency of dialysis. Dietary restriction is an unwelcome change in lifestyle for many patients with CRF. Patients can feel stigmatized in social situations because there may be few food choices available for their diet. If the restrictions are ignored, life-threatening complications, such as hyperkalemia and pulmonary edema, may result. Thus, the patient may feel punished for responding to basic human drives to eat and drink. The nurse who cares for a patient with symptoms or complications resulting from dietary indiscretion must avoid harsh, judgmental, or punitive tones when communicating with him or her. Regular education with reinforcement is needed to achieve this difficult change in life style (Castner, 2010) (Chart 45-8).

Meeting Psychosocial Needs Patients requiring long-term hemodialysis are often concerned about the unpredictability of the illness and the disruption of their lives. They often have financial problems, difficulty holding a job, waning sexual desire and impotence, depression from being chronically ill, and fear of dying. Younger patients worry about marriage, having children, and the burden that they bring to their families. The regimented lifestyle that frequent dialysis treatments and restrictions in food and fluid intake impose is often demoralizing to the patient and family. Dialysis alters the lifestyle of the patient and family. The amount of time required for dialysis and physician visits and being chronically ill can create conflict, frustration, guilt, and depression. It may be difficult for the patient, spouse, and family to express anger and negative feelings. The nurse needs to give the patient and family the opportunity to express feelings of anger and concern about the limitations that the disease and treatment impose, possible financial problems, and job insecurity. If anger is not expressed, it may be directed inward and lead to depression, despair, and attempts at suicide (suicide is more prevalent in patients on dialysis); however, if anger is projected outward to other people, it may destroy already threatened family relationships. Although these feelings are normal in this situation, they are often profound and overwhelming. Counselling and psychotherapy may be necessary. Depression may require treatment with antidepressant agents. Referring the patient and family to a mental health provider with expertise in the care of patients receiving dialysis may also be helpful. Clinical nurse specialists, psychologists, and social workers may be helpful in assisting the patient and family to cope with the changes brought about by renal failure and its treatment. The “sense of loss” that the patient experiences cannot be underestimated because every aspect of a “normal life” is disrupted. Some patients use denial to deal with the overwhelming array of medical problems (e.g., infections, hypertension, anemia, neuropathy). Staff who are tempted to label the patient as noncompliant must consider the impact of renal failure and its treatment on the patient and family and the coping strategies that they may use. Palliative care principles that focus on symptom control are becoming increasingly important as greater attention is focused on quality-of-life issues (Kane, Vinen, & Murtagh, 2013).


Management of Patients With Renal Disorders



Chart 45-8. Hemodialysis and Nonadherence Belguzar, K., Kayser, C., & Kilic, S. (2007). Nonadherence with diet and fluid restrictions and perceived social support in patients receiving hemodialysis. Journal of Nursing Scholarship, 39 (3), 243–248. Purpose Nonadherence to diet and fluid restrictions has adverse consequences for patients receiving hemodialysis. The purpose of this study was to describe nonadherence with diet and fluid restrictions and the level of perceived social support in hemodialysis patients. Nonadherence often occurs when a person’s behaviour conflicts with medical advice regarding taking medications, following diets, or other lifestyle changes. Design This descriptive study surveyed 160 patients on hemodialysis in three centres in Turkey. Participants were asked about personal characteristics, and data were collected using the Dialysis Diet and Fluid Nonadherence Questionnaire (DDFQ) and Multidimensional Scale of Perceived Social Support (MSP). Data were collected during the patient’s regularly scheduled dialysis session. The DDFQ is a four-item

Patients and their families should be encouraged to discuss end-of-life options and have developed advanced directives or living wills.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Preparing a patient for hemodialysis is challenging. Often the patient does not fully comprehend the impact of dialysis, and learning needs may go unrecognized. Good communication between dialysis staff and home care nurses is essential. Assessment helps identify the learning needs of the patient and family members. In many cases, the patient is discharged home before learning needs and readiness to learn can be thoroughly evaluated; therefore, hospital-based nurses, dialysis staff, and home care nurses must work together to provide appropriate teaching that meets the patient’s and family’s changing needs and readiness to learn. The diagnosis of CRF and the need for dialysis often overwhelm the patient and family. In addition, many patients with ESRD have depressed mentation, a shortened attention span, a decreased level of concentration, and altered perception. Therefore, teaching must occur in brief, 10- to 15-minute sessions, with time added for clarification, repetition, reinforcement, and questions from the patient and family. The nurse needs to convey a nonjudgmental attitude to enable the patient and family to discuss options and their feelings about those options. Team conferences are helpful for sharing information and providing every team member the opportunity to discuss the needs of the patient and family. HOME HEMODIALYSIS. Most patients who undergo hemodialysis do so in an outpatient setting, but home hemodialysis is an option for some. Home hemodialysis requires a highly motivated patient who is willing to take

self-report questionnaire that assesses the frequency of nonadherence to diet and fluid restrictions for the previous 14 days. The MSP is a 12-item scale used to assess emotional support and the degree of satisfaction with perceived social support from family, friends, and significant others. Findings Adherence to fluid restriction is a difficult and stressful aspect of hemodialysis treatment, and most patients in this study showed some degree of nonadherence to fluid restrictions (68%) and diet (58%). Participants perceived total social support as low. Nonadherence was most common with younger patients, those who were married, and those with lower levels of perceived social support. Nursing Implications Nurses working in hemodialysis centres need to consider social support and how it affects adherence in patients receiving hemodialysis. The results of this study suggest that younger, married patients may require assistance to develop the levels of social support needed to adhere to fluid and diet restrictions between hemodialysis sessions.

responsibility for the procedure and is able to adjust each treatment to meet the body’s changing needs. It also requires the commitment and cooperation of a caregiver to assist the patient. However, many patients are not comfortable imposing on others this way and do not wish to subject family members to the feeling that their home is being turned into a clinic. The health care team never forces a patient to use home hemodialysis because this treatment requires significant changes in the home and family. Home hemodialysis must be the patient’s and family’s decision because full cooperation and participation are required (Peters, 2014). The patient undergoing home hemodialysis and the caregiver assisting that patient must be trained to prepare, operate, and disassemble the dialysis machine; maintain and clean the equipment; administer medications (e.g., heparin) into the machine lines; and handle emergency problems (hemodialysis dialyzer rupture, electrical or mechanical problems, hypotension, shock, and seizures). Because home hemodialysis places primary responsibility for the treatment on the patient and the family member, they must understand and be capable of performing all aspects of the hemodialysis procedure (Chart 45-9). Before home hemodialysis is initiated, the home environment, household and community resources, and ability and willingness of the patient and family to carry out this treatment are assessed. The home is surveyed to see if electrical outlets, plumbing facilities, and storage space are adequate. Modifications may be needed to enable the patient and assistant to perform dialysis safely and to deal with emergencies. Once home hemodialysis is initiated, the home care nurse must visit periodically to evaluate compliance with the recommended techniques, to assess the patient for complications, to reinforce previous teaching, and to provide reassurance.



Urinary Tract Function

CHART 45-9


Hemodialysis Patient


• Discuss renal failure and its effects on the body.

• Describe the cause of renal failure and why hemodialysis is necessary.

• Describe the basic principles of hemodialysis.

• Discuss common problems that may occur during hemodialysis and their prevention

• Demonstrate knowledge about prescribed medications and the reason for their use, potential

• Acknowledge dietary and fluid restrictions, rationale, and consequences of noncompliance.

• Describe commonly measured laboratory values, results, and implications.

• List guidelines for prevention and detection of fluid overload, meaning of “dry” weight, and how

• Demonstrate vascular access care, how to check patency, signs and symptoms of infection, and

• Discuss strategies for detection, management, and relief of pruritus, neuropathy, and other

• Develop strategies to manage or reduce anxiety and maintain independence.

• Coordinate financial arrangements for dialysis and strategies to identify and obtain resources.

At the completion of the home care instruction, the patient or caregiver will be able to:

and management.

side effects, guidelines on when to notify physician, and the schedule of medications on dialysis and nondialysis days.

to weigh self.

prevention of complications.

complications of renal failure.

CONTINUING CARE. The health care team’s goal in treating patients with CRF is to maximize their vocational potential, functional status, and quality of life. To facilitate renal rehabilitation, appropriate follow-up and monitoring by members of the health care team (physicians, dialysis nurses, social worker, psychologist, home care nurses, and others as appropriate) are essential to identify and resolve problems early on. Many patients with CRF can resume relatively normal lives, doing the things that are important to them: travelling, exercising, working, or actively participating in family activities. If appropriate interventions are available early in the course of dialysis, the potential for better health improves, and the patient can remain active in family and community life. Outcome goals for renal rehabilitation include employment for those able to work, improved physical functioning of all patients, improved understanding about adaptation and options for living well, increased control over the effects of kidney disease and dialysis, and resumption of activities enjoyed before dialysis.

Continuous Renal Replacement Therapies CRRTs may be indicated for patients with acute or CRF who are too clinically unstable for traditional hemodialysis, for patients with fluid overload secondary to oliguric (low urine output) renal failure, and for patients whose kidneys cannot handle their acutely high metabolic or

nutritional needs. CRRT does not produce rapid fluid shifts, does not require dialysis machines or dialysis personnel to carry out the procedures, and can be initiated quickly. Several types of CRRT are available and widely used in critical care units (Fig. 45-6). The methods are similar as they require access to the circulation and blood to pass through an artificial filter. A hemofilter (an extremely porous blood filter containing a semipermeable membrane) is used in all types.

Continuous Venovenous Hemofiltration Continuous venovenous hemofiltration (CVVH) is used to manage ARF. Blood from a double-lumen venous catheter is pumped (using a small blood pump) through a hemofilter and then returned to the patient through the same catheter. CVVH provides continuous slow fluid removal (ultrafiltration); therefore, hemodynamic effects are mild and better tolerated by patients with unstable conditions. CVVH does not require arterial access, and critical care nurses can set up, initiate, maintain, and terminate the system.

Continuous Venovenous Hemodialysis Continuous venovenous hemodialysis (CVVHD) is similar to CVVH. Blood is pumped from a double-lumen venous


FIGURE 45-6. Devices for administering continuous renal replacement therapy (CRRT) offer an integrated fluid warmer for the heating of infusion and dialysate fluids, a weighing system to reduce the possibility of error in assessing fluid balance, and a battery backup that allows treatments to continue when the patient is moved. A, Diapact CRRT System, B-Braun Medical, Inc., Bethlehem, PA. B, PRISMA, Gambro Corporation, Lakewood, CO.


catheter through a hemofilter and returned to the patient through the same catheter. In addition to the benefits of ultrafiltration, CVVHD uses a concentration gradient to facilitate the removal of uremic toxins and fluid. No arterial access is required, hemodynamic effects are usually mild, and critical care nurses can set up, initiate, maintain, and terminate the system (Muzzy & Snyder, 2013). Examples of less frequently used CRRT include slow continuous ultrafiltration (SCUF), continuous arteriovenous hemofiltration (CAVH), and continuous arteriovenous hemodialysis (CAVHD) (Martin & Jurschak, 2007).


Management of Patients With Renal Disorders


centration (the blood stream) to an area of lesser concentration (the dialysate fluid) through a semipermeable membrane (the peritoneum). This movement of solute from the blood into the dialysate fluid is called clearance. Since substances cross the peritoneal membrane at different rates, adjustments in dwell time and amount of fluid


Peritoneal Dialysis The goals of peritoneal dialysis (PD) are to remove toxic substances and metabolic wastes and to reestablish normal fluid and electrolyte balance. PD may be the treatment of choice for patients with renal failure who are unable or unwilling to undergo hemodialysis or renal transplantation. Patients who are susceptible to the rapid fluid, electrolyte, and metabolic changes that occur during hemodialysis experience fewer of these problems with the slower rate of PD. Therefore, patients with diabetes or cardiovascular disease, many older patients, and those who may be at risk for adverse effects of systemic heparin are likely candidates for PD. In addition, severe hypertension, heart failure, and pulmonary edema not responsive to usual treatment regimens have been successfully treated with PD. In PD, the peritoneal membrane that covers the abdominal organs and lines the abdominal wall serves as the semipermeable membrane. Sterile dialysate fluid is introduced into the peritoneal cavity through an abdominal catheter at intervals (Fig. 45-7). Once the sterile solution is in the peritoneal cavity, uremic toxins such as urea and creatinine begin to be cleared from the blood. Diffusion and osmosis occur as waste products move from an area of higher con-



Subcutaneous fat Muscle Peritoneum Bowel

FIGURE 45-7. In peritoneal dialysis and in acute intermittent perito-

neal dialysis, dialysate is infused into the peritoneal cavity by gravity, after which the clamp on the infusion line is closed. After a dwell time (when the dialysate is in the peritoneal cavity), the drainage tube is unclamped and the fluid drains from the peritoneal cavity, again by gravity. A new container of dialysate is infused as soon as drainage is complete. The duration of the dwell time depends on the type of peritoneal dialysis.



Urinary Tract Function

used are made to facilitate the process. Ultrafiltration (water removal) occurs in PD through an osmotic gradient created by using a dialysate fluid with a higher glucose concentration. PD usually takes 36 to 48 hours to achieve what hemodialysis accomplishes in 6 to 8 hours.

Procedure As with other forms of treatment, the decision to begin PD is made by the patient and family in consultation with the physician. The patient may be acutely ill, thus requiring short-term treatment to correct severe disturbances in fluid and electrolyte status, or may have ESRD and need to receive ongoing treatments.

Preparing the Patient The nurse’s preparation of the patient and family for PD depends on the patient’s physical and psychological status, level of alertness, previous experience with dialysis, and understanding of and familiarity with the procedure. The nurse explains the procedure to the patient and assists in obtaining signed consent. Baseline vital signs, weight, and serum electrolyte levels are recorded. Evaluation of the abdomen for placement of the catheter is done to facilitate self-care. Typically the catheter is placed on the nondominant side to allow the patient easier access to the catheter connection site when exchanges are done. The patient is encouraged to empty the bladder and bowel to reduce the risk of puncture of internal organs during the insertion procedure. Broad-spectrum antibiotic agents may be administered to prevent infection. The peritoneal catheter can be inserted in interventional radiology, in the operating room, or at the bedside. Depending on the situation, this will need to be explained to the patient and family.

Preparing the Equipment In addition to assembling the equipment for PD, the nurse consults with the physician to determine the concentration of dialysate to be used and the medications to be added to it. Heparin may be added to prevent fibrin formation and resultant occlusion of the peritoneal catheter. Potassium chloride may be prescribed to prevent hypokalemia. Antibiotics may be added to treat peritonitis (inflammation of the peritoneal membrane) caused by infection. Regular insulin may be added for patients with diabetes. Aseptic technique is imperative whenever medications are added. Before medications are added, the dialysate is warmed to body temperature to prevent patient discomfort and abdominal pain and to dilate the vessels of the peritoneum to increase urea clearance. Solutions that are too cold cause pain, cramping, and vasoconstriction and reduce clearance. Dry heating (heating cabinet, incubator, or heating pad) is recommended. Methods not recommended include soaking the bags of solution in warm water (can introduce bacteria to the exterior of the bags of solution and increase the chance of peritonitis) and use of a microwave to heat the fluid (increases the danger of burning the peritoneum). Immediately before initiating dialysis, using aseptic technique, the nurse assembles the administration set and tubing. The tubing is filled with the prepared dialysate to

reduce the amount of air entering the catheter and peritoneal cavity, which could increase abdominal discomfort and interfere with instillation and drainage of the fluid.

Inserting the Catheter Ideally, the peritoneal catheter is inserted in the operating room or radiology suite to maintain surgical asepsis and minimize the risk of contamination. However, in some circumstances, the physician may insert the rigid stylet catheter at the bedside using strict asepsis. Whenever a rigid catheter is used, careful securing and close observation for bowel perforation is essential to minimize complications. Catheters for long-term use (e.g., Tenckhoff, Swan, or Cruz) are usually soft and flexible and made of silicone with a radiopaque strip to permit visualization on x-ray. These catheters have three sections: (1) an intraperitoneal section, with numerous openings and an open tip to let dialysate flow freely; (2) a subcutaneous section that passes from the peritoneal membrane and tunnels through muscle and subcutaneous fat to the skin; and (3) an external section for connection to the dialysate system. Most of these catheters have two cuffs, which are made of Dacron polyester. The cuffs stabilize the catheter, limit movement, prevent leaks, and provide a barrier against microorganisms. One cuff is placed just distal to the peritoneum, and the other cuff is placed subcutaneously. The subcutaneous tunnel (5 to 10 cm long) further protects against bacterial infection (Fig. 45-8).

Performing the Exchange Peritoneal dialysis involves a series of exchanges or cycles. An exchange is defined as the infusion (fill), dwell, and drainage of the dialysate. This cycle is repeated throughout the course of the dialysis. The dialysate is infused by gravity into the peritoneal cavity. A period of about 5 to 10 minutes is usually required to infuse 2 to 3 L of fluid. The prescribed dwell, or equilibration, time allows diffusion and osmosis to occur. At the end of the dwell time, the drainage portion of the exchange begins. The tube is unclamped and the solution drains from the peritoneal cavity by gravity through a closed system. Drainage is usually completed in 10 to 20 minutes. The drainage fluid is normally colourless or straw-coloured and should not be cloudy. Bloody drainage may be seen in the first few exchanges after insertion of a new catheter but should not occur after that time. The number of cycles or exchanges and their frequency are prescribed based on monthly laboratory values and presence of uremic symptoms. The removal of excess water during PD occurs because dialysate has a high dextrose concentration, making it hypertonic. An osmotic gradient is created between the blood and the dialysate solution. Dextrose solutions of 1.5%, 2.5%, and 4.25% are available in several volumes, from 1,000 mL to 3,000 mL. The higher the dextrose concentration, the greater the osmotic gradient and the more water will be removed. Selection of the appropriate solution is based on the patient’s fluid status.

Complications Most complications of PD are minor, but several, if unattended, can have serious consequences.



Management of Patients With Renal Disorders

Fresh peritoneal dialysate

Peritoneal cavity


Silicone catheter

Collecting tube


Subcutaneous tissue Position of bag to receive dialysate drainage

Rectus muscle




FIGURE 45-8. Continuous ambulatory peritoneal dialysis. A, The peritoneal catheter is implanted through

the abdominal wall. B, Dacron cuffs and a subcutaneous tunnel provide protection against bacterial infection. C, Dialysate flows by gravity through the peritoneal catheter into the peritoneal cavity. After a prescribed period of time, the fluid is drained by gravity and discarded. New solution is then infused into the peritoneal cavity until the next drainage period. Dialysis thus continues on a 24-hour-a-day basis, during which the patient is free to move around and engage in his or her usual activities.

Acute Complications PERITONITIS. Peritonitis is the most common and serious complication of PD. The first sign of peritonitis is cloudy dialysate drainage fluid. Diffuse abdominal pain and rebound tenderness occur much later. Hypotension and other signs of shock may also occur with advancing infection. The patient with peritonitis may be treated as an inpatient or outpatient (most common), depending on the severity of the infection and the patient’s clinical status. Drainage fluid is examined for cell count; Gram stain and culture are used to identify the organism and guide treatment. Antibiotic agents (aminoglycosides or cephalosporins) are usually added to subsequent exchanges until Gram stain or culture results are available for appropriate antibiotic determination. Intraperitoneal administration of antibiotics is as effective as IV administration and therefore most often used. Antibiotic therapy continues for 10 to 14 days. Careful selection and calculation of the antibiotic dosage are needed to prevent nephrotoxicity and further compromise of residual renal function. Regardless of which organism causes peritonitis, the patient with peritonitis loses large amounts of protein through the peritoneum. Acute malnutrition and delayed healing may result. Therefore, attention must be given to detecting and promptly treating peritonitis. LEAKAGE. Leakage of dialysate through the catheter site may occur immediately after the catheter is inserted. Usually, the leak stops spontaneously if dialysis is withheld for several days, giving the tissue surrounding the cuffs located on the abdominal catheter a chance to infiltrate the Dacron and seal the insertion tunnel. It also allows the exit site time to heal. During this time, it is important to

reduce factors that might delay healing, such as undue abdominal muscle activity and straining during bowel movement. In many cases, leakage can be avoided by using small volumes (500 mL) of dialysate, gradually increasing the volume up to 2,000 to 3,000 mL. BLEEDING. A bloody effluent (drainage) may be observed occasionally, especially in young, menstruating women. (The hypertonic fluid pulls blood from the uterus, through the opening in the fallopian tubes, and into the peritoneal cavity.) Bleeding is also common during the first few exchanges after a new catheter insertion because some blood enters the abdominal cavity following insertion. In many cases, no cause can be found for the bleeding, although catheter displacement from the pelvis has occasionally been associated with bleeding. Some patients have had bloody effluent after an enema or from minor trauma. Invariably, bleeding stops in 1 to 2 days and requires no specific intervention. More frequent exchanges and the addition of heparin to the dialysate during this time may be necessary to prevent blood clots from obstructing the catheter.

Long-Term Complications Hypertriglyceridemia is common in patients undergoing long-term PD, suggesting that the therapy may accelerate atherogenesis. Despite this, the use of cardioprotective medications is relatively uncommon, and many patients have suboptimal blood pressure control. Given the high burden of disease in these patients, beta-blockers and ACE inhibitors should be used to control hypertension or protect the heart, and the use of aspirin and statins should be considered.



Urinary Tract Function

Other complications that may occur with long-term PD include abdominal hernias (incisional, inguinal, diaphragmatic, and umbilical), probably resulting from continuously increased intra-abdominal pressure. The persistently elevated intra-abdominal pressure also aggravates symptoms of hiatal hernia and hemorrhoids. Low back pain and anorexia from fluid in the abdomen and a constant sweet taste related to glucose absorption may also occur. Mechanical problems occasionally occur and may interfere with instillation or drainage of the dialysate. Formation of clots in the peritoneal catheter and constipation are factors that may contribute to these problems.

Approaches Peritoneal dialysis can be performed using several different approaches: acute intermittent peritoneal dialysis, continuous ambulatory peritoneal dialysis (CAPD), and continuous cyclic peritoneal dialysis (CCPD).

Acute Intermittent Peritoneal Dialysis Indications for acute intermittent PD, a variation of PD, include uremic signs and symptoms (nausea, vomiting, fatigue, altered mental status), fluid overload, acidosis, and hyperkalemia. Although PD is not as efficient as hemodialysis in removing solute and fluid, it permits a more gradual change in the patient’s fluid volume status and in waste product removal. Therefore, it may be the treatment of choice for the hemodynamically unstable patient. It can be carried out manually (the nurse warms, spikes, and hangs each container of dialysate) or by a cycler machine. Exchange times range from 30 minutes to 2 hours. A common routine is hourly exchanges consisting of a 10-minute infusion, a 30-minute dwell time, and a 20-minute drain time. Maintaining the PD cycle is a nursing responsibility. Strict aseptic technique is maintained when changing solution containers and emptying drainage containers. Vital signs, weight, I&O, laboratory values, and patient status are frequently monitored. The nurse uses a flow sheet to document each exchange and records vital signs, dialysate concentration, medications added, exchange volume, dwell time, dialysate fluid balance for each exchange (fluid lost or gained), and cumulative fluid balance. The nurse also carefully assesses skin turgor and mucous membranes to evaluate fluid status and monitor the patient for edema. If the peritoneal fluid does not drain properly, the nurse can facilitate drainage by turning the patient from side to side or raising the head of the bed. The catheter should never be pushed further into the peritoneal cavity. Other measures to promote drainage include checking the patency of the catheter by inspecting for kinks, closed clamps, or an air lock. The nurse monitors for complications, including peritonitis, bleeding, respiratory difficulty, and leakage of peritoneal fluid. Abdominal girth may be measured periodically to determine if the patient is retaining large amounts of dialysis solution. In addition, the nurse must ensure that the PD catheter remains secure and that the dressing remains dry. Physical comfort measures, frequent turning, and skin care are provided. The patient

and family are educated about the procedure and are kept informed about progress (fluid loss, weight loss, laboratory values). Emotional support and encouragement are given to the patient and family during this stressful and uncertain time.

Continuous Ambulatory Peritoneal Dialysis CAPD is performed at home by the patient or a trained caregiver who is usually a family member. The procedure allows the patient reasonable freedom and control of daily activities but requires a serious commitment to be successful. Chart 45-10 discusses suitability for CAPD. CAPD works on the same principles as other forms of PD: diffusion and osmosis. Less extreme fluctuations in the patient’s laboratory values occur with CAPD than with intermittent PD or hemodialysis because the dialysis is constantly in progress. The serum electrolyte levels usually remain in the normal range. PROCEDURE. The patient performs exchanges four or five times a day, 24 hours a day, 7 days a week, at intervals scheduled throughout the day. Different manufacturers supply different equipment. Most commonly used is a Y-shaped system, in which a bag containing dialysate solution comes connected to one branch of the “Y” and a sterile empty bag is connected to the second branch. This leaves the third part of the “Y” open and available for connection to the transfer set on the PD catheter. To perform an exchange, the patient (or person doing the exchange) washes his or her hands, dons a mask, and then removes the cap from the transfer set while maintaining sterility. The open end of the “Y” set is connected to the end of the transfer set and the dialysate infused where it will dwell. After the dialysate is infused, the patient clamps off the transfer set and the tubing set, disconnects the tubing set, and applies a new cap to the transfer set, making it a closed system. The patient drains the fluid (effluent) from the peritoneal cavity through the catheter (over about 20 to 30 minutes) into an empty bag. Once the effluent has been fully drained, fresh fluid is instilled into the peritoneal cavity. The longer the dwell time, the better the clearance of uremic toxins is. If dwell time is excessive, the patient will absorb some of the effluent back into the body simply because the osmotic gradient is lost. Once equilibrium is reached, the movement of fluid and toxins stops. COMPLICATIONS. To reduce the risk of peritonitis, the patient (and all caregivers) must use meticulous care to avoid contaminating the catheter, fluid, or tubing and to avoid accidentally disconnecting the catheter from the tubing. Whenever a connection/disconnection is made, hands must be washed and a mask worn by anyone within 6 ft of the area to avoid contamination with airborne bacteria. Excess manipulation should be avoided and meticulous care of the catheter entry site is provided using a standardized protocol.

Continuous Cyclic Peritoneal Dialysis Continuous cyclic peritoneal dialysis (CCPD) uses a machine called a cycler to provide the exchanges. It is programmed as to how much fluid to use and how long and how many exchanges need to be done. Since it is programmed, it also keeps track of the total amounts removed and will sound an alarm if limits are not met. It requires


Management of Patients With Renal Disorders


CHART 45-10

Considerations in CAPD Although CAPD is not suitable for all patients with end-stage renal disease (ESRD), it is a viable therapy for those who can perform self-care and exchanges and who can fit therapy into their own routines. Often, patients report having more energy and feeling healthier once they begin CAPD. Nurses can be instrumental in helping patients with ESRD find the dialysis therapy that best suits their lifestyle. Those considering CAPD need to understand the advantages and disadvantages along with the indications and contraindications for this form of therapy.

Advantages • Freedom from a dialysis machine • Control over daily activities • Opportunities to avoid dietary restrictions, increase fluid intake, raise serum hematocrit values, improve blood pressure control, avoid venipuncture, and gain a sense of well-being

Disadvantages • Continuous dialysis 24 hours a day, 7 days a week

Indications • Patient’s willingness, motivation, and ability to perform dialysis at home

• Strong family or community support system (essential for success), particularly if the patient is an older adult

that a person set up and break down the system for use, which typically takes about 15 minutes. CCPD combines overnight intermittent PD with a prolonged dwell time during the day. The peritoneal catheter is connected to a cycler machine every evening, usually just before the patient goes to sleep for the night. Because the machine is very quiet, the patient can sleep, and the extra long tubing allows the patient to move and turn normally during sleep. In the morning, the patient disconnects from the cycler. Sometimes dialysate is left in the abdominal cavity for a longer day dwell cycle. This day exchange is drained during the day either by using a “Y” set or reattaching to the cycler. This process is done every day to achieve the effects of dialysis required. CCPD has a lower infection rate than other forms of PD because there are fewer opportunities for contamination with bag changes and tubing disconnections. It also allows the patient to be free from exchanges throughout the day, making it possible to engage in work and activities of daily living more freely.

Nursing Management Meeting Psychosocial Needs In addition to the complications of PD previously described, patients who elect to do PD may experience altered body image because of the presence of the abdominal catheter, bag, tubing, and cycler. Waist size increases from 2.5 to 5 cm (or more) with fluid in the abdomen. This affects

• Special problems with long-term hemodialysis, such as dys-

functional or failing vascular access devices, excessive thirst, severe hypertension, postdialysis headaches, and severe anemia requiring frequent transfusion • Interim therapy while awaiting kidney transplantation • ESRD secondary to diabetes because hypertension, uremia, and hyperglycemia are easier to manage with CAPD than with hemodialysis

Contraindications • Adhesions from previous surgery (adhesions reduce clearance of solutes) or systemic inflammatory disease

• Chronic backache and pre-existing disk disease, which

could be aggravated by the continuous pressure of dialysis fluid in the abdomen • Risk of complications, for example, in patients receiving immunosuppressive medications, which impede healing of the catheter site, and in patients with a colostomy, ileostomy, nephrostomy, or ileal conduit because of the risk of peritonitis. The risk for complications is not an absolute contraindication for CAPD therapy. • Diverticulitis because CAPD has been associated with rupture of the diverticulum • Severe arthritis or poor hand strength necessitating assistance in performing the exchange. However, blind or partially blind patients and those with other physical limitations can learn to perform CAPD.

clothing selection and may make the patient feel “fat.” Body image may be so altered that patients do not want to look at or care for the catheter for days or weeks. The nurse may arrange for the patient to talk with other patients who have adapted well to PD. Although some patients have no psychological problems with the catheter–they think of it as their lifeline and as a life-sustaining device–other patients feel they are doing exchanges all day long and have no free time, particularly in the beginning. They may experience depression because they feel overwhelmed with the responsibility of self-care. Patients undergoing PD may also experience altered sexuality patterns and sexual dysfunction. The patient and partner may be reluctant to engage in sexual activities, partly because of the catheter being psychologically “in the way” of sexual performance. The peritoneal catheter, drainage bag, and about 2 L of dialysate may interfere with the patient’s sexual function and body image as well. In patients on CCPD, the presence of the dialysis cycler in the bedroom and the continual connection during the sleeping hours can also cause interference with intimacy. Although these problems may resolve with time, some problems may warrant special counselling. Questions by the nurse about concerns related to sexuality and sexual function often provide the patient with a welcome opportunity to discuss these issues and a first step toward their resolution.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. Patients are taught as inpatients or outpatients to perform PD once their condition



Urinary Tract Function

CHART 45-11


Peritoneal Dialysis (CAPD or CCPD) Patient


• Discuss basic information about normal kidney function.

• Discuss basic information about the disease process.

• Discuss the basic principles of peritoneal dialysis.

• Demonstrate catheter and exit site care.

• Demonstrate measurement of vital signs and weight measurement.

• Discuss monitoring and management of fluid balance.

• Discuss basic principles of aseptic technique.

• Demonstrate the CAPD exchange procedure using aseptic technique (CCPD patients should

• Demonstrate cycler setup procedure and maintenance if on CCPD.

• Discuss complications of peritoneal dialysis; prevention, recognition, and management of

• Demonstrate procedure for adding medications to the dialysis solution.

• Demonstrate procedure for obtaining sterile dialysis fluid samples.

• Discuss routine laboratory tests needed and implications of results.

• Discuss medications: name of medications, their actions, potential side effects, and when to

• Discuss ordering, storage, and inventory of dialysis supplies.

• Describe plan for follow-up care.

• Demonstrate maintenance of home dialysis records.

• Describe actions in case of emergency.

At the completion of the home care instruction, the patient or caregiver will be able to:

also demonstrate exchange procedure in case of failure or unavailability of cycling machine).


• Discuss dietary restrictions. contact physician.

is medically stable. Training usually takes 5 days to 2 weeks. Patients are taught according to their own learning ability and knowledge level and only as much at one time as they can handle without feeling uncomfortable or becoming overwhelmed. Education topics for the patient and family who will be performing PD at home are described in Chart 45-11. The use of an adult learning theory–based curriculum may decrease peritonitis and exit site infection rates. Because of protein loss with continuous PD, the patient is instructed to eat a high-protein, well-balanced diet. The patient is also encouraged to increase his or her daily fibre intake to help prevent constipation, which can impede the flow of dialysate into or out of the peritoneal cavity. Many patients gain 1.5 to 2.5 kg within a month of initiating PD, so they may be asked to limit their carbohydrate intake to avoid excessive weight gain. Potassium, sodium, and fluid restrictions are not usually needed. Patients commonly lose about 2 to 3 L of fluid over and above the volume of dialysate infused into the abdomen during a 24-hour period, permitting a normal fluid intake even in an anephric patient (a patient without kidneys).

CONTINUING CARE. Follow-up care through phone calls, visits to the outpatient department, and continuing home care assists patients in the transition to home and promotes their active participation in their own health care. Patients often depend on checking with the nurse to see if they are making the correct choices about dialysate or control of blood pressure, or simply to discuss a problem. Patients may be seen by the PD team as outpatients once a month or more often if needed. The exchange procedure is evaluated at that time to see that strict aseptic technique is being used. Blood chemistry values are followed closely to make certain the therapy is adequate for the patient. If a referral is made for home care, the home care nurse assesses the home environment and suggests modifications to accommodate the equipment and facilities needed to carry out PD. In addition, the nurse assesses the patient’s and family’s understanding of PD and evaluates their technique in performing PD. Assessments include checking for changes related to renal disease, complications such as peritonitis, and treatment-related problems such as heart failure, inadequate drainage, and weight gain or loss. The nurse continues to reinforce and clarify teaching about PD


and renal disease and assesses the patient’s and family’s progress in coping with the procedure. This is also an opportunity to remind patients about the need to participate in appropriate health promotion activities and health screening (e.g., gynecologic examinations, colonoscopy). Because of the projected high numbers of older adult patients who will develop ESRD, the nursing home or extended care facility is likely to become an increasingly important site for both rehabilitation and long-term management of patients with renal failure.

Special Considerations: Nursing Management of the Hospitalized Patient on Dialysis Whether undergoing hemodialysis or PD, the patient may be hospitalized for treatment of complications related to the dialysis treatment, the underlying renal disorder, or health problems not related to renal dysfunction or its treatment.

Protecting Vascular Access When the patient undergoing hemodialysis is hospitalized for any reason, care must be taken to protect the vascular access. The nurse assesses the vascular access for patency and takes precautions to ensure that the extremity with the vascular access is not used for measuring blood pressure or for obtaining blood specimens; tight dressings, restraints, or jewelry over the vascular access must be avoided as well. The bruit, or “thrill,” over the venous access site must be evaluated at least every 8 hours. Absence of a palpable thrill or audible bruit may indicate blockage or clotting in the vascular access. Clotting can occur if the patient has an infection anywhere in the body (serum viscosity increases) or if the blood pressure has dropped. When blood flow is reduced through the access for any reason (hypotension, application of blood pressure cuff or tourniquet), the access can clot. If a patient has a hemodialysis catheter or implanted hemodialysis access device, the nurse must observe for signs and symptoms of infection such as redness, swelling, drainage from the exit site, fever, and chills. The nurse must assess the integrity of the dressing and change it as needed. Patients with renal disease are more prone to infection; therefore, infection control measures must be used for all procedures.

Taking Precautions During Intravenous Therapy When the patient needs IV therapy, the rate of administration must be as slow as possible and should be strictly controlled by a volumetric infusion pump. Because patients on dialysis cannot excrete water, rapid or excessive administration of IV fluid can result in pulmonary edema. Accurate I&O records are essential.

Monitoring Symptoms of Uremia As metabolic end products accumulate, symptoms of uremia worsen. Patients whose metabolic rate accelerates (those receiving corticosteroid medications or parenteral nutrition, those with infections or bleeding disorders,

Management of Patients With Renal Disorders


those undergoing surgery) accumulate waste products more quickly and may require daily dialysis. These same patients are more likely than other patients receiving dialysis to experience complications.

Detecting Cardiac and Respiratory Complications Cardiac and respiratory assessment must be conducted frequently. As fluid builds up, fluid overload, heart failure, and pulmonary edema develop. Crackles in the bases of the lungs may indicate pulmonary edema. Pericarditis may result from the accumulation of uremic toxins. If not detected and treated promptly, this serious complication may progress to pericardial effusion and cardiac tamponade. Pericarditis is detected by the patient’s report of substernal chest pain (if the patient can communicate), low-grade fever (often overlooked), and pericardial friction rub. A pulsus paradoxus (a decrease in blood pressure of more than 10 mm Hg during inspiration) is often present. When pericarditis progresses to effusion, the friction rub disappears, heart sounds become distant and muffled, ECG waves show very low voltage, and the pulsus paradoxus worsens. The effusion may progress to life-threatening cardiac tamponade, noted by narrowing of the pulse pressure in addition to muffled or inaudible heart sounds, crushing chest pain, dyspnea, and hypotension. Although pericarditis, pericardial effusion, and cardiac tamponade can be detected by chest x-ray, they should also be detected through astute nursing assessment. Because of their clinical significance, assessment of the patient for these complications is a priority.

Controlling Electrolyte Levels and Diet Electrolyte alterations are common, and potassium changes can be life-threatening. All IV solutions and medications to be administered are evaluated for their electrolyte content. Serum laboratory values are assessed daily. If blood transfusions are required, they may be administered during hemodialysis, if possible, so that excess potassium can be removed. Dietary intake must also be monitored. The patient’s frustrations related to dietary restrictions typically increase if the hospital food is unappetizing. The nurse needs to recognize that this may lead to dietary indiscretion and hyperkalemia. Hypoalbuminemia is an indicator of malnutrition in patients undergoing long-term or maintenance dialysis. Although some patients can be treated with adequate nutrition alone, some patients remain hypoalbuminemic for reasons that are poorly understood.

Managing Discomfort and Pain Complications such as pruritus and pain secondary to neuropathy must be managed. Antihistamine agents, such as diphenhydramine hydrochloride (Benadryl), are commonly used, and analgesic medications may be prescribed. However, because elimination of the metabolites of medications occurs through dialysis rather than through renal excretion, medication dosages may need to be adjusted. Keeping the skin clean and well moisturized using bath oils, superfatted soap, and creams or lotions helps promote comfort and reduce itching. Teaching the patient to



Urinary Tract Function

keep the nails trimmed to avoid scratching and excoriation also promotes comfort.

Monitoring Blood Pressure Hypertension in renal failure is common. It is usually the result of fluid overload and, in part, oversecretion of renin. Many patients undergoing dialysis receive some form of antihypertensive therapy and require ongoing teaching about its purpose and adverse effects. The trial-and-error approach that may be necessary to identify the most effective antihypertensive agent and dosage may confuse the patient if no explanation is provided. Antihypertensive agents must be withheld before dialysis to avoid hypotension due to the combined effect of the dialysis and the medication. Typically these patients require single or multiple antihypertensive agents to achieve normal blood pressure, thus adding to the total number of medications needed on an ongoing basis.

Preventing Infection Patients with ESRD commonly have low WBC counts (and decreased phagocytic ability), low RBC counts (anemia), and impaired platelet function. Together, these pose a high risk for infection and potential for bleeding after even minor trauma. Preventing and controlling infection are essential because the incidence of infection is high. Infection of the vascular access site and pneumonia are common.

Caring for the Catheter Site Patients receiving CAPD usually know how to care for the catheter site; however, the hospital stay is an opportunity to assess catheter care technique and correct misperceptions or deviations from recommended technique. Recommended daily or three-or-four-times-weekly routine catheter site care is typically performed during showering or bathing. The exit site should not be submerged in bath water. The most common cleaning method is soap and water; liquid soap is recommended. During care, the nurse and patient need to make sure that the catheter remains secure to avoid tension and trauma. The patient may wear a gauze or semitransparent dressing over the exit site.

Administering Medications All medications and the dosage prescribed for any patient on dialysis must be closely monitored to avoid those that are toxic to the kidneys and may threaten remaining renal function. Medications are also scrutinized for potassium and magnesium content, because medications containing potassium or magnesium must be avoided. Care must be taken to evaluate all problems and symptoms that the patient reports without automatically attributing them to renal failure or to dialysis therapy.

Providing Psychological Support Patients undergoing dialysis for a while may begin to reevaluate their status, the treatment modality, their satisfaction with life, and the impact of these factors on their families and support systems. Nurses must provide opportunities for these patients to express their feelings and

reactions and to explore options. The decision to begin dialysis does not require that dialysis be continued indefinitely, and it is not uncommon for patients to consider discontinuing treatment. These feelings and reactions must be taken seriously, and the patient should have the opportunity to discuss them with the dialysis team as well as with a psychologist, psychiatrist, psychiatric nurse, trusted friend, or spiritual advisor. The patient’s informed decision about discontinuing treatment, after thoughtful deliberation, should be respected.

KIDNEY SURGERY A patient may undergo surgery to remove obstructions that affect the kidney (tumours or calculi), to insert a tube for draining the kidney (nephrostomy, ureterostomy), or to remove the kidney involved in unilateral kidney disease, renal carcinoma, or kidney transplantation.

Management of Patients Undergoing Kidney Surgery Preoperative Considerations Surgery is performed only after a thorough evaluation of renal function. Patient preparation to ensure that optimal renal function is maintained is essential. Fluids are encouraged to promote increased excretion of waste products before surgery unless contraindicated because of preexisting renal or cardiac dysfunction. If kidney infection is present preoperatively, broad-spectrum antimicrobial agents may be prescribed to prevent bacteremia. Antibiotic agents must be given with extreme care because many are toxic to the kidneys. Coagulation studies (prothrombin time, partial thromboplastin time, platelet count) may be indicated if the patient has a history of bruising and bleeding. The preoperative preparation is similar to that described in Chapter 19. Because many patients facing kidney surgery are apprehensive, the nurse encourages the patient to recognize and verbalize concerns. Confidence is reinforced by establishing a relationship of trust and by providing expert care. Patients faced with the prospect of losing a kidney may think that they will be dependent on dialysis for the rest of their lives. It is important to teach the patient and family that normal function may be maintained by a single healthy kidney.

Perioperative Concerns Renal surgery requires various patient positions to expose the surgical site adequately. Three surgical approaches are common: flank, lumbar, and thoracoabdominal (Fig. 45-9). During surgery, plans are carried out for managing altered urinary drainage. These may include inserting a nephrostomy or other drainage tube.

Postoperative Management Because the kidney is a highly vascular organ, hemorrhage and shock are the chief complications of renal surgery.


Management of Patients With Renal Disorders

Incision Kidney

FIGURE 45-9. Patient positioning and incisional approaches (A, flank; B, lumbar; C, thoracoabdominal) for kidney surgery are associated with significant postoperative discomfort.

A Flank approach

Fluid and blood component replacement is frequently necessary in the immediate postoperative period to treat intraoperative blood loss. Abdominal distention and paralytic ileus are fairly common after renal and ureteral surgery and are thought to be due to a reflex paralysis of intestinal peristalsis and manipulation of the colon or duodenum during surgery. Abdominal distention is relieved by decompression through a nasogastric tube (see Chapter 39 for treatment of paralytic ileus). Oral fluids are permitted when the passage of flatus is noted. If infection occurs, antibiotics are prescribed after a culture reveals the causative organism. The toxic effects that antibiotic agents have on the kidneys (nephrotoxicity) must be kept in mind when assessing the patient. Lowdose heparin therapy may be initiated postoperatively to prevent thromboembolism in patients who had any type of urologic surgery.

Nursing Management In addition to those interventions listed in this section, Chart 45-12 provides a plan of nursing care for the patient undergoing kidney surgery.

Providing Immediate Postoperative Care Immediate postoperative care of the patient who has undergone surgery of the kidney includes assessment of all body systems. Respiratory and circulatory status, pain level, fluid and electrolyte status, and patency and adequacy of urinary drainage systems are assessed. RESPIRATORY STATUS. As with any surgery, the use of anesthesia increases the risk for respiratory complications. Noting the location of the surgical incision assists the nurse in anticipating respiratory problems and pain. Respiratory status is assessed by monitoring the rate, depth, and pattern of respirations. The location of the incision frequently causes pain on inspiration and coughing; therefore, the patient tends to splint the chest wall and take shallow respirations. Auscultation is performed to assess normal and adventitious breath sounds. CIRCULATORY STATUS AND BLOOD LOSS. The patient’s vital signs and arterial or central venous pressure are monitored. Skin colour and temperature and urine output pro-

Incision Kidney

B Lumbar approach


Incision Kidney


Thoracoabdominal approach

vide information about circulatory status. The surgical incision and drainage tubes are observed frequently to help detect unexpected blood loss and hemorrhage. PAIN. Postoperative pain is a major problem for the patient because of the location of the surgical incision and patient’s position on the operating table to permit access to the kidney. The location and severity of pain are assessed before and after analgesic medications are administered. Abdominal distention, which increases discomfort, is also noted. URINARY DRAINAGE. Urine output and drainage from tubes inserted during surgery are monitored for amount, colour, and type or characteristics. Decreased or absent drainage is promptly reported to the physician because it may indicate obstruction that could cause pain, infection, and disruption of the suture lines.

Monitoring and Managing Potential Complications Bleeding is a major complication of kidney surgery. If undetected and untreated it can result in hypovolemia and hemorrhagic shock. The nurse’s role is to observe for these complications, to report their signs and symptoms, and to administer prescribed parenteral fluids and blood and blood components. Monitoring of vital signs, skin condition, the urinary drainage system, the surgical incision, and the level of consciousness is necessary to detect evidence of bleeding, decreased circulating blood, and fluid volume and cardiac output. Frequent monitoring of vital signs (initially monitored at least at hourly intervals) and urinary output is necessary for early detection of these complications. If bleeding goes undetected or is not detected promptly, the patient may lose significant amounts of blood and may experience hypoxemia. In addition to hypovolemic shock due to hemorrhage, this type of blood loss may precipitate a myocardial infarction or transient ischemic attack. Bleeding may be suspected when the patient experiences fatigue and when urine output is less than 30 mL/h. As bleeding persists, late signs of hypovolemia occur, such as cool skin, flat neck veins, and change in level of consciousness or responsiveness. Transfusions of blood components are indicated, along with surgical repair of the bleeding vessel. Pneumonia may be prevented through use of an incentive spirometer, adequate pain control, and early ambulation. (text continued on page 1442)



Urinary Tract Function


Chart 45-12. Care of Patient Undergoing Kidney Surgery



Nursing Diagnosis: Ineffective airway clearance related to pain of high abdominal or flank incision, abdominal discomfort, and immobility; risk for ineffective breathing pattern related to high abdominal incision Goal: Improved airway clearance 1. Administer analgesic agent as prescribed. 2. Splint incision with hands or pillow to assist patient in coughing. 3. Assist patient to change positions frequently. 4. Encourage use of incentive spirometer if indicated or prescribed. 5. Assist with and encourage early ambulation.

1. Enables patient to take deep breaths and cough 2. Splints incision and promotes adequate cough and prevention of atelectasis 3. Promotes drainage and inflation of all lobes of the lungs 4. Encourages adequate deep breaths

• Takes deep breaths and coughs

5. Mobilizes pulmonary secretions

• • •

• • • •

adequately when encouraged and assisted Exhibits respiratory rate of 12–18 breaths/min Exhibits normal breath sounds without adventitious sounds Exhibits full thoracic excursion without shallow respirations Uses incentive spirometer with encouragement Splints incision while taking deep breaths and coughing Reports progressively less pain and discomfort with coughing and deep breaths Exhibits normal blood gas levels and chest x-ray Exhibits normal body temperature with no signs of atelectasis or pneumonia on assessment

Nursing Diagnosis: Acute pain and discomfort related to surgical incision, positioning, and stretching of muscles during kidney surgery Goal: Relief of pain and discomfort 1. Assess level of pain. 2. Administer analgesic agents as prescribed. 3. Splint incision with hands or pillow during movement or deep breathing and coughing exercises. 4. Assist and encourage early ambulation.

1. Provides baseline for later evaluation of pain relief strategies 2. Promotes pain relief 3. Minimizes sensation of pulling or tension on incision and provides sense of support to the patient 4. Promotes resumption of muscle activity exercise

• Reports relief of severe pain and discomfort

• Takes analgesia as prescribed • Exercises aching muscles within recommendations

• Uses distraction, relaxation exercises, and imagery to relieve pain

• Exhibits no behavioural manifesta-

tions of pain and discomfort (e.g., restlessness, perspiration, verbal expressions of pain) • Participates in deep breathing and coughing exercises • Gradually increases physical activity and exercise

Nursing Diagnosis: Fear and anxiety related to diagnosis, outcome of surgery, and alteration in urinary function Goal: Reduction of fear and anxiety 1. Assess patient’s anxiety and fear before surgery if possible. 2. Assess patient’s knowledge about procedure and expected surgical outcome preoperatively. 3. Evaluate the meaning of alterations resulting from surgical procedure for the patient and family or partner.

1. Provides a baseline for postoperative assessment 2. Provides a basis for further teaching

• Verbalizes reactions and feelings to staff

• Shares reactions and feelings with family or partner

3. Enables understanding of patient’s reactions and responses to expected and unexpected results of surgery

• Grieves appropriately for self and for changes in role and function

• Identifies information needed to

promote own adaptation and coping


Plan of Nursing Care


Management of Patients With Renal Disorders

Chart 45-12. Care of Patient Undergoing Kidney Surgery, Continued




4. Encourage patient to verbalize reactions, feelings, and fears.

4. Affirms patient’s understanding of and ultimate resolution of feelings and fears 5. Enables patient and partner to receive mutual support and reduces sense of isolation from each other 6. Provides support from another person who has encountered the same or a similar surgical procedure and an example of how others have coped with the alteration

• Participates in activities and events in

5. Encourage patient to share feelings with spouse or partner. 6. Offer and arrange for visit from member of support group (e.g., ostomy group, if indicated).

immediate environment

• Accepts visit from ostomy group if indicated

• Identifies support person or support group

Nursing Diagnosis: Impaired urinary elimination related to urinary drainage; risk for infection related to altered urinary drainage Goal: Maintenance of urinary elimination; infection-free urinary tract 1. Assess urinary drainage system immediately. 2. Assess adequacy of urinary output and patency of drainage system. 3. Use asepsis and hand hygiene when providing care and manipulating drainage system. 4. Maintain closed urinary drainage system. 5. If irrigation of the drainage system is necessary, use sterile gloves and sterile irrigating solution and a closed drainage and irrigation system. 6. If irrigation is necessary and prescribed, perform it gently with sterile saline and the prescribed amount of irrigating fluid. 7. Assist patient in turning and moving in bed and when ambulating to prevent displacement or inadvertent removal of urinary stent or ureteral catheters if in place. 8. Observe urine colour, volume, odour, and components. 9. Minimize trauma and manipulation of catheter, drainage system, and urethra. 10. Clean catheter gently with soap during bath, avoiding any to-andfro movement of catheter. 11. Anchor drainage tube.

12. Maintain adequate fluid intake.

1. Provides basis for further assessment and action 2. Provides baseline

• Exhibits adequate urinary output and

3. Prevents or reduces risk of contamination of urinary drainage system

• Demonstrates normal laboratory

4. Reduces risk of bacterial contamination and infection 5. Permits irrigation when necessary while maintaining closed drainage system, minimizing risk of infection

• •

6. Maintains patency of the catheter or drainage system and prevents sudden increases in pressure in the urinary tract that may cause trauma, pressure on sutures or urinary tract structures, and pain 7. Prevents trauma from accidental displacement of urinary stent or ureteral catheter necessitating repeated instrumentation of the urinary tract (e.g., cystoscopy) to replace them 8. Provides information about adequacy of urine output, condition and patency of drainage system, and debris in urine 9. Reduces risk of contamination of drainage system and eliminates site of bacterial invasion 10. Removes debris and encrustations without causing trauma to or contamination of urethra 11. Prevents movement or slipping of drainage tube, minimizing trauma to and contamination of urethra or catheter 12. Promotes adequate urine output and prevents urinary stasis

patent drainage system

• Exhibits urinary output consistent with fluid intake

• • • • • • • • • • •

values: BUN, serum creatinine levels, urine specific gravity, and osmolality Exhibits sterile urine on urine culture Exhibits clear, dilute urine without debris or encrustation in the drainage system States rationale for avoiding manipulation of catheter, drainage, or irrigation system Exhibits normal placement of urinary stent or ureteral catheters until removed by physician Maintains closed urinary drainage system Exhibits normal body temperature without signs or symptoms of urinary tract infection Cleans catheter with soap and water Consumes adequate fluid intake (six to eight glasses of water or more per day, unless contraindicated) Urinary drainage system remains in place until physician removes or discontinues it Maintains urinary drainage system without infection or obstruction Maintains urinary diversion as instructed Maintains self-care so that environment is odour-free States rationale for close follow-up and maintains recommended schedule of appointments with health care providers

continued >



Urinary Tract Function

Plan of Nursing Care

Chart 45-12. Care of Patient Undergoing Kidney Surgery, Continued



13. Assist with and encourage early ambulation while ensuring placement of urinary drainage system.

13. Minimizes cardiovascular and pulmonary complications while preventing loss, dislodging, or disruption of drainage system 14. Knowledge and understanding of the drainage system or urinary diversion are essential to prevent infection and other complications

14. If patient is to be discharged with urinary drainage system (catheter) in place or a urinary diversion, instruct patient and family member in care.


Nursing Diagnosis: Risk for imbalanced fluid volume related to surgical fluid loss, altered urinary output, parenteral fluid administration Goal: Normal fluid balance will be maintained 1. Weigh patient daily. 2. Take accurate intake and output measurements. 3. Place all parenteral therapy on an infusion pump. 4. Monitor amount and characteristics of urine. 5. Monitor vital signs: temperature, pulse, respirations, and blood pressure. 6. Auscultate heart and lungs every shift.

1. Daily weight is the most sensitive indicator of fluid loss or gain 2. Detects fluid retention due to poor cardiac or renal output 3. Ensures that the patient does not receive excess or insufficient intravenous fluids 4. Assists in early detection of possible complications of surgery or tube insertion 5. When fluid volume or cardiac output is altered, vital signs are affected 6. When fluid volume is increased because of poor cardiac or renal output, fluid accumulates in the lungs. Also, heart sounds change as heart failure develops; frequent auscultation ensures early detection.

Early signs of pneumonia include fever, increased heart and respiratory rates, and adventitious breath sounds. Preventing infection is the rationale for using asepsis when changing dressings and handling and preparing catheters, other drainage tubes, central venous catheters, and IV catheters for administration of fluids. Insertion sites are monitored closely for signs and symptoms of inflammation: redness, drainage, heat, and pain. Special care must be taken to prevent UTI, which is associated with the use of indwelling urinary catheters. Catheters and other invasive tubes are removed as soon as they are no longer needed. Antibiotics are commonly administered postoperatively to prevent infection. If antibiotic agents are prescribed, serum creatinine and BUN values must be monitored closely because many antibiotic agents are toxic to the kidney or can accumulate to toxic levels if renal function is decreased. Preventing fluid imbalance is critical when caring for a patient undergoing kidney surgery, because both fluid loss and fluid excess are possible adverse effects of the surgery. Fluid loss may occur during surgery as a result of excessive urinary drainage when the obstruction is removed, or it may occur if diuretic agents are used. Such loss may also

• Patient’s weight will be within 2–3 lb of patient’s baseline

• Intake that exceeds output will be detected early

• The exact amount of solution is

infused with no adverse effects resulting from overinfusion or underinfusion • Urine is clear and absent of blood, pus, or any foreign substances • Temperature, pulse, respiration, and blood pressure are normal • Normal heart and lung sounds are present

occur with GI losses, with diarrhea resulting from antibiotic use, or with nasogastric drainage. When postoperative IV therapy is inadequate to match the output or fluids lost, a fluid deficit results. Fluid excess, or overload, may result from cardiac effects of anesthesia, administration of excessive amounts of fluids, or the patient’s inability to excrete fluid because of changes in renal function. Decreased urine output may be an indication of fluid excess. Astute assessment skills are needed to detect early signs of fluid excess (such as weight gain, pedal edema, urine output below 30 mL/h, and slightly elevated pulmonary wedge pressure, if available) before they become severe (appearance of adventitious breath sounds, shortness of breath). Fluid excess may be treated with fluid restriction and administration of furosemide (Lasix) or other diuretic agents. If renal insufficiency is present, these medications may prove ineffective; therefore, dialysis may be necessary to prevent heart failure and pulmonary edema. Deep venous thrombosis (DVT) may occur postoperatively because of surgical manipulation of the iliac vessels during surgery or prolonged immobility. Antiembolism stockings are applied, and the patient is monitored closely for signs and symptoms of thrombosis and encouraged to


exercise the legs. Heparin may be administered postoperatively to reduce the risk of thrombosis.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. If the patient has a drainage system in place, measures are taken to ensure that both the patient and family understand the importance of maintaining the system correctly at home and preventing infection. Verbal and written instructions and guidelines are provided to the patient and family at the time of hospital discharge. The patient may be asked to demonstrate management of the drainage system to ensure understanding. The importance of strategies to prevent postoperative complications (UTI and obstruction, DVT, atelectasis, and pneumonia) is stressed to the patient and family. Those signs, symptoms, problems, and questions that should be referred to the physician or other primary health care provider are reviewed by the nurse with the patient and family. CONTINUING CARE. The need for postoperative assessment and care after renal surgery continues regardless of the setting: the home, subacute care unit, outpatient clinic or office, or rehabilitation facility. Referral for home care is indicated for the patient going home with a urinary drainage system in place. During the home visit, the home care nurse reviews the instructions and guidelines given to the patient at hospital discharge. The nurse assesses the patient’s ability to carry out the instructions in the home and answers questions that the patient or family has about management of the drainage system and the surgical incision. In addition, the home care nurse obtains vital signs and assesses the patient for signs and symptoms of UTI and obstruction. The nurse also ensures that pain is adequately controlled and that the patient is complying with recommendations. The home care nurse encourages adequate fluid intake and increased levels of activity. Together the nurse, patient, and family review the signs, symptoms, problems, and questions that should be referred to the physician or other primary health care provider. If the patient has a drainage tube in place, the nurse assesses the site and the patency of the system and monitors the patient for complications, such as DVT, bleeding, or pneumonia. Because it is easy for the patient, family, and health care team to focus on the patient’s immediate disorder to the exclusion of other health issues, the nurse reminds the patient and family about the importance of participating in health promotion activities, including health screening.

KIDNEY TRANSPLANTATION Kidney transplantation has become the treatment of choice for most patients with ESRD. At the end of 2012, 1,358 Canadians underwent kidney transplantation: 713 from deceased donors and 392 from living donors. Another 3,428 were waiting for a kidney transplant in 2012 (Canadian Organ Replacement Register/Canadian Institute for Health Information, 2014). Patients choose kidney transplantation for various reasons, such as the desire to avoid dialysis or to improve their sense of well-being and the wish to lead a more normal life.

Management of Patients With Renal Disorders


CHART 45-13

Kidney Donation An inadequate number of available kidneys remains the greatest limitation to treating patients with end-stage renal disease successfully. For those interested in donating a kidney, the National Kidney Foundation provides written information describing the organ donation program and a card specifying the organs to be donated in the event of death. The organ donation card is signed by the donor and two witnesses and should be carried by the donor at all times. Procurement of an adequate number of kidneys for potential recipients is still a major problem, despite national legislation that requires relatives of deceased patients or patients declared brain-dead to be asked if they would consider organ donation. In some states in the United States, drivers can indicate their desire to be organ donors on their driver’s license application on renewal.

In addition, the cost of maintaining a successful transplantation is one third the cost of dialysis treatment. Kidney transplantation is an elective procedure, not an emergency life-saving procedure. Therefore, patients should be in the best possible condition prior to transplantation. Kidney transplantation involves transplanting a kidney from a living donor or deceased donor to a recipient who no longer has renal function (Chart 45-13). A living donor is a person who is alive at the time of donation and may or may not be related to the recipient. A deceased or cadaveric transplant comes from someone who has died and donated his or her organs. Transplantation from wellmatched living donors who are related to the patient (those with compatible ABO and human leukocyte antigens) is slightly more successful than from cadaver donors. Prior to either receiving or donating an organ, an extensive medical evaluation is performed. Not everyone is suitable for a kidney transplant. Contraindications include recent malignancy, active or chronic infection, severe irreversible extrarenal disease (e.g., inoperable cardiac disease, chronic lung disease, severe peripheral vascular disease), active autoimmune disease (e.g., HIV, hepatitis B and C), morbid obesity (body mass index greater than 35), current substance abuse, inability to give informed consent, and history of nonadherence to treatment regimens. Donors may be rejected for the same reasons or any condition that is determined to have an impact on the remaining kidney. Examples include hypertension and diabetes mellitus since both are known causes of renal disease. It is imperative when donors are evaluated that serious consideration be given to the overall long-term health of the donor. Every precaution must be taken to ensure that the remaining kidney in the donor will remain healthy. If these conditions are met, the donor should remain healthy after donation and have a normal lifespan. Since one kidney can easily handle the body’s needs, no longterm adjustments will need to be made. The patient’s native kidneys are not usually removed. The transplanted kidney is placed in the patient’s iliac fossa anterior to the iliac crest because it allows for easier access to the blood supply needed to perfuse the kidney.



Urinary Tract Function

Inferior vena cava


Diseased kidney Adrenal gland remains intact Renal artery and vein tied off

Adrenal gland Ureter

1. Transplanted donor kidney cradled in ilium 2. Renal artery sutured to iliac artery Renal vein sutured to iliac vein 3. Ureter sutured

The ureter of the newly transplanted kidney is transplanted into the bladder or anastomosed to the ureter of the recipient (Fig. 45-10). Once the blood supply has been reestablished to the transplanted kidney in the operating room, urine should begin to flow. The production of urine at this stage is an important indicator of the overall success of the procedure and ultimate long-term outcome.

Preoperative Management Preoperative management goals include bringing the patient’s metabolic state to a level as close to normal as possible, making sure that the patient is free of infection, and preparing the patient for surgery and the postoperative course.

Medical Management A complete physical examination is performed to detect and treat any conditions that could cause complications after transplantation. Tissue typing, blood typing, and antibody screening are performed to determine compatibility of the tissues and cells of the donor and recipient. Other diagnostic tests must be completed to identify conditions requiring treatment before transplantation. The lower urinary tract is studied to assess bladder neck function and to detect ureteral reflux. The patient must be free of infection at the time of renal transplantation, because after surgery medications to prevent transplant rejection will be prescribed. These medications suppress the immune response, leaving the patient immunosuppressed and at risk for infection. Therefore, the patient is evaluated and treated for any infections, including gingival (gum) disease and dental caries. A psychosocial evaluation is conducted to assess the patient’s ability to adjust to the transplant, coping styles, social history, social support available, and financial resources. A history of psychiatric illness is important to obtain because psychiatric conditions are often aggravated

Ilium Internal iliac artery Inguinal ligament

FIGURE 45-10. Renal transplantation: 1, The transplanted kidney is placed in the iliac fossa. 2, The renal artery of the donated kidney is sutured to the ileac artery, and the renal vein is sutured to the iliac vein. 3, The ureter of the donated kidney is sutured to the bladder or to the patient’s ureter.

by the corticosteroids needed for immunosuppression after transplantation. If a dialysis routine has been established, hemodialysis is often performed the day before the scheduled transplantation procedure to optimize the patient’s physical status.

Nursing Management The nursing aspects of preoperative care for the patient undergoing renal transplant are similar to those for patients undergoing other types of kidney or elective abdominal surgery. Preoperative teaching can be conducted in a variety of settings, including the outpatient preadmission area, the hospital, or the transplantation clinic during the preliminary workup phase. Patient teaching addresses postoperative pulmonary hygiene, pain management options, dietary restrictions, IV and arterial lines, tubes (indwelling catheter and possibly a nasogastric tube), and early ambulation. The patient who receives a kidney from a living related donor may be concerned about the donor and how the donor will tolerate the surgical procedure. Most patients have been on dialysis for months or years before transplantation. Many have waited months to years for a kidney transplant and are anxious about the surgery, possible rejection, and the need to return to dialysis. Helping the patient to deal with these concerns is part of the nurse’s role in preoperative management, as is teaching the patient about what to expect after surgery.

Postoperative Management The goal of care is to maintain homeostasis until the transplanted kidney is functioning well. The patient whose kidney functions immediately has a more favourable prognosis than the patient whose kidney does not.

Medical Management After a kidney transplant, rejection and failure can occur within 24 hours (hyperacute), within 3 to 14 days (acute),


or after many years. The long-term survival of a transplanted kidney depends on how well it matches the recipient and how well the body’s immune response is controlled. Since the body’s immune system views the transplanted kidney as “foreign,” it continually works to reject it. To overcome or minimize the body’s defense mechanisms, immunosuppressive agents are administered. Optimally, medications modify the immune system enough to prevent rejection, but not enough to allow infections or malignancies to occur. Combinations of glucocorticoids and medications specifically developed to affect the action of lymphocytes are used to minimize the body’s reaction to the transplanted organ. Treatment with combinations of new agents has dramatically improved survival rates, and now 90% to 95% of transplanted kidneys still function after 1 year (American Nephrology Nurses Association, 2007b). Doses of immunosuppressive agents are often adjusted depending on the patient’s immunologic response to the transplant. However, the patient will be required to take some form of immunosuppressive therapy for the entire time that he or she has the transplanted kidney.


After kidney transplantation, the nurse assesses the patient for signs and symptoms of transplant rejection: oliguria, edema, fever, increasing blood pressure, weight gain, and swelling or tenderness over the transplanted kidney or graft. Patients receiving cyclosporine may not exhibit the usual signs and symptoms of acute rejection. In these patients, the only sign may be an asymptomatic rise in the serum creatinine level (more than a 20% rise is considered acute rejection). PREVENTING INFECTION. The results of blood chemistry tests and leukocyte and platelet counts are monitored closely because immunosuppression depresses the formation of leukocytes and platelets. The patient is closely monitored for infection because of susceptibility to impaired healing and infection related to immunosuppressive therapy and complications of renal failure. Clinical manifestations of infection include shaking chills, fever, rapid heartbeat (tachycardia), and respirations (tachypnea), as well as either an increase or a decrease in WBCs (leukocytosis or leukopenia). Infection may be introduced through the urinary tract, the respiratory tract, the surgical site, or other sources. Urine cultures are performed frequently because of the high incidence of bacteriuria during early and late stages of transplantation. Any type of wound drainage should be viewed as a potential source of infection because drainage is an excellent culture medium for bacteria. Catheter and drain tips may be cultured when removed by cutting off the tip of the catheter or drain (using aseptic technique) and placing the tip in a sterile container to be taken to the laboratory for culture (Chart 45-14). The nurse ensures that the patient is protected from exposure to infection by hospital staff, visitors, and other patients with active infections. Attention to hand hygiene by all who come in contact with the patient is imperative. MONITORING URINARY FUNCTION. A kidney from a living donor related to the patient usually begins to function immediately after surgery and may produce large

Management of Patients With Renal Disorders


CHART 45-14

Renal Transplant Rejection and Infection Renal graft rejection and failure may occur within 24 hours (hyperacute), within 3 to 14 days (acute), or after many years (chronic). It is not uncommon for rejection to occur during the first year after transplantation.

Detecting Rejection Ultrasonography may be used to detect enlargement of the kidney; percutaneous renal biopsy (most reliable) and x-ray techniques are used to evaluate transplant rejection. If the body rejects the transplanted kidney, the patient needs to return to dialysis. The rejected kidney may or may not be removed, depending on when the rejection occurs (acute vs. chronic) and the risk for infection if the kidney is left in place.

Potential Infection About 75% of kidney transplant recipients have at least one episode of infection in the first year after transplantation because of immunosuppressant therapy. Immunosuppressants of the past made the transplant recipient more vulnerable to opportunistic infections (candidiasis, cytomegalovirus, Pneumocystis pneumonia) and infection with other relatively nonpathogenic viruses, fungi, and protozoa, which can be a major hazard. Cyclosporine therapy has reduced the incidence of opportunistic infections because it selectively exerts its effect, sparing T cells that protect the patient from life-threatening infections. In addition, combination immunosuppressant therapy and improved clinical care have produced 1-year patient survival rates approaching 100% and graft survival exceeding 90%. Infections, however, remain a major cause of death at all points in time for kidney transplant recipients (Danovitch, 2005).

quantities of dilute urine. A kidney from a cadaver donor may undergo ATN and therefore may not function for 2 or 3 weeks, during which time anuria, oliguria, or polyuria may be present. During this stage, the patient may experience significant changes in fluid and electrolyte status. Therefore, careful monitoring is indicated. The output from the urinary catheter (connected to a closed drainage system) is measured every hour. IV fluids are administered on the basis of urine volume and serum electrolyte levels and as prescribed by the physician. Hemodialysis may be necessary postoperatively to maintain homeostasis until the transplanted kidney is functioning well. It may also be required if fluid overload and hyperkalemia occur. After successful renal transplantation, the vascular access device may clot, possibly from improved coagulation with the return of renal function. The vascular access for hemodialysis is monitored to ensure patency and to evaluate for evidence of infection. ADDRESSING PSYCHOLOGICAL CONCERNS. The rejection of a transplanted kidney is of great concern to the patient, the family, and the health care team for many months. The fear of kidney rejection and the complications of immunosuppressive therapy (Cushing’s syndrome, diabetes, capillary fragility, osteoporosis, glaucoma, cataracts, acne, nephrotoxicity) place tremendous psychological stress on the patient. Anxiety and uncertainty about the



Urinary Tract Function

future and difficult posttransplantation adjustment are often sources of stress for the patient and family. An important nursing function is the assessment of the patient’s stress and coping. The nurse uses each visit with the patient to determine if the patient and family are coping effectively and the patient is adhering to the prescribed medication regimen. If indicated or requested, the nurse refers the patient for counselling. MONITORING AND MANAGING POTENTIAL COMPLICATIONS. The patient undergoing kidney transplantation

is at risk for the postoperative complications that are associated with any surgical procedure. In addition, the patient’s physical condition may be compromised because of the effects of long-standing renal failure and its treatment. Therefore, careful assessment for the complications related to renal failure and those associated with a major surgery are important aspects of nursing care. Breathing exercises, early ambulation, and care of the surgical incision are important aspects of postoperative care. GI ulceration and corticosteroid-induced bleeding may occur. Fungal colonization of the GI tract (especially the mouth) and urinary bladder may occur secondary to corticosteroid and antibiotic therapy. Closely monitoring the patient and notifying the physician about the occurrence of these complications are important nursing interventions. In addition, the patient is monitored closely for signs and symptoms of adrenal insufficiency if the treatment has included use of corticosteroids. PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care. The nurse works closely with the patient and family to be sure that they understand the need for continuing immunosuppressive therapy as prescribed. In addition, the patient and family are instructed to assess for and report signs and symptoms of transplant rejection, infection, or significant adverse effects of the immunosuppressive regimen. These include decreased urine output; weight gain; malaise; fever; respiratory distress; tenderness over the transplanted kidney; anxiety; depression; changes in eating, drinking, or other habits; and changes in blood pressure. The patient is instructed to inform other health care providers (e.g., dentist) about the kidney transplant and the use of immunosuppressive agents. Continuing Care. The patient needs to know that follow-up care after transplantation is a lifelong necessity. Individual verbal and written instructions are provided concerning diet, medication, fluids, daily weight, daily measurement of urine, management of I&O, prevention of infection, resumption of activity, and avoidance of contact sports in which the transplanted kidney may be injured. Because of the risk for other potential complications, the patient is followed closely. Cardiovascular disease is the major cause of morbidity and mortality after transplantation, due in part to the increasing age of patients with transplants. An additional problem is possible malignancy; patients receiving longterm immunosuppressive therapy are at higher risk for cancers than the general population. So the patient is reminded of the importance of health promotion and health screening. The Kidney Foundation of Canada and its provincial branches provide information and support to patients with kidney disease and their families.

It can provide many helpful suggestions for patients and family members learning to cope with dialysis and transplantation.

RENAL TRAUMA The kidneys are protected by the rib cage and musculature of the back posteriorly and by a cushion of abdominal wall and viscera anteriorly. They are highly mobile and are fixed only at the renal pedicle (stem of renal blood vessels and the ureter). With traumatic injury, the kidneys can be thrust against the lower ribs, resulting in contusion and rupture. Rib fractures or fractures of the transverse process of the upper lumbar vertebrae may be associated with renal contusion or laceration. Failure to wear seat belts contributes to the incidence of renal trauma in motor vehicle crashes. Up to 80% of patients with renal trauma have associated injuries of other internal organs. Injuries may be blunt (automobile and motorcycle crashes, falls, athletic injuries, assaults) or penetrating (gunshot wounds, stabbings). Blunt renal trauma accounts for 80% to 90% of all renal injuries; penetrating renal trauma accounts for the remaining 10% to 20%. Blunt renal trauma is classified into one of four groups, as follows: • Contusion: bruises or hemorrhages under the renal capsule; capsule and collecting system intact • Minor laceration: superficial disruption of the cortex; renal medulla and collecting system are not involved • Major laceration: parenchymal disruption extending into cortex and medulla, possibly involving the collecting system • Vascular injury: tears of renal artery or vein The most common renal injuries are contusions, lacerations, ruptures, and renal pedicle injuries or small internal lacerations of the kidney (Fig. 45-11). The kidneys receive half of the blood flow from the abdominal aorta; therefore, even a fairly small renal laceration can produce massive bleeding. About 70% of patients are in shock when admitted to the hospital. In some cases, there is an isolated renal artery thrombosis. Clinical manifestations include pain, renal colic (due to blood clots or fragments obstructing the collecting system), hematuria, mass or swelling in the flank, ecchymoses, and lacerations or wounds of the lateral abdomen and flank. Hematuria is the most common manifestation of renal trauma; its presence after trauma suggests renal injury. There is no relationship between the degree of hematuria and the degree of injury. Hematuria may not occur, or it may be detectable only on microscopic examination. Signs and symptoms of hypovolemia and shock are likely with significant hemorrhage.

Medical Management The goals of management in patients with renal trauma are to control hemorrhage, pain, and infection as well as to preserve and restore renal function. All urine is saved and sent to the laboratory for analysis to detect RBCs and to evaluate the course of bleeding. Hematocrit and hemoglobin


Expanding hematoma may cause rupture, extravasation, exsanguination

Pedicle injury; may cause ischemic necrosis of kidney

Contusion Bleeding into collecting system, shock Laceration

Management of Patients With Renal Disorders


the nature of the injury, major lacerations may be treated through surgical intervention or conservatively (bed rest, no surgery). Vascular injuries require immediate exploratory surgery because of the high incidence of involvement of other organ systems and the serious complications that may result if these injuries are untreated. The patient is often in shock and requires aggressive fluid resuscitation. The damaged kidney may have to be removed (nephrectomy). Early postoperative complications (within 6 months) include rebleeding, perinephritic abscess formation, sepsis, urine extravasation, and fistula formation. Other complications include stone formation, infection, cysts, vascular aneurysms, and loss of renal function. Hypertension can be a complication of any renal surgery but usually is a late complication of renal injury.

Nursing Management

Blood in urine FIGURE 45-11. Types and pathophysiologic effects of renal injuries: contusions, lacerations, rupture, and pedicle injury.

levels are monitored closely; decreasing values indicate hemorrhage. The patient is monitored for oliguria and signs of hemorrhagic shock, because a pedicle injury or shattered kidney can lead to rapid exsanguination (lethal blood loss). An expanding hematoma may cause rupture of the kidney capsule. To detect hematoma, the area around the lower ribs, upper lumbar vertebrae, flank, and abdomen is palpated for tenderness. A palpable flank or abdominal mass with local tenderness, swelling, and ecchymosis suggests renal hemorrhage. The area of the original mass can be outlined with a marking pen so that the examiner can evaluate the area for change. Renal trauma is often associated with other injuries to the abdominal organs (liver, colon, small intestines); therefore, the patient is assessed for skin abrasions, lacerations, and entry and exit wounds of the upper abdomen and lower thorax because these may be associated with renal injury. With a contusion of the kidney, healing may take place with conservative measures. If the patient has microscopic hematuria and a normal IV urogram, outpatient management is possible. If gross hematuria or a minor laceration is present, the patient is hospitalized and kept on bed rest until the hematuria clears. Antimicrobial medications may be prescribed to prevent infection from perirenal hematoma or urinoma (a cyst containing urine). Patients with retroperitoneal hematomas may develop low-grade fever as absorption of the clot takes place.

Surgical Management In renal trauma, any sudden change in the patient’s condition suggests hemorrhage and requires rapid surgical intervention. Depending on the patient’s condition and

The patient with renal trauma must be assessed frequently during the first few days after injury to detect flank and abdominal pain, muscle spasm, and swelling over the flank. During this time, the patient who has undergone surgery is instructed about care of the incision and the importance of an adequate fluid intake. In addition, instructions about changes that should be reported to the physician, such as fever, hematuria, flank pain, or any signs and symptoms of decreasing kidney function, are provided. Guidelines for gradually increasing activity, lifting, and driving are also provided in accordance with the physician’s prescription. Follow-up nursing care includes monitoring the blood pressure to detect hypertension and advising the patient to restrict activities for about 1 month after trauma to minimize the incidence of delayed or secondary bleeding. The patient should be advised to schedule periodic follow-up assessments of renal function (creatinine clearance, BUN and serum creatinine analyses). If a nephrectomy was necessary, the patient is advised to wear medical identification.

Critical Thinking Exercises 1 You are a staff nurse in an outpatient dialysis facility. A 50-year-old woman with ESRD is scheduled to be seen in the clinic; it is anticipated that she will need dialysis in the near future. The patient lives alone and will require teaching about the dialysis options. Develop a teaching plan to explain the different types of dialysis, goals, and level of involvement on the part of the patient. 2 A 45-year-old married man visits the nephrology department to discuss options for dealing with his ESRD. His brother has begun the workup to donate one of his kidneys and the preliminary reports show that a match is possible. The patient states that he does not want his brother to go through the process of kidney donation if dialysis is possible. Identify the evidence for and the criteria used to evaluate the strength of the evidence for dialysis compared to kidney transplantation.



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3 You are caring for a 35-year-old woman who has been recently diagnosed with renal cancer. Identify possible treatment options. What nursing assessment and interventions should you make at this time? What explanations would you give the patient about renal cancer?

Kopp, J. B. (2013). Rethinking hypertensive kidney disease: Arterionephrosclerosis as a genetic, metabolic, & inflammatory disorder. Current Opinion in Nephrology & Hypertension, 22(3), 266–272. Mosenkis, A., Kirk, D., & Berns, J. S. (2006). When chronic kidney disease becomes advanced. Postgraduate Medicine, 110(1), 83–91.

4 A 55-year-old man who is blind has just had a catheter placed for PD. His wife, his primary caretaker, is deaf. Develop a teaching plan to explain peritoneal dialysis, goals, and level of involvement to the patient and family.

Ali, B., & Gray-Vickrey, P. (2011). Limiting the damage from acute kidney injury. Nursing, 41(3), 22–31. Barreto, R. (2007). Prevention of contrast induced nephropathy. The rational use of sodium bicarbonate. Nephrology Nursing Journal, 34(4), 417–421. Dennen, P., Douglas, I. S., & Anderson, R. (2010). Acute kidney injury in the intensive care unit: An update and primer for the intensivist. Critical Care Medicine, 38(1), 261–275. Dirkes, S. (2011). Acute kidney injury. Not just acute renal failure anymore? Critical Care Nurse, 31(1), 37–50. Ejaz, A. A., & Mohandas, R. (2014). Are diuretics harmful in the management of acute kidney injury? Current Opinion in Nephrology & Hypertension, 23(3), 155–160. Isaac, S. (2012). Contrast-induced nephropathy: Nursing implications. Critical Care Nurse, 32(3), 41–48. Jorgensen, A. L. (2013). Contrast-induced nephropathy: Pathophysiology & preventive strategies. Critical Care Nurse, 33(1), 37–47. Warise, L. (2010). Update: Diuretic therapy in acute renal failure-a clinical case study. MEDSURG Nursing, 19 (3), 149–152. Yaklin, K. M. (2011). Acute kidney injury: An overview of pathophysiology & treatments. Nephrology Nursing Journal, 38(1), 13–30.

REFERENCES AND SELECTED READINGS *Asterisk indicates nursing research article.

BOOKS Danovitch, G. M. (2005). Handbook of kidney transplantation. Philadelphia, PA: Lippincott Williams & Wilkins. Hannon, R. A., Pooler, C., & Porth, C. M. (2010). Porth pathophysiology: Concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Holcombe, D. M., & Kern Feely, N. (2013). Renal failure. In P. G. Morton, & D. K. Fontaine (Eds). Critical care nursing a holistic approach (10th ed., pp. 663–690). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Mount, D.B., & Zandi-Nejad, K. (2012). Disorders of potassium balance. In M. W. Taal, G. M. Chertow, P. A. Marsden, K. Skorecki, A. S. Yu, & B. M. Brenner (Eds.), Brenner & Rector’s the kidney (9th ed., pp. 640–688). Philadelphia, PA: Elsevier. Muzzy, A. C., & Snyder, K. A. (2013). Patient management: Renal system. In P. G. Morton, & D. K. Fontaine (Eds.), Critical care nursing a holistic approach (10th ed., pp. 637–662). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (2010). Canadian Bates’ guide to health assessment for nurses (1st ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Stephen, T. C., Skillen, D. L., Day, R. A., et al. (2012). Canadian Jensen’s nursing health assessment: A best practice approach (1st ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

JOURNALS AND ELECTRONIC DOCUMENTS General Mentes, J. C. (2013). The complexities of hydration issues in the elderly. Nutrition Today, 48(4S), S10–S12. Perico, N., Remuzzi, G., Benigni, A. (2011). Aging and the kidney. Current Opinion in Nephrology & Hypertension, 20, 312–317. Chronic Kidney Disease Canadian Institute for Health Information (CIHI). (2013). Canadian Organ Replacement Register Annual Report: Treatment of End-Stage Organ Failure in Canada, 2003 to 2012. Ottawa: Author. Retrieved from https:// Canadian Organ Replacement Register/Canadian Institute for Health Information. (2014). CORR Annual Report:Treatment of End-Stage Organ Failure in Canada 2003–2012, 1–143. Retrieved from https:// Castner, D. (2010). Understanding the stages of chronic kidney disease, Nursing, 40(5), 25–31. Elliot, M. J., Ronksley, P. E., Clase, C. M., et al. (2010). Management of patients with acute hyperkalemia, Canadian Medical Association Journal, 182(15), 1631–1635. Gosmanov, A. R., Wall, B. M., & Gosmanova, E. O. (2014). Diagnosis & treatment of diabetic kidney disease. The American Journal of the Medical Sciences, 0(0), 1–8. Kidney Disease Improving Global Outcomes (KDIGO). (2012). Clinical practice guideline for the evaluation & management of chronic kidney disease. Kidney International Supplement, 2013, 3(1), 1–150. Retrieved from

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Renal Carcinoma American Cancer Society. (2009). Cancer facts and figures: 2009. Available at: Aschenbrenner, D. S. (2007). Drug watch. American Journal of Nursing, 107 (11), 25–26. Canadian Cancer Society. (2014). Signs and symptoms of kidney cancer. Retrieved from cancer-type/kidney/signs-and-symptoms/?region=on Canadian Cancer Society’s Steering Committee. (2013). Canadian Cancer Statistics 2013. Toronto: Canadian Cancer Society. Cohen, H. T., & McGovern, F. J. (2005). Renal-cell carcinoma. New England Journal of Medicine, 353(23), 2477–2490. Wood, L. S. (2010). New therapeutic strategies for renal cell carcinoma, Urologic Nursing, 30(1), 40–53. Chronic Renal Failure Bhan, I. (2014). Phosphate management in chronic kidney disease. Current Opinion in Nephrology & Hypertension, 23(2), 174–179. Bidani, A. K., Poliochnowski, A. J., Loutzenhiser, R., et al. (2013). Renal microvascular dysfunction, hypertension, & CKD progression. Current Opinion in Nephrology & Hypertension, 22(1), 1–9. Broscious, S. K., Castagnola, J. (2006). Chronic kidney disease: Acute manifestations and role of critical care nurses. Critical Care Nurse, 26(4), 17–20, & 22–27. Dutka, P. (2012). Erythropoiesis-stimulating agents for the management of anemia of chronic kidney disease: Past advancements and current innovations. Nephrology Nursing Journal, 39 (6), 447–457. Kane, P. M., Vinen, K., & Murtagh, F. E. (2013). Palliative care for advance renal disease: A summary of the evidence and future direction, Palliative Medicine, 27 (9), 817–821. Lane, B. R., Demirjian, S., Derweesh, I. H., et al. (2014). Is all chronic kidney disease created equal? Current Opinion in Urology, 24(20), 127–134. Schreiber, M. (2013a). Fluids and electrolytes: The highs and lows of potassium. Nursing 2013 Critical Care, 8(4), 8–13. Schreiber, M. (2013b). Understanding hyponatremia. Nursing 2013 Critical Care, 8(2), 8–10. Vasundhara, M., Kozman, H., Liu, K., et al. (2014). Cardiac troponins: Bench to bedside interpretation in cardiac disease. The American Journal of Medical Sciences, 347 (4), 331–337. Zuber, K., Liles, A. M., & Davies, J. (2013). Medication dosing in patients with chronic kidney disease. Journal of American Academy of Physician Assistants, 26(10), 19–25. Renal Replacement Therapies Castner, D. (2011). Management of patients on hemodialysis before, during, and after hospitalization:Challenges and suggestions for improvement. Nephrology Nursing Journal, 38(4), 319–330.

CHAPTER 45 Horigan, A., Rocchiccioli, J., & Trimm, D. (2012). Dialysis and fatigue: Implications for Nurses-a case study analysis. Medsurg Nursing, 21(3), 158–175. *Ka yee Chow, S., & Wong, F. K. (2010). Health-related quality of life in patients undergoing peritoneal dialysis: Effects of a nurse-led case management programme. Journal of Advanced Nursing, 66(8), 1780–1792. Martin, R. K., & Jurschak, J. (2007). Nursing management of continuous renal replacement therapy. Seminars in Dialysis, 9 (2), 192–199. Peters, A. (2014). Safety issues in home dialysis. Nephrology Nursing Journal, 41(1), 89–92. Richard, C. J. (2011). Preservation of vascular access for hemodialysis in acute care settings, Critical Care Nursing, 34(1), 76–83. Roeder, V. R., Atkins, H. N., Ryan, M., et al. (2013). Putting the C back into continuous renal replacement therapy. Nephrology Nursing Journal, 40(6), 509–516. Welch, J. L., & Perkins, S. M. (2006). Patterns of interdialytic weight gain during the first year of hemodialysis. Nephrology Nursing Journal, 33(5), 493–498. Kidney Transplantation American Nephrology Nurses Association (2007b). Chronic kidney disease. What every nurse should know. Module 6: The post transplant patient. Pitman, NJ. Author

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Gill, J. S. (2011). Managing patients with a failed kidney transplant: How can we do better? Current Opinion in Nephrology & Hypertension, 20(6), 616–621. Kim, S. P., & Thompson, R. H. (2013). Kidney function after partial nephrectomy: Current thinking. Current Opinion in Urology, 23(2), 105–111. Morgan, A., Scott, A., & Darbyshire, P. (2010). Waiting for kidney transplant: Patient’s experiences of hemodialysis therapy. Journal of Advanced Nursing, 67 (3), 501–509. Nierste, D. (2013). Issues in organ procurement, allocation, & transplantation. Journal of Christian Nursing, 30(2), 80–87. Russell, C. L. (2013). Optimal care for kidney transplant recipients. OR Nurse, 7 (1), 36–40.

RESOURCES Canadian Cancer Society Canadian Society of Nephrology Canadian Society of Transplantation Canadian Urological Association Polycystic Kidney Disease Foundation of Canada Kidney Foundation of Canada Kidney Cancer Research Network of Canada entrez/query.fcgi?db=OMIM


46 Management of Patients With Urinary Disorders Adapted by Kathryn Martin

Learning Objectives On completion of this chapter, the learner will be able to: 1. Identify factors contributing to upper and lower urinary tract infections. 2. Use the nursing process as a framework for care of the patient with a urinary tract infection. 3. Differentiate between the various adult dysfunctional voiding patterns. 4. Develop a patient education plan for a patient who has mixed (stress and urge) urinary incontinence. 5. Identify potential causes of an obstruction of the urinary tract and management of the patient with this condition. 6. Develop a teaching plan for the patient undergoing treatment for renal calculi (kidney stones). 7. Formulate preoperative and postoperative nursing diagnoses for the patient undergoing surgery for urinary diversion.



The urinary system is responsible for providing the route for drainage of urine formed by the kidneys. The field of urologic nursing requires an understanding of the anatomy, physiology, diagnostic testing, nursing care, and rehabilitation of patients with multiple processes that interfere with the urinary system. Nurses care for patients with urologic disorders in all settings. This chapter focuses on the nursing management of patients with common urinary dysfunctions, including infections, dysfunctional voiding patterns, urolithiasis, genitourinary trauma, cancer of the urinary tract, and urinary diversions.

INFECTIONS OF THE URINARY TRACT Urinary tract infections (UTIs) are caused by pathogenic microorganisms in the urinary tract (the normal urinary tract is sterile above the urethra). UTIs are generally

Management of Patients With Urinary Disorders


classified as infections involving the upper or lower urinary tract (Chart 46-1). Lower UTIs include bacterial cystitis (inflammation of the urinary bladder), bacterial prostatitis (inflammation of the prostate gland), and bacterial urethritis (inflammation of the urethra). There can be acute or chronic nonbacterial causes of inflammation in any of these areas that can be misdiagnosed as bacterial infections. Upper UTIs are much less common and include acute or chronic pyelonephritis (inflammation of the renal pelvis), interstitial nephritis (inflammation of the kidney), and renal abscesses. Upper and lower UTIs are further classified as uncomplicated or complicated, depending on other patient-related conditions (e.g., whether the UTI is recurrent and the duration of the infection). Most uncomplicated UTIs are community acquired. Complicated UTIs usually occur in people with urologic abnormalities or recent catheterization and are often hospital acquired. A UTI is the second most common reason patients seek out health care (Hannon, Pooler, & Porth, 2010). Women are more likely to develop a UTI than men; over 500,000 Canadian women visit the doctor each

Glossary bacteriuria: more than 105 colonies of bacteria per millilitre of urine continent urinary diversion (Kock or Charleston pouch): transplantation of the ureters to a segment of bowel with construction of an effective continence mechanism or valve Charleston pouch: uses the ileum and ascending colon as the pouch, with the appendix and colon junction serving as the one-way valve mechanism cystectomy: removal of the urinary bladder cystitis: inflammation of the urinary bladder dysuria: painful or difficult urination frequency: voiding more often than every 3 hours functional incontinence: physical impairments make it difficult or impossible for the patient to reach the toilet in time for voiding iatrogenic incontinence: the involuntary loss of urine due to extrinsic medical factors, predominantly medications ileal conduit: transplantation of the ureters to an isolated section of the terminal ileum, with one end of the ureters brought to the abdominal wall interstitial cystitis: inflammation of the bladder wall that eventually causes disintegration of the lining and loss of bladder elasticity interstitial nephritis: inflammation of the kidney Kock pouch: U-shaped pouch constructed of ileum, with a nipple-like one-way valve micturition: voiding or urination mixed incontinence: a combination of stress and urge incontinence neurogenic bladder: bladder dysfunction that results from a disorder or dysfunction of the nervous system; may result in either urinary retention or bladder overactivity, resulting in urinary urgency and urge incontinence nocturia: awakening at night to urinate

overflow incontinence: involuntary urine loss associated with overdistention of the bladder due to mechanical or anatomic bladder outlet obstruction prostatitis: inflammation of the prostate gland pyelonephritis: inflammation of the renal pelvis pyuria: white blood cells in the urine reflex incontinence: involuntary loss of urine due to hyperreflexia or involuntary urethral relaxation in the absence of normal sensations; usually associated with micturition (voiding) residual urine: urine that remains in the bladder after voiding stress incontinence: involuntary loss of urine through an intact urethra as a result of a sudden increase in intraabdominal pressure suprapubic catheter: a urinary catheter that is inserted through a suprapubic incision into the bladder urge incontinence: involuntary loss of urine associated with urinary urgency due to hypersensory disorders of the bladder, motor instability, or both urinary incontinence: involuntary or uncontrolled loss of urine from the bladder sufficient to cause a social or hygienic problem urethritis: inflammation of the urethra ureterosigmoidostomy: transplantation of the ureters into the sigmoid colon, allowing urine to flow through the colon and out the rectum ureterovesical or vesicoureteral reflux: backward flow of urine from the bladder into one or both ureters urethrovesical reflux: backward flow of urine from the urethra into the bladder urosepsis: sepsis resulting from infected urine, most often a urinary tract infection wound care specialist: a nurse specially educated in appropriate skin, wound, ostomy, and continence care; often referred to as an enterostomal therapist or a wound-ostomy-continence nurse (WOCN)



Urinary Tract Function

CHART 46-2

CHART 46-1

Risk Factors for Urinary Tract Infection

Classifying Urinary Tract Infections Urinary tract infections (UTIs) are classified by location: the lower urinary tract (which includes the bladder and structures below the bladder) or the upper urinary tract (which includes the kidneys and ureters). They can also be classified as uncomplicated or complicated UTIs.

• Inability or failure to empty the bladder completely • Obstructed urinary flow

Lower UTIs Cystitis, prostatitis, urethritis

Upper UTIs Acute pyelonephritis, chronic pyelonephritis, renal abscess, interstitial nephritis, perirenal abscess

• •

Uncomplicated Lower or Upper UTIs

• •

Community-acquired infection; common in young women and not usually recurrent

Complicated Lower or Upper UTIs Often nosocomial (acquired in the hospital) and related to catheterization; occur in patients with urologic abnormalities, pregnancy, immunosuppression, diabetes mellitus, and obstructions and are often recurrent

year because of a UTI (Kidney Foundation of Canada, 2007). Population-based research in Canada reflects an annual incidence of community onset UTIs of 17.5 per 1,000. Women, as well as the very old and the very young, are at increased risk. The most common organisms identified were Escherichia coli, Klebsiella pneumoniae, and Enterococcus sp. (Laupland, Ross, Pitout, et al., 2007). The urinary tract is also the most common site of nosocomial infection. In most of these hospital-acquired UTIs, instrumentation of the urinary tract or catheterization is the precipitating cause.

Lower Urinary Tract Infections Several mechanisms maintain the sterility of the bladder: the physical barrier of the urethra, urine flow, ureterovesical junction competence, various antibacterial enzymes and antibodies, and antiadherent effects mediated by the mucosal cells of the bladder. Abnormalities or dysfunctions of these mechanisms are contributing factors to lower UTIs (Chart 46-2).

Pathophysiology For infection to occur, bacteria must gain access to the bladder, attach to and colonize the epithelium of the urinary tract to avoid being washed out with voiding, evade host defense mechanisms, and initiate inflammation (Moore, Day, & Albers, 2002). Most UTIs result from fecal organisms that ascend from the perineum to the urethra and the bladder and then adhere to the mucosal surfaces.

Bacterial Invasion of the Urinary Tract By increasing the normal slow shedding of bladder epithelial cells (resulting in bacteria removal), the bladder can

Congenital abnormalities Urethral strictures Contracture of the bladder neck Bladder tumours Calculi (stones) in the ureters or kidneys Compression of the ureters Neurologic abnormalities Decreased natural host defenses or immunosuppression Instrumentation of the urinary tract (e.g., catheterization, cystoscopic procedures) Inflammation or abrasion of the urethral mucosa Contributing conditions Diabetes mellitus (increased urinary glucose levels create an infection-prone environment in the urinary tract) Pregnancy Neurologic disorders Gout Altered states caused by incomplete emptying of the bladder and urinary stasis

clear itself of even large numbers of bacteria. Glycosaminoglycan (GAG), a hydrophilic protein, normally exerts a nonadherent protective effect against various bacteria. The GAG molecule attracts water molecules, forming a water barrier that serves as a defensive layer between the bladder and the urine. GAG may be impaired by certain agents (cyclamate, saccharin, aspartame, and tryptophan metabolites). The normal bacterial flora of the vagina and urethral area also interfere with adherence of E. coli (the most common microorganism causing UTI). Urinary immunoglobulin A (IgA) in the urethra may also provide a barrier to bacteria.

Reflux An obstruction to free-flowing urine is a problem known as urethrovesical reflux, which is the reflux (backward flow) of urine from the urethra into the bladder (Fig. 46-1). With coughing, sneezing, or straining, the bladder pressure rises, which may force urine from the bladder into the urethra. When the pressure returns to normal, the urine flows back into the bladder, bringing into the bladder bacteria from the anterior portions of the urethra. Urethrovesical reflux is also caused by dysfunction of the bladder neck or urethra. The urethrovesical angle and urethral closure pressure may be altered with menopause, increasing the incidence of infection in postmenopausal women. Reflux is most often noted, however, in young children. Treatment is based on its severity. Ureterovesical or vesicoureteral reflux refers to the backward flow of urine from the bladder into one or both ureters (Fig. 46-1). Normally, the ureterovesical junction prevents urine from travelling back into the ureter. The ureters tunnel into the bladder wall so that the bladder musculature compresses a small portion of the ureter


Management of Patients With Urinary Disorders


Routes of Infection





There are three well-recognized routes by which bacteria enter the urinary tract: up the urethra (ascending infection), through the bloodstream (hematogenous spread), or by means of a fistula from the intestine (direct extension). The most common route of infection is transurethral, in which bacteria (often from fecal contamination) colonize the periurethral area and subsequently enter the bladder by means of the urethra. In women, the short urethra offers little resistance to the movement of uropathogenic bacteria (Hannon, Pooler, & Porth, 2010). Sexual intercourse or massage of the urethra forces the bacteria up into the bladder. This accounts for the increased incidence of UTIs in sexually active women. Bacteria may also enter the urinary tract by means of the blood (hematogenous spread) from a distant site of infection or through direct extension by way of a fistula from the intestinal tract.

Clinical Manifestations FIGURE 46-1. Mechanisms of urethrovesical and ureterovesical reflux

may cause urinary tract infection. Urethrovesical reflux: With coughing and straining, bladder pressure rises, which may force urine from the bladder into the urethra. A: When bladder pressure returns to normal, the urine flows back to the bladder (B), which introduces bacteria from the urethra to the bladder. Ureterovesical reflux: With failure of the ureterovesical valve, urine moves up the ureters during voiding (C) and flows into the bladder when voiding stops (D). This prevents complete emptying of the bladder. It also leads to urinary stasis and contamination of the ureters with bacteria-laden urine.

during normal voiding. When the ureterovesical valve is impaired by congenital causes or ureteral abnormalities, the bacteria may reach the kidneys and eventually destroy them (Hannon, Pooler, & Porth, 2010).

Uropathogenic Bacteria Bacteriuria is generally defined as more than 105 colonies of bacteria per millilitre of urine. Since urine samples (especially in women) are commonly contaminated by the bacteria normally present in the urethral area, a bacterial count exceeding 105 colonies/mL of clean-catch midstream urine is the measure that distinguishes true bacteriuria from contamination. In men, contamination of the collected urine sample occurs less frequently; hence, bacteriuria can be defined as 104 colonies/mL urine. Community-acquired UTIs are among the most common bacterial infections in women (Hannon, Pooler, & Porth, 2010). The organisms most frequently responsible for UTIs are those normally found in the lower gastrointestinal (GI) tract. In a large-scale study of the types and prevalence of organisms of patients with UTIs in both the community and hospital setting, E. coli was responsible for 54.7% of UTIs. Isolation of E. coli is decreasing in comparison to previous observations, especially in males and in patients with indwelling bladder catheters, who instead had higher rates of Pseudomonas and Enterococcus organisms than females and noncatheterized patients (Hannon, Pooler, & Porth, 2010).

A variety of signs and symptoms are associated with UTI. About half of all patients with bacteriuria have no symptoms. Signs and symptoms of uncomplicated lower UTI (cystitis) include frequent pain and burning on urination, frequency, urgency, nocturia, incontinence, and suprapubic or pelvic pain. Hematuria and back pain may also be present (Stephen, Skillen, Day, et al., 2010). In older individuals, these symptoms are less common (see Gerontologic Considerations). Signs and symptoms of upper UTI (pyelonephritis) include fever, chills, flank or low back pain, nausea and vomiting, headache, malaise, and painful urination. Physical examination for tenderness begins by palpating with the fingertips over the area of the costovertebral angles, which are the angles formed on each side of the body by the bottom rib of the rib cage and the vertebral column (see Fig. 44-6 in Chapter 44). This will be enough pressure to detect tenderness or pain in some patients. If no pain is elicited, the examiner places the ball of one hand over each costovertebral angle in turn and strikes that hand with the ulnar side of the other fist, hard enough to jar the patient. In patients with complicated UTIs, such as those with indwelling catheters, manifestations can range from asymptomatic bacteriuria to a gram-negative sepsis with shock. Complicated UTIs are often due to a broader spectrum of organisms, have a lower response rate to treatment, and tend to recur. Many patients with catheter-associated UTIs are asymptomatic; however, any patient who suddenly develops signs and symptoms of septic shock should be evaluated for urosepsis.

Gerontologic Considerations The incidence of bacteriuria in the older adult differs from that in younger adults. Bacteriuria increases with age and disability, and women are affected more frequently than men. UTI is the most common cause of acute bacterial sepsis in patients older than 65 years of age, in whom gram-negative sepsis carries a mortality rate exceeding 50%. Urologists see many asymptomatic older patients



Urinary Tract Function

with bacteriuria, and these individuals represent 20% of women over the age of 65 years. In the nursing home environment, up to 50% of women have asymptomatic bacteriuria (Goldrick, 2005). In the older adult population at large, structural abnormalities secondary to decreased bladder tone and neurogenic bladder (dysfunctional bladder) secondary to stroke or autonomic neuropathy of diabetes may prevent complete emptying of the bladder and increase the risk for UTI (Morton, Fontaine, Hudak, et al., 2005). When indwelling catheters are used, the risk for UTI increases dramatically. Older adult women often have incomplete emptying of the bladder and urinary stasis. In the absence of estrogen, following menopause, women are susceptible to colonization and increased adherence of bacteria to the vagina and urethra. Oral or topical estrogen has been used to restore the glycogen content of vaginal epithelial cells and an acidic pH for some of these women with recurrent cystitis. The antibacterial activity of prostatic secretions that protects men from bacterial colonization of the urethra and bladder decreases with aging. Although UTIs are rare in men, the prevalence of infection in men older than 50 years of age approaches that of women in the same age group. The dramatic rise in UTI in men as they age is due largely to prostatic hyperplasia or carcinoma, strictures of the urethra, and neuropathic bladder. The use of catheterization or cystoscopy in evaluation or treatment may contribute further to the higher incidence of UTI. The incidence of bacteriuria rises in men with confusion, dementia, or bowel or bladder incontinence. The most common cause of recurrent UTI in the older male patient is chronic bacterial prostatitis. Resection of the prostate gland may help to reduce its incidence (see Chapter 50). In older patients in institutions, such as those in longterm care facilities, infecting pathogens are often resistant to many antibiotics. Factors that may contribute to UTI include high incidence of chronic illness; frequent use of antimicrobial agents; infected pressure ulcers; immobility and incomplete emptying of the bladder; and use of a bedpan rather than a commode or toilet (Chart 46-3). Diligent hand hygiene, careful perineal care, and frequent toileting may decrease the incidence of UTIs. The organisms responsible for UTIs in the older adult in longterm care facilities may differ from those found in patients residing in the community; this is thought to be due in

CHART 46-3

Gerontologic Considerations Factors That Contribute to Urinary Tract Infection in Older Adults • • • • • • •

High incidence of chronic illness Frequent use of antimicrobial agents Presence of infected pressure ulcers Immunocompromise Cognitive impairment Immobility and incomplete emptying of bladder Use of a bedpan rather than a commode or toilet

part to the frequent use of antibiotic agents by patients in these facilities. E. coli is the most common organism seen in older patients in the community or hospital. Patients with indwelling catheters, however, are more likely to be infected with Proteus, Klebsiella, Pseudomonas, or Staphylococcus sp. Patients who have been previously treated with antibiotics may be infected with Enterococcus sp. Frequent reinfections are common in older adults. The most common subjective presenting symptom of UTI in older adults is generalized fatigue. The most common objective finding is a change in cognitive functioning, especially in those with dementia, because these patients usually exhibit even more profound cognitive changes with the onset of a UTI. Controversy continues about the need for treatment of asymptomatic bacteriuria in older patients in long-term care facilities, because resulting antibiotic-resistant organisms and sepsis may be greater threats to patients. Most experts now recommend withholding antibiotics unless symptoms develop. However, treatment regimens are generally the same as those for younger adults, although age-related changes in the intestinal absorption of medications and decreased renal function and hepatic flow may necessitate alterations in the antimicrobial regimen. Renal function must be monitored, and medication dosages should be altered accordingly.



Older adult patients often lack the typical symptoms of UTI and sepsis. Although frequency, urgency, and dysuria may occur, nonspecific symptoms, such as altered sensorium, lethargy, anorexia, new incontinence, hyperventilation, and low-grade fever, may be the only clues.

Assessment and Diagnostic Findings Results of various tests, such as colony counts, cellular studies, and urine cultures, help to confirm the diagnosis of UTI. Pregnant women are generally screened for asymptomatic bacteriuria because the bladder may not empty as well as it usually does. In an uncomplicated UTI, the strain of bacteria will determine the antibiotic of choice.

Colony Counts UTI is diagnosed by bacteria in the urine. A colony count of at least 105 colony-forming units (CFU) per millilitre of urine on a clean-catch midstream or catheterized specimen is a major criterion for infection (Hannon, Pooler, & Porth, 2010). However, UTI and subsequent sepsis have occurred with lower bacterial colony counts. About one third of women with symptoms of acute infections have negative midstream urine culture results and may go untreated if 105 CFU/mL is used as the criterion for infection. The presence of any bacteria in specimens obtained by suprapubic needle aspiration of the urinary bladder or catheterization is considered indicative of infection.


The following groups of patients should have urine cultures obtained when bacteriuria is present: • All men (because of the likelihood of structural or functional abnormalities) • All children • Women with a history of compromised immune function or renal problems • Patients with diabetes mellitus • Patients who have undergone recent instrumentation (including catheterization) of the urinary tract • Patients who were recently hospitalized or who live in long-term care facilities • Patients with prolonged or persistent symptoms • Patients with three or more UTIs in the past year • Pregnant women • Women following menopause • Women who are sexually active or have new sexual partners

Cellular Studies Microscopic hematuria (greater than 4 red blood cells [RBCs] per high-power field) is present in about half of patients with acute infection. Pyuria (greater than 4 white blood cells [WBCs] per high-power field) occurs in all patients with UTI; however, it is not specific for bacterial infection. Pyuria can also be seen with kidney stones, interstitial nephritis, and renal tuberculosis.

Urine Cultures Urine cultures remain the gold standard in documenting a UTI and can identify the specific organism present. Due to the high probability that the organism in young women with their first UTI is E. coli, cultures are often omitted.

Testing Methods Multistrip dipstick testing for WBCs, known as the leukocyte esterase test, and nitrite testing (nitrate reduction test) are common. If the leukocyte esterase test is positive, it is assumed that the patient has pyuria (WBCs in the urine) and should be treated. The nitrate reduction test is considered positive if bacteria that reduce normal urinary nitrates to nitrites are present. Tests for sexually transmitted infections (STIs) may be performed because acute urethritis caused by sexually transmitted organisms (i.e., Chlamydia trachomatis, Neisseria gonorrhoeae, herpes simplex) or acute vaginitis infections (caused by Trichomonas or Candida sp.) may be responsible for symptoms similar to those of UTI. Therefore, evaluation for STIs may be performed (see Chapter 71). Diagnostic studies such as computed tomography (CT) and ultrasonography are useful diagnostic tools. A CT scan may detect pyelonephritis or abscesses, and ultrasonography is extremely sensitive for detecting obstruction, abscesses, tumours, and cysts. Transrectal ultrasonography (to assess the prostate and bladder) is the procedure of choice for men with recurrent or complicated UTIs. A cystourethroscopy may be indicated to visualize the ureters or to detect strictures, calculi, or tumours (Karpoff & Labus, 2008).

Management of Patients With Urinary Disorders


Medical Management Management of UTIs typically involves pharmacologic therapy and patient education. The nurse is a key figure in teaching the patient about medication regimens and infection prevention measures.

Acute Pharmacologic Therapy The ideal treatment of UTI is an antibacterial agent that eradicates bacteria from the urinary tract with minimal effects on fecal and vaginal flora, thereby minimizing the incidence of vaginal yeast infections. (Yeast vaginitis occurs in as many as 25% of patients treated with antimicrobial agents that affect vaginal flora. Yeast vaginitis often causes more symptoms and is more difficult and costly to treat than the original UTI.) In addition, the antibacterial agent should be affordable and should produce few adverse effects and low resistance. Since the organism in initial, uncomplicated UTIs in women is most likely E. coli or other fecal flora, the agent should be effective against these organisms. Various treatment regimens have been successful in treating uncomplicated lower UTIs in women: single-dose administration, short-course (3 to 4 days) medication regimens, or 7- to 10-day therapeutic courses. The trend is toward a shortened course of antibiotic therapy for uncomplicated UTIs because most are cured after 3 days of treatment. In a complicated UTI (i.e., pyelonephritis), the general treatment of choice is usually a cephalosporin or an ampicillin/aminoglycoside combination. Patients in institutional settings may require 7 to 10 days of medication for the treatment to be effective. Other commonly used medications include trimethoprim/sulfamethoxazole (TMPSMZ, Bactrim, Septra) and nitrofurantoin (Macrodantin, Furantoin). Occasionally, medications such as ampicillin or amoxicillin are used, but E. coli organisms have developed resistance to these agents. Because of the problem of resistance, the fluoroquinolone ciprofloxacin (Cipro) is often used as a first-line agent (Mehnert-Kay, 2005). Nitrofurantoin should not be used in patients with renal insufficiency because it is ineffective at glomerular filtration rates (GFRs) of less than 50 mL/minute and may cause peripheral neuropathy. A urinary analgesic, may be prescribed to relieve the discomfort associated with the infection. Regardless of the regimen prescribed, the patient is instructed to take all the doses prescribed, even if relief of symptoms occurs promptly. Longer medication courses are indicated for men, pregnant women, and women with pyelonephritis and other types of complicated UTIs. Hospitalization and intravenous (IV) antibiotics are occasionally needed.

Long-Term Pharmacologic Therapy Although brief pharmacologic treatment of UTI for 3 days is usually adequate in women, infection recurs in about 20% of women treated for uncomplicated UTI. Infections that recur within 2 weeks after therapy (referred to as a relapse) do so because organisms of the original offending strain remain in the vagina. Relapses suggest that the source of bacteriuria may be the upper urinary tract or that initial treatment was inadequate or administered for



Urinary Tract Function

too short a time. Recurrent infections in men are usually due to persistence of the same organism; further evaluation and treatment are indicated. Reinfection of the female patient with new bacteria is the reason for more than 90% of recurrent UTIs in women. If the diagnostic evaluation reveals no structural abnormalities in the urinary tract, the woman with recurrent UTIs may be instructed to begin treatment on her own whenever symptoms occur and to contact the health care provider only when symptoms persist, fever occurs, or the number of treatment episodes exceeds four in a 6-month period. The patient may be taught to use dip-slide culture devices to detect bacteria. If infection recurs after completing antimicrobial therapy, another short course (3 to 4 days) of full-dose antimicrobial therapy followed by a regular bedtime dose of an antimicrobial agent may be prescribed. If there is no recurrence, medication is taken every other night for 6 to 7 months. Other options include a dose of an antimicrobial agent after sexual intercourse, a dose at bedtime, or a dose every other night or three times per week. Longterm use of antimicrobial agents decreases the risk of reinfection and may be indicated in patients with recurrent infections. If recurrence is caused by persistent bacteria from preceding infections, the cause (i.e., kidney stone, abscess), if known, must be treated. After treatment and sterilization of the urine, low-dose preventive therapy (trimethoprim with or without sulfamethoxazole) each night at bedtime is often prescribed. Studies suggest that the regular use of Cranberry juice or blueberry juice reduces bacterial adherence to the epithelial lining of the urinary tract thus acting as a prevention rather than treatment of UTI’s (Hannon, Pooler, & Porth, 2010). !!"##

Nursing Process

The Patient With Lower Urinary Tract Infection Nursing care of the patient with lower UTI focuses on treating the underlying infection and preventing its recurrence.

Assessment A history of signs and symptoms related to UTI is obtained from the patient with a suspected UTI. The presence of pain, frequency, urgency, and hesitancy and changes in urine are assessed, documented, and reported. The patient’s usual pattern of voiding is assessed to detect factors that may predispose him or her to UTI. Infrequent emptying of the bladder, the association of symptoms of UTI with sexual intercourse, contraceptive practices, and personal hygiene are assessed. The patient’s knowledge about prescribed antimicrobial medications and preventive health care measures is also assessed. In addition,

the urine is assessed for volume, colour, concentration, cloudiness, and odour, all of which are altered by bacteria in the urinary tract.

Diagnosis Nursing Diagnoses Based on assessment data, the nursing diagnoses may include the following: • Acute pain related to inflammation and infection of the urethra, bladder, and other urinary tract structures • Deficient knowledge related to factors predisposing the patient to infection and recurrence, detection and prevention of recurrence, and pharmacologic therapy

Collaborative Problems/ Potential Complications Based on assessment data, the following complications may develop: • Sepsis • Renal failure, which may occur as the long-term result of either an extensive infective or inflammatory process.

Planning and Goals Major goals for the patient may include relief of pain and discomfort, increased knowledge of preventive measures and treatment modalities, and absence of complications.

Nursing Interventions Relieving Pain The pain associated with UTI is quickly relieved once effective antimicrobial therapy is initiated. Antispasmodic agents may also be useful in relieving bladder irritability and pain. Aspirin and applying heat to the perineum help to relieve pain and spasm. The patient is encouraged to drink liberal amounts of fluids (water is the best choice) in order to promote renal blood flow and to flush the bacteria from the urinary tract. Urinary tract irritants (e.g., coffee, tea, citrus, spices, colas, alcohol) are avoided. Frequent voiding (every 2 to 3 hours) is encouraged to empty the bladder completely, as this can significantly lower urine bacterial counts, reduce urinary stasis, and prevent reinfection.

Monitoring and Managing Potential Complications Early recognition of UTI and prompt treatment are essential to prevent recurrent infection and the possibility of complications, such as renal failure, sepsis (urosepsis), strictures, and obstructions. The goal of


treatment is to prevent infection from progressing and causing permanent renal damage and renal failure. Thus, the patient must be taught to recognize early signs and symptoms, to test for bacteriuria, and to initiate treatment as prescribed. Appropriate antimicrobial therapy, liberal fluid intake, frequent voiding, and hygienic measures are commonly prescribed for managing UTI. The patient is instructed to notify the physician if fatigue, nausea, vomiting, or pruritus occurs. Periodic monitoring of renal function (creatinine clearance, blood urea nitrogen [BUN], and serum creatinine levels) and evaluation for strictures, obstructions, or stones may be indicated for patients with recurrent UTIs. Patients with UTI, especially catheter-associated infection, are at increased risk for gram-negative sepsis. Indwelling catheters should be avoided, if possible, and removed at the earliest opportunity. If an indwelling catheter is necessary, however, specific nursing interventions are initiated to prevent infection and urosepsis:

Management of Patients With Urinary Disorders


to the physician. At the same time, appropriate antibiotic therapy and increased fluid intake are prescribed (IV antibiotic therapy and fluids may be required). Aggressive early treatment is the key to reducing the mortality rate associated with gram-negative sepsis, especially in older patients.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE. In helping patients learn about and prevent or manage a recurrent UTI, the nurse needs to implement teaching that meets individual patient needs. Health-related behaviours that help to prevent recurrent UTIs include practicing careful personal hygiene, increasing fluid intake to promote voiding and dilution of urine, urinating regularly and more frequently, and adhering to the therapeutic regime. For a detailed discussion of patient teaching interventions, refer to Chart 46-4.


• Using strict aseptic technique during insertion of the smallest catheter possible • Securing the catheter with tape to prevent movement • Frequently inspecting urine colour, odour, and consistency • Performing meticulous daily perineal care with soap and water • Maintaining a closed system • Following the manufacturer’s instructions when using the catheter port to obtain urine specimens

Expected Patient Outcomes Expected patient outcomes may include the following: 1. Experiences relief of pain a. Reports absence of pain, urgency, dysuria, nocturia, or hesitancy on voiding b. Takes analgesic and antibiotic agents as prescribed 2. Explains UTIs and their treatment a. Demonstrates knowledge of preventive measures and prescribed treatments b. Drinks eight to ten glasses of fluids daily c. Voids every 2 to 3 hours d. Voids urine that is clear and odourless

Careful assessment of vital signs and level of consciousness may alert the nurse to kidney involvement or impending sepsis. Blood cultures that are positive for infection and elevated WBC counts are reported

CHART 46-4

Patient Education: Preventing Recurrent Urinary Tract Infections Hygiene • Shower rather than bathe in tub because bacteria in the bathwater may enter the urethra. • After each bowel movement, clean the perineum and urethral meatus from front to back. This will help to reduce concentrations of pathogens at the urethral opening and, in women, the vaginal opening. Fluid Intake

• Drink liberal amounts of fluids daily to flush out bacteria. • Avoid coffee, tea, colas, alcohol, and other fluids that are urinary tract irritants.

Voiding Habits • Void every 2 to 3 hours during the day, and completely empty the bladder. This prevents overdistention of the bladder and compromised blood supply to the bladder wall. Both predispose the patient to urinary tract infection. Pre-

cautions expressly for women include voiding immediately after sexual intercourse. Therapy

• Take medication exactly as prescribed. • If bacteria continue to appear in the urine, long-term anti• • • • •

microbial therapy may be required to prevent colonization of the periurethral area and recurrence of infection. Special timing of administration may be required. For recurrent infection, consider acidification of the urine through ascorbic acid (vitamin C), 1,000 mg daily, or cranberry juice. If prescribed, test urine for presence of bacteria following manufacturer and health care provider’s instructions. Notify the primary health care provider if fever occurs or if signs and symptoms persist. Consult the primary health care provider regularly for follow-up.



Urinary Tract Function

3. Experiences no complications a. Reports no symptoms of infection (fever, dysuria, frequency) or renal failure (nausea, vomiting, fatigue, pruritus) b. Has normal BUN and serum creatinine levels; negative urine and blood cultures c. Exhibits normal vital signs and temperature; no signs or symptoms of sepsis (urosepsis) d. Maintains adequate urine output of more than 30 mL/hour

Upper Urinary Tract Infection: Acute Pyelonephritis Pyelonephritis is a bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys. Causes involve either the upward spread of bacteria from the bladder or spread from systemic sources reaching the kidney via the bloodstream. It is not uncommon for bacteria that are causing a bladder infection to ascend into the kidney, causing pyelonephritis. An incompetent ureterovesical valve or obstruction occurring in the urinary tract increases the susceptibility of the kidneys to infection (see Fig. 46-1), because static urine provides a good medium for bacterial growth. Bladder tumours, strictures, benign prostatic hyperplasia, and urinary stones are some potential causes of obstruction that can lead to infections. Systemic infections (such as tuberculosis) can spread to the kidneys and result in abscesses. Pyelonephritis may be acute or chronic. Acute pyelonephritis is an infection of the renal parenchyma and renal pelvis. It is usually manifested by enlarged kidneys with interstitial infiltrations of inflammatory cells. Abscesses may be noted on the renal capsule and at the corticomedullary junction. Eventually, atrophy and destruction of tubules and the glomeruli may result. When pyelonephritis becomes chronic, there is scarring and deformation of the renal calyces and pelvis. The most common cause of chronic pyelonephritis is reflux involving either a single kidney or both, with the eventual development of chronic renal insufficiency (Hannon, Pooler, & Porth, 2010).

Acute Pyelonephritis Clinical Manifestations The patient with acute pyelonephritis is acutely ill with chills, fever, leukocytosis, bacteriuria, and pyuria. Low back pain, flank pain, nausea and vomiting, headache, malaise, and painful urination are common findings. Physical examination reveals pain and tenderness in the area of the costovertebral angle (see Fig. 44-6 in Chapter 44). In addition, symptoms of lower urinary tract involvement, such as dysuria and frequency, are common.

Assessment and Diagnostic Findings An ultrasound study or a CT scan may be performed to locate any obstruction in the urinary tract. Relief of

obstruction is essential to save the kidney from destruction. An IVP is rarely indicated during acute pyelonephritis because findings are normal in up to 75% of patients. Radionuclide imaging with gallium citrate and Indium-111 labelled WBCs may be useful to identify sites of infection that may not be visualized on CT scan or ultrasound. Urine culture and sensitivity tests are performed to determine the causative organism so that appropriate antimicrobial agents can be prescribed.

Medical Management Patients with acute uncomplicated pyelonephritis are most often treated on an outpatient basis if they are not exhibiting dehydration, nausea or vomiting, or symptoms of sepsis. In addition, they must be responsible and reliable to ensure that all medications are taken as prescribed. Other patients, including all pregnant women, may be hospitalized for at least 2 or 3 days of parenteral therapy. Oral agents may be substituted once the patient is afebrile and showing clinical improvement.

Pharmacologic Therapy Antibiotic therapy is longer for pyelonephritis (7–14 days) than cystis (1 dose -7 days) because renal parenchymal infection is more difficult to eradicate than mucosal bladder infections. Increased resistance to E. coli, the primary causative bacteria in pyelonephritis, has changed the treatment options and monitoring required for this infection. An oral third-generation cephalosporin drug (i.e., cefixime) is now the drug of choice for the treatment of uncomplicated pyelonephritis (Blondel-Hill & Fryters, 2012). Other agents such as TMP-SMZ, ciprofloxacin, and amoxicillin-clavulanate may be used, however; pre-treatment urine cultures should be collected to detect any drug resistance (BaudrySimner, Singh, Karlowsky, et al., 2012; Blondel-Hill & Fryters, 2012). Intravenous third-generation cephalosporin agents (i.e., ceftriaxone) or gentamicin are used, as first line and second line therapies respectively, in pregnant patients or those with severe disease. Oral antibiotic agents, tailored to urine culture and sensitivity results, may be prescribed once the patient is afebrile and showing clinical improvement. A possible issue in acute pyelonephritis treatment is a chronic or recurring symptomless infection persisting for months or years. After the initial antibiotic regimen, the patient may need antibiotic therapy for up to 6 weeks if evidence of a relapse is seen. A follow-up urine culture is obtained 2 weeks after completion of antibiotic therapy to document clearing of the infection. Similarly, monthly urine cultures following pyelonephritis are recommended in pregnant females for the duration of their pregnancy (Blondel-Hill & Fryters, 2012).

Upper Urinary Tract Infection: Chronic Pyelonephritis Repeated bouts of acute pyelonephritis may lead to chronic pyelonephritis.


Clinical Manifestations The patient with chronic pyelonephritis usually has no symptoms of infection unless an acute exacerbation occurs. Noticeable signs and symptoms may include fatigue, headache, poor appetite, polyuria, excessive thirst, and weight loss. Persistent and recurring infection may produce progressive scarring of the kidney resulting in renal failure (see Chapter 45).

Assessment and Diagnostic Findings The extent of the disease is assessed by an IV urogram and measurements of creatinine clearance, blood urea nitrogenand creatinine levels. Bacteria, if detected in the urine, are eradicated, if possible.

Complications Complications of chronic pyelonephritis include endstage renal disease (from progressive loss of nephrons secondary to chronic inflammation and scarring), hypertension, and formation of kidney stones (from chronic infection with urea-splitting organisms).

Medical Management Long-term use of prophylactic antimicrobial therapy may help to limit recurrence of infections and renal scarring (Wein, Kavoussi, Novick, et al., 2007). Impaired renal function alters the excretion of antimicrobial agents and neces-

TABLE 46-1

Neurogenic Disorders Cerebellar ataxia Cerebrovascular accident Dementia Diabetes mellitus

Multiple sclerosis Parkinson’s disease Spinal Cord Dysfunction Acute injury Degenerative disease Nonneurogenic Disorders “Bashful bladder”

Post general surgery Post prostatectomy

Stress incontinence

Management of Patients With Urinary Disorders


sitates careful monitoring of renal function, especially if the medications are potentially toxic to the kidneys.

Nursing Management The patient may require hospitalization or may be treated as an outpatient. When the patient is hospitalized, fluid intake and output are carefully measured and recorded. Unless contraindicated, fluids are encouraged (3 to 4 L/day) to dilute the urine, decrease burning on urination, and prevent dehydration. The patient’s temperature is assessed every 4 hours and antipyretic and antibiotic agents are administered as prescribed. Often, the patient is more comfortable on bed rest during the acute phase of the illness. Patient teaching focuses on prevention of UTIs by consuming adequate fluids, emptying the bladder regularly, and performing recommended perineal hygiene. The importance of taking antimicrobial medications exactly as prescribed is stressed to the patient, as is the need for keeping follow-up appointments.

ADULT VOIDING DYSFUNCTION Both neurogenic and non-neurogenic disorders can cause adult voiding dysfunction (Table 46-1). The micturition (voiding or urination) process involves several highly coordinated neurologic responses that mediate bladder function. A functional urinary system allows for appropriate bladder filling and complete bladder emptying (see Chapter 44). If voiding dysfunction goes undetected and untreated, the upper urinary system may be compromised.

Conditions Causing Adult Voiding Dysfunction


Overactive bladder

Voiding Dysfunction


Incontinence or dyssynergia Retention or incontinence Incontinence Incontinence and/or incomplete bladder emptying

Timed voiding; anticholinergics Anticholinergics; bladder retraining Prompted voiding; anticholinergics Timed voiding; electromyography (EMG)/biofeedback; pelvic floor nerve stimulation; anticholinergics/antispasmodics; well-controlled blood glucose levels Timed voiding; EMG/biofeedback to learn pelvic muscle exercises and urge inhibition; pelvic floor nerve stimulation; antispasmodics Anticholinergics/antispasmodics

Incontinence or incomplete bladder emptying Incontinence Urinary retention Incontinence and/or incomplete bladder emptying

Indwelling catheter EMG/biofeedback; pelvic floor nerve stimulation; anticholinergics

Inability to initiate voiding in public bathrooms Urgency, frequency, and/or urge incontinence Acute urine retention Incontinence

Relaxation therapy; EMG/biofeedback

Incontinence with cough, laugh, sneeze, and/or position change

EMG/biofeedback; pelvic floor nerve stimulation; bladder drill (see Chart 46-7); anticholinergics Catheterization Mild: Biofeedback; bladder drill (see Chart 46-7); pelvic floor nerve stimulation Moderate/Severe: Surgery—artificial sphincter Mild: Biofeedback: bladder drill (see Chart 46-7); periurethral bulking with collagen Moderate/Severe: Surgery



Urinary Tract Function

Chronic incomplete bladder emptying from poor detrusor pressure results in recurrent bladder infection. Incomplete bladder emptying due to bladder outlet obstruction (such as benign prostatic hyperplasia), causing high-pressure detrusor contractions, can result in hydronephrosis from the high detrusor pressure that radiates up the ureters to the renal pelvis.

Urinary Incontinence It is estimated that as many as 3.3 million Canadians have urinary incontinence in some form (Canadian Continence Foundation, 2014). Despite widespread media coverage, urinary incontinence remains underdiagnosed and underreported. Patients may be too embarrassed to seek help, causing them to ignore or conceal symptoms. Many patients resort to using absorbent pads or other devices without having their condition properly diagnosed and treated. Health care providers must be alert to subtle cues of urinary incontinence and stay informed about current management strategies (Newman, 2003). The costs of care for patients with urinary incontinence include cost of absorbent products, medications, and surgical or nonsurgical treatment modalities as well as the psychosocial costs of urinary incontinence. These include embarrassment, loss of self-esteem, and social isolation. Urinary incontinence affects people of all ages but is particularly common among the older adult; it can decrease their ability to maintain an independent lifestyle. This increases dependence on caregivers and may lead to institutionalization. More than half of all residents of long-term care have urinary incontinence. Although urinary incontinence is not a normal consequence of aging, age-related changes in the urinary tract predispose the older person to incontinence. Although urinary incontinence is commonly regarded as a condition that occurs in older multiparous women, it is also common in young nulliparous women, especially during vigourous high-impact activity. Age, gender, and number of vaginal deliveries are established risk factors (Chart 46-5); they explain, in part, the increased incidence

CHART 46-5

Risk Factors for Urinary Incontinence • • • • • • • • • • • • • •

Pregnancy: vaginal delivery, episiotomy Menopause Genitourinary surgery Pelvic muscle weakness Incompetent urethra due to trauma or sphincter relaxation Immobility High-impact exercise Diabetes mellitus Stroke Age-related changes in the urinary tract Morbid obesity Cognitive disturbances: dementia, Parkinson’s disease Medications: diuretics, sedatives, hypnotics, opioids Caregiver or toilet unavailable

in women. Urinary incontinence is a symptom of many possible disorders.

Types of Incontinence Stress incontinence is the involuntary loss of urine through an intact urethra as a result of sneezing, coughing, or changing position (Miller, 2011). It predominantly affects women who have had vaginal deliveries and is thought to be the result of decreasing ligament and pelvic floor support of the urethra and decreasing or absent estrogen levels within the urethral walls and bladder base. In men, stress incontinence is often experienced after a radical prostatectomy for prostate cancer primarily as a result of intrinsic sphincter deficiency that can coexist with new or recurring detrusor over activity (Hunter, Moore, & Glazener, 2007). Urge incontinence is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed. The patient is aware of the need to void but is unable to reach a toilet in time (Miller, 2011). An uninhibited detrusor contraction is the precipitating factor. This can occur in a patient with neurologic dysfunction that impairs inhibition of bladder contraction or in a patient without overt neurologic dysfunction. Reflex incontinence is the involuntary loss of urine due to hyperreflexia in the absence of normal sensations usually associated with voiding. This commonly occurs in patients with spinal cord injury because they have neither neurologically mediated motor control of the detrusor nor sensory awareness of the need to void (see chapter 64). Reduced urethral function or overactivity/low bladder compliance is the involuntary loss of urine that occurs when intravesical pressure exceeds maximal urtethral pressure. This occurs because of bladder distension in the absence of detrusor activity (Hannon, Pooler, C & Porth, 2010). Such over distention results from the bladder’s inability to empty normally, despite frequent urine loss. Both neurologic abnormalities (e.g., spinal cord lesions) and factors that obstruct the outflow of urine (e.g., tumours, strictures, and prostatic hyperplasia) can cause overflow incontinence (Muller, 2005). Functional incontinence refers to those instances in which lower urinary tract function is intact but other factors, such as severe cognitive impairment (e.g., Alzheimer’s dementia), make it difficult for the patient to identify the need to void or physical impairments make it difficult or impossible for the patient to reach the toilet in time for voiding. Iatrogenic incontinence refers to the involuntary loss of urine due to extrinsic medical factors, predominantly medications. One such example is the use of alphaadrenergic agents to decrease blood pressure. In some people with an intact urinary system, these agents adversely affect the alpha receptors responsible for bladder neck closing pressure; the bladder neck relaxes to the point of incontinence with a minimal increase in intraabdominal pressure, thus mimicking stress incontinence. As soon as the medication is discontinued, the apparent incontinence resolves. Mixed urinary incontinence which encompasses several types of urinary incontinence, is involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing (Miller, 2011).


Only with appropriate recognition of the problem, assessment, and referral for diagnostic evaluation and treatment can the outcome of incontinence be determined. All people with incontinence should be considered for evaluation and treatment.

Gerontologic Considerations If nurses and other health care providers accept incontinence as an inevitable part of illness or aging or consider it irreversible and untreatable, it cannot be treated successfully. Collaborative, interdisciplinary efforts are essential in assessing and effectively treating urinary incontinence (Specht, 2005). Many older people experience transient episodes of incontinence that tend to be abrupt in onset. When this occurs, the nurse should question the patient, as well as the family if possible, about the onset of symptoms and any signs or symptoms of a change in other organ systems. Acute UTI, infection elsewhere in the body, constipation, decreased fluid intake, or a change in a chronic disease pattern, such as elevated blood glucose levels in patients with diabetes or decreased estrogen levels in menopausal women, can provoke the onset of urinary incontinence. If the cause is identified and modified or eliminated early at the onset of incontinence, the incontinence itself may be eliminated. Although the bladder of the older person is more vulnerable to altered detrusor activity, age alone is not a risk factor for urinary incontinence (Vinsnes, Harkless, & Nyronning, 2007). Decreased bladder muscle tone is a normal age-related change found in the older adult. This leads to decreased bladder capacity, increased residual urine, and an increase in urgency (Miller, 2011). Many medications affect urinary continence in addition to causing other unwanted or unexpected effects. All medications need to be assessed for potential interactions.

Assessment and Diagnostic Findings Once incontinence is recognized, a thorough history is necessary. This includes a detailed description of the problem and a history of medication use. The patient’s voiding history, a diary of fluid intake and output, and bedside tests (e.g., residual urine, stress manoeuvres) may be used to help determine the type of urinary incontinence involved. Extensive urodynamic tests may be performed (see Chapter 44). Urinalysis and urine culture are performed to identify infection. Urinary incontinence may be transient or reversible if the underlying cause is successfully treated and the voiding pattern reverts to normal (Chart 46-6).

Medical Management Management depends on the type of urinary incontinence and its causes. Management of urinary incontinence may be behavioural, pharmacologic, or surgical.

Behavioural Therapy Behavioural therapies are the first choice to decrease or eliminate urinary incontinence (Chart 46-7). In using

Management of Patients With Urinary Disorders


CHART 46-6

Causes of Transient Incontinence: DIAPPERS Delirium Infection of urinary tract Atrophic vaginitis, urethritis Pharmacologic agents (anticholinergics, sedatives, alcohol, analgesics, diuretics, muscle relaxants, adrenergic agents) Psychological factors (depression, regression) Excessive urine production (increased intake, diabetes insipidus, diabetic ketoacidosis) Restricted activity Stool impaction

these techniques, health care professionals help patients avoid potential adverse effects of pharmacologic or surgical interventions. Pelvic floor muscle exercises (sometimes called Kegel exercises) represent the cornerstone of behavioural intervention for addressing symptoms of stress, urge, and mixed incontinence. Other behavioural treatments include use of a voiding diary, biofeedback, verbal instruction (prompted voiding), and physical therapy (Miller, 2011). Pessaries can be used as an additional conservative treatment for women with stress urinary incontinence or obstruction related to pelvic organ prolapse.

Pharmacologic Therapy Pharmacologic therapy works best when used as an adjunct to behavioural interventions. Bladder-specific anticholinergic agents (e.g., oxybutynin [Ditropan], tolterodine [Detrol], trospium [Trosec]) inhibit bladder contraction and are considered first-line medications for urge incontinence in Canada (Canadian Continence Foundation, 2014). Several tricyclic antidepressant medications (e.g., amitriptyline) can also decrease bladder contractions but have high anticholinergic side effects, so they should be avoided in older adults. Hormone therapy (e.g., estrogen) taken orally, transdermally, or topically was once the treatment of choice for urinary incontinence in postmenopausal women. Estrogen is believed to decrease obstruction to urine flow by restoring the mucosal, vascular, and muscular integrity of the urethra. The use of oral estrogen is now avoided as it is associated with worsening incontinence (Robinson & Cardozo, 2011). Topical intravaginal estrogen, however, is associated with one to two fewer voids per day and decreased urinary frequency (Cody, Jacobs, Richardson, et al., 2012). Few studies have investigated the use of Duloxetine for the treatment of stress urinary incontinence. Initial results show some clinical effectiveness in reducing the number of incontinent episodes; however, drug tolerability and thus drug adherence is low (Davila, 2011; Li, Chunxiao, Tang, 2013). Although previously only used for the treatment neurogenic urge incontinence (multiple sclerosis, spinal cord injury), Canadian researchers have found a clinical reduction in urinary urge incontinence by injecting botulinum



Urinary Tract Function

CHART 46-7

Behavioural Interventions for Urinary Incontinence Behavioural strategies are largely carried out, coordinated, and monitored by the nurse. These interventions may or may not be augmented by the use of medications.

Fluid Management One of the most common approaches is fluid management because adequate daily fluid intake of approximately 1,500 to 1,600 mL, taken as small increments between breakfast and the evening meal, helps to reduce urinary urgency related to concentrated urine production, decreases the risk of urinary tract infection, and maintains bowel functioning. (Constipation, resulting from inadequate daily fluid intake, can increase urinary urgency and/or urine retention.) The best fluid is water. Fluids containing caffeine, carbonation, alcohol, or artificial sweetener should be avoided because they irritate the bladder wall, thus resulting in urinary urgency. Some patients who have coexisting medical diagnoses, such as heart failure or end-stage renal disease, need to discuss their daily fluid limit with their primary health care provider.

Standardized Voiding Frequency After establishing a patient’s natural voiding and urinary incontinence tendencies, voiding on a schedule can be very effective in those with and without cognitive impairment, although patients with cognitive impairment may require assistance with this technique from nursing personnel or family members. The object is to purposely empty the bladder before the bladder reaches the critical volume that would cause an urge or stress incontinence episode. This approach involves the following: • Timed voiding involves establishing a set voiding frequency (such as every 2 hours if incontinent episodes tend to occur 2 or more hours after voiding). The individual chooses to “void by the clock” at the given interval while awake, rather than wait until a voiding urge occurs. • Prompted voiding is timed voiding that is carried out by staff or family members when the individual has cognitive difficulties that make it difficult to remember to void at set intervals. The caregiver checks the patient to assess if he or she has remained dry and, if so, assists the patient to use the bathroom while providing positive reinforcement for remaining dry. • Habit retraining is timed voiding at an interval that is more frequent than the individual would usually choose. This technique helps to restore the sensation of the need to void in individuals who are experiencing diminished sensation of bladder filling due to various medical conditions such as a mild cerebrovascular accident (CVA). • Bladder retraining, also known as bladder drill, incorporates a timed voiding schedule and urinary urge inhibition exercises to inhibit voiding, or leaking urine, in an attempt to remain dry for a set time. When the first timing interval is easily reached on a consistent basis without urinary urgency or incontinence, a new voiding interval, usually 10 to 15 minutes beyond the last, is established. Again,

Toxin A injections into the detrusor muscle (Jabs & Carleton, 2013).

Surgical Management Surgical correction may be indicated in patients who have not achieved continence using behavioural and

the individual practices urge inhibition exercises to delay voiding or avoid incontinence until the next preset interval arrives. When an acceptable voiding interval is reached, the patient continues that timed voiding sequence throughout the day.

Pelvic Muscle Exercise Also known as Kegel exercises, pelvic muscle exercise (PME) aims to strengthen the voluntary muscles that assist in bladder and bowel continence in both men and women. Research shows that written and/or verbal instruction alone is usually inadequate to teach an individual how to identify and strengthen the pelvic floor for sufficient bladder and bowel control. Biofeedback-assisted PME uses either electromyography or manometry to help the individual identify the pelvic muscles as he or she attempts to learn which muscle group is involved when performing PME. The biofeedback method also allows assessment of the strength of this muscle area. PME involves gently tightening the same muscles used to stop flatus or the stream of urine for 5- to 10-second increments, followed by 10-second resting phases. To be effective, these exercises need to be performed two or three times a day for at least 6 weeks. Depending on the strength of the pelvic musculature when initially evaluated, anywhere from 10 to 30 repetitions of PME are prescribed at each session. Elderly patients may need to exercise for an even longer time to strengthen the pelvic floor muscles. Pelvic muscle exercises are helpful for women with stress, urge, or mixed incontinence and for men who have undergone prostate surgery.

Vaginal Cone Retention Exercises Vaginal cone retention exercises are an adjunct to the Kegel exercises. Vaginal cones of varying weight are inserted intravaginally twice a day. The patient tries to retain the cone for 15 minutes by contracting the pelvic muscles.

Transvaginal or Transrectal Electrical Stimulation Commonly used to treat urinary incontinence, electrical stimulation is known to elicit a passive contraction of the pelvic floor musculature, thus re-educating these muscles to provide enhanced levels of continence. This modality is often used with biofeedback-assisted pelvic muscle exercise training and voiding schedules. At high frequencies, it is effective for stress incontinence. At low frequencies, electrical stimulation can also relieve symptoms of urinary urgency, frequency, and urge incontinence. Intermediate ranges are used for mixed incontinence.

Neuromodulation Neuromodulation via transvaginal or transrectal nerve stimulation of the pelvic floor inhibits detrusor overactivity and hypersensory bladder signals and strengthens weak sphincter muscles.

pharmacologic therapy. Surgical options vary according to the underlying anatomy and the physiologic problem. Most procedures involve lifting and stabilizing the bladder or urethra to restore the normal urethrovesical angle or to lengthen the urethra. Women with stress incontinence may undergo an anterior vaginal repair, retropubic suspension, or needle


suspension to reposition the urethra. Procedures to compress the urethra and increase resistance to urine flow include sling procedures and placement of periurethral bulking agents such as artificial collagen. Recent introduction of minimally invasive procedures for placement of a mesh midurethral sling has been demonstrated as effective treatment of stress incontinence in women who have failed conservative therapy such as pelvic floor muscle therapy and behaviour modification. Periurethral bulking is a semipermanent procedure in which small amounts of artificial collagen are placed within the walls of the urethra to enhance the closing pressure of the urethra. This procedure takes only 10 to 20 minutes and may be performed under local anesthesia or moderate sedation. A cystoscope is inserted into the urethra. An instrument is inserted through the cystoscope to deliver a small amount of collagen into the urethral wall at locations selected by the urologist. The patient is usually discharged home after voiding. There are no restrictions following the procedure, although occasionally more than one collagen bulking session may be necessary if the initial procedure has not halted the stress urinary incontinence. Collagen placement anywhere in the body is considered semipermanent because its durability averages between 12 and 24 months, until the body absorbs the material. Periurethral bulking with collagen offers an alternative to surgery, as in a frail, elderly person. It is also an option for people who are seeking help with stress urinary incontinence who prefer to avoid surgery and who do not have access to behavioural therapies. An artificial urinary sphincter can be used to close the urethra and promote continence. Two types of artificial sphincters are a periurethral cuff and a cuff inflation pump. Men with overflow and stress incontinence may undergo a transurethral or laser resection to relieve symptoms of prostatic enlargement. An artificial sphincter can be used after prostatic surgery for sphincter incompetence (Fig. 46-2). After surgery, periurethral bulking agents can be injected into the periurethral area to increase compression of the urethra. Ureter Pressureregulating reservoir Inflatable cuff Prostate


Management of Patients With Urinary Disorders


CHART 46-8

Patient Education: Strategies for Promoting Urinary Continence • Increase your awareness of the amount and timing of all fluid intake.

• Avoid taking diuretics after 4 PM. • Avoid bladder irritants, such as caffeine, alcohol, and aspartame (NutraSweet).

• Take steps to avoid constipation: Drink adequate fluids,

eat a well-balanced diet high in fibre, exercise regularly, and take stool softeners if recommended. • Void regularly, five to eight times a day (about every 2 to 3 hours): First thing in the morning Before each meal Before retiring to bed Once during night if necessary • Perform all pelvic floor muscle exercises as prescribed, every day. • Stop smoking (smokers usually cough frequently, which increases incontinence).

Nursing Management Nursing management is based on the premise that incontinence is not inevitable with illness or aging and that it is often reversible and treatable. The nursing interventions are determined in part by the type of treatment that is undertaken. For behavioural therapy to be effective, the nurse must provide support and encouragement because it is easy for the patient to become discouraged if therapy does not quickly improve the level of continence. Patient teaching is important and should be provided verbally and in writing (Chart 46-8). The patient should be taught to develop and use a log or diary to record timing of pelvic floor muscle exercises, frequency of voiding, any changes in bladder function, and any episodes of incontinence (Miller, 2011). If pharmacologic treatment is used, its purpose is explained to the patient and family. It is important to educate patients who have mixed incontinence (both stress and urge incontinence) that anticholinergic and antispasmodic agents can help to decrease urinary urgency and frequency and urge incontinence but that they do not decrease the urinary incontinence related to stress incontinence. If surgical correction is undertaken, the procedure and its desired outcomes are described to the patient and family. Follow-up contact with the patient enables the nurse to answer the patient’s questions and to provide reinforcement and encouragement.

Control pump

Urinary Retention


Urinary retention is the inability to empty the bladder completely during attempts to void. Chronic urine retention often leads to overflow incontinence (from the pressure of the retained urine in the bladder). Residual urine is urine that remains in the bladder after voiding. In a

FIGURE 46-2. Male artificial urinary sphincter. An inflatable cuff is

inserted surgically around the urethra or neck of the bladder. To empty the bladder, the cuff is deflated by squeezing the control pump located in the scrotum.



Urinary Tract Function

healthy adult younger than 60 years, complete bladder emptying should occur with each voiding. In adults older than 60 years, 50 to 100 mL of residual urine may remain after each voiding because of the decreased contractility of the detrusor muscle. Urinary retention can occur postoperatively in any patient, particularly if the surgery affected the perineal or anal regions and resulted in reflex spasm of the sphincters. General anesthesia reduces bladder muscle innervation and suppresses the urge to void, impeding bladder emptying.

urodynamic studies, described in Chapter 43, may be performed to identify the type of bladder dysfunction and to aid in determining appropriate treatment. The patient may complete a voiding diary to provide a written record of the amount of urine voided and the frequency of voiding. Postvoid residual urine may be assessed either using straight catheterization or an ultrasound bladder scanner and is considered diagnostic of urinary retention if there is more than 100 mL of residual urine.


Urine retention can lead to chronic infection. Infections that are unresolved predispose the patient to renal calculi (urolithiasis or nephrolithiasis), pyelonephritis, and sepsis. The kidney may also eventually deteriorate if large volumes of urine are retained, causing hydronephrosis. In addition, urine leakage can lead to perineal skin breakdown, especially if regular hygiene measures are neglected.

Urinary retention may result from diabetes; prostatic enlargement; urethral pathology (infection, tumour, calculus); trauma (pelvic injuries); pregnancy; or neurologic disorders such as stroke, spinal cord injury, multiple sclerosis, or Parkinson’s disease. Some medications cause urinary retention, either by inhibiting bladder contractility or by increasing bladder outlet resistance. Medications that cause retention by inhibiting bladder contractility include anticholinergic agents (atropine sulfate, dicyclomine hydrochloride [Antispas, Bentyl]); antispasmodic agents (oxybutynin chloride [Ditropan], belladonna, and opioid suppositories); and tricyclic antidepressant medications (imipramine [Tofranil], doxepin [Sinequan]). Medications that cause urine retention by increasing bladder outlet resistance include alpha-adrenergic agents (ephedrine sulfate, pseudoephedrine), beta-adrenergic blockers (propranolol), and estrogens.

Assessment and Diagnostic Findings The assessment of a patient for urinary retention is multifaceted because the signs and symptoms may be easily overlooked. The following questions serve as a guide in assessment: • What was the time of the last voiding, and how much urine was voided? • Is the patient voiding small amounts of urine frequently? • Is the patient dribbling urine? • Does the patient complain of pain or discomfort in the lower abdomen? (Discomfort may be relatively mild if the bladder distends slowly.) • Is the pelvic area rounded and swollen (could indicate urine retention and a distended bladder)? • Does percussion of the suprapubic region elicit dullness (possibly indicating urine retention and a distended bladder)? • Are other indicators of urinary retention present, such as restlessness and agitation? • Does a postvoid bladder ultrasound test reveal residual urine? The patient may verbalize an awareness of bladder fullness and a sensation of incomplete bladder emptying. Signs and symptoms of UTI (hematuria, urgency, frequency, nocturia, and dysuria) may be present. A series of


Nursing Management Management strategies are instituted to prevent overdistention of the bladder and to treat infection or correct obstruction. However, many problems can be prevented with careful assessment and appropriate nursing interventions. The nurse explains why normal voiding is not occurring and monitors urine output closely. The nurse also provides reassurance about the temporary nature of retention and successful management strategies.

Promoting Urinary Elimination Nursing measures to encourage normal voiding patterns include providing privacy, ensuring an environment and a position conducive to voiding, and assisting the patient with the use of the bathroom or bedside commode, rather than a bedpan, to provide a more natural setting for voiding. The male patient may stand beside the bed while using the urinal; most men find this position more comfortable and natural. Additional measures include applying warmth to relax the sphincters (i.e., sitz baths, warm compresses to the perineum, showers), giving the patient hot tea, and offering encouragement and reassurance. Simple trigger techniques, such as turning on the water faucet while the patient is trying to void, may also be used. Other examples of trigger techniques are stroking the abdomen or inner thighs, tapping above the pubic area, and dipping the patient’s hands in warm water. A combination of techniques may be necessary to initiate voiding. After surgery or childbirth, prescribed analgesics should be administered because pain in the perineal area can make voiding difficult. When the patient cannot void, catheterization is used to prevent overdistention of the bladder (see later Neurogenic Bladder and Catheterization sections). In the case of prostatic obstruction, attempts at catheterization (by the urologist) may not be successful, requiring insertion of a suprapubic catheter (catheter inserted through a small abdominal incision into the bladder). After urinary drainage is restored, bladder retraining is initiated for the patient who cannot void spontaneously.


Management of Patients With Urinary Disorders


Promoting Home and Community-Based Care

Medical Management

In addition to the strategies listed for promoting urinary continence found in Chart 46-8, modifications to the home environment can provide simple and effective ways to assist in treating urinary incontinence and retention. For example, the patient may need to remove obstacles, such as throw rugs or other objects, to provide easy, safe access to the bathroom. Other modifications that the nurse may recommend include installing support bars in the bathroom; placing a bedside commode, bedpan, or urinal within easy reach; leaving lights on in the bedroom and bathroom; and wearing clothing that is easy to remove quickly.

The problems resulting from neurogenic bladder disorders vary considerably from patient to patient and are a major challenge to the health care team. There are several longterm objectives appropriate for all types of neurogenic bladders:

Neurogenic Bladder Neurogenic bladder is a dysfunction that results from a lesion of the nervous system and leads to urinary incontinence. It may be caused by spinal cord injury, spinal tumour, herniated vertebral disk, multiple sclerosis, congenital disorders (spina bifida or myelomeningocele), infection, or diabetes mellitus (see Chapters 42, 64, and 65).

Pathophysiology The two types of neurogenic bladder are spastic (or reflex) bladder and flaccid bladder. Spastic bladder is the more common type and is caused by any spinal cord lesion above the voiding reflex arc (upper motor neuron lesion). The result is a loss of conscious sensation and cerebral motor control. A spastic bladder empties on reflex, with minimal or no controlling influence to regulate its activity. Flaccid bladder is caused by a lower motor neuron lesion, commonly resulting from trauma. This form of neurogenic bladder is also increasingly being recognized in patients with diabetes mellitus. The bladder continues to fill and becomes greatly distended, and overflow incontinence occurs. The bladder muscle does not contract forcefully at any time. Because sensory loss may accompany a flaccid bladder, the patient feels no discomfort.

Assessment and Diagnostic Findings Evaluation for neurogenic bladder involves measurement of fluid intake, urine output, and residual urine volume; urinalysis; and assessment of sensory awareness of bladder fullness and degree of motor control. Comprehensive urodynamic studies are also performed.

Complications The most common complication of neurogenic bladder is infection resulting from urinary stasis and catheterization. Long-term complications include urolithiasis (stones in the urinary tract), vesicoureteral reflux, and hydronephrosis, all of which can lead to destruction of the kidney.

• • • •

Preventing overdistention of the bladder Emptying the bladder regularly and completely Maintaining urine sterility with no stone formation Maintaining adequate bladder capacity with no reflux

Specific interventions include continuous, intermittent, or self-catheterization (discussed later in this chapter); use of an external condom-type catheter; a diet low in calcium (to prevent calculi), and encouragement of mobility and ambulation. A liberal fluid intake is encouraged to reduce the urinary bacterial count, reduce stasis, decrease the concentration of calcium in the urine, and minimize the precipitation of urinary crystals and subsequent stone formation. A bladder retraining program may be effective in treating a spastic bladder or urine retention. Use of a timed, or habit, voiding schedule may be established. To further enhance emptying of a flaccid bladder, the patient may be taught to “double void.” After each voiding, the patient is instructed to remain on the toilet, relax for 1 to 2 minutes, and then attempt to void again in an effort to further empty the bladder.

Pharmacologic Therapy Parasympathomimetic medications, such as bethanechol (Urecholine), may help to increase the contraction of the detrusor muscle in acute retention not related to obstruction. These medications are not effective in chronic urinary retention.

Surgical Management In some cases, surgery may be carried out to correct bladder neck contractures or vesicoureteral reflux or to perform some type of urinary diversion procedure.

Catheterization In patients with a urologic disorder or with marginal kidney function, care must be taken to ensure that urinary drainage is adequate and that kidney function is preserved. When urine cannot be eliminated naturally and must be drained artificially, catheters may be inserted directly into the bladder, the ureter, or the renal pelvis. Catheters vary in size, shape, length, material, and configuration. The type of catheter used depends on its purpose. Catheterization is performed to achieve the following: • Relieve urinary tract obstruction • Assist with postoperative drainage in urologic and other surgeries • Provide a means to monitor accurate urine output in critically ill patients • Promote urinary drainage in patients with neurogenic bladder dysfunction or urine retention • Prevent urinary leakage in patients with stage III to IV pressure ulcers (see Chapter 12)



Urinary Tract Function

A patient should be catheterized only if necessary, as catheterization commonly leads to UTI. Catheters impede most of the natural defenses of the lower urinary tract by obstructing the periurethral ducts, irritating the bladder mucosa, and providing an artificial route for organisms to enter the bladder. Organisms may be introduced from the urethra into the bladder during catheterization, or they may migrate along the epithelial surface of the urethra or external surface of the catheter. Many of the organisms can form a bacterial biofilm impenetrable to antibiotics. In addition, urinary catheters have been associated with other complications, such as bladder spasms, urethral strictures, and pressure necrosis.

Removable trocar cannula Abdominal wall


Suprapubic catheter

Indwelling Catheters When an indwelling catheter cannot be avoided, a closed drainage system is essential. This drainage system is designed to prevent any disconnections, thereby reducing the risk of contamination. Triple-lumen catheters are commonly used after transurethral prostate surgery (see Chapter 50). This system has a triple-lumen indwelling urethral catheter attached to a closed sterile drainage system. With the triple-lumen catheter, urinary drainage occurs through one channel. The retention balloon of the catheter is inflated with water or air through the second channel, and the bladder is continuously irrigated with sterile irrigating solution through the third channel. The spout (or drainage port) of any urinary drainage bag can become contaminated when opened to drain the bag. Bacteria enter the urinary drainage bag, multiply rapidly, and then migrate to the drainage tubing, catheter, and bladder. By keeping the drainage bag lower than the patient’s bladder and not allowing urine to flow back into the bladder, this risk is minimized.

Suprapubic Catheters Suprapubic catheterization allows bladder drainage by inserting a catheter or tube into the bladder through a suprapubic (above the pubis) incision or puncture (Fig. 46-3). The catheter or suprapubic drainage tube is then threaded into the bladder and secured with sutures or tape, and the area around the catheter is covered with a sterile dressing. The catheter is connected to a sterile closed drainage system, and the tubing is secured to prevent tension on the catheter. This may be a temporary measure to divert the flow of urine from the urethra when the urethral route is impassable (because of injuries, strictures, prostatic obstruction), after gynecologic or other abdominal surgery when bladder dysfunction is likely to occur, and occasionally after pelvic fractures. Suprapubic bladder drainage may be maintained continuously for several weeks. When the patient’s ability to void is to be tested, the catheter is clamped for 4 hours, during which time the patient attempts to void. After the patient voids, the catheter is unclamped, and the residual urine is measured. If the amount of residual urine is less than 100 mL on two separate occasions (morning and evening), the catheter is usually removed. However, if the patient complains of pain or discomfort, the suprapubic catheter is usually left in place until the patient can void successfully.

FIGURE 46-3. Suprapubic bladder drainage. A trocar cannula is used to puncture the abdominal and bladder walls. The catheter is threaded through the trocar cannula, which is then removed, leaving the catheter in place. The catheter is secured by tape or sutures to prevent unintentional removal.

Suprapubic drainage offers certain advantages. Patients can usually void sooner after surgery than those with urethral catheters, and they may be more comfortable. The catheter allows greater mobility, permits measurement of residual urine without urethral instrumentation, and presents less risk of bladder infection. The suprapubic catheter is removed when it is no longer required, and a sterile dressing is placed over the site. The patient requires liberal amounts of fluid to prevent encrustation around the catheter. Other potential problems include the formation of bladder stones, acute and chronic infections, and problems collecting urine. A wound care specialist/enterostomal therapist, also referred to as a wound-ostomy-continence nurse, may be consulted to assist the patient and family in selecting the most suitable urine collection system and to teach them about its use and care.

Nursing Management During Catheterization Assessing the Patient and the System For patients with indwelling catheters, the nurse assesses the drainage system to ensure that it provides adequate urinary drainage. The colour, odour, and volume of urine are also monitored. An accurate record of fluid intake and urine output provides essential information about the adequacy of renal function and urinary drainage. The nurse observes the catheter to make sure that it is properly anchored, to prevent pressure on the urethra at the penoscrotal junction in male patients, and to prevent


tension and traction on the bladder in both male and female patients. Patients at high risk for UTI from catheterization need to be identified and monitored carefully. These include women; older adults; and patients who are debilitated, malnourished, chronically ill, immunosuppressed, or have diabetes. They are observed for signs and symptoms of UTI: cloudy malodourous urine, hematuria, fever, chills, anorexia, and malaise. The area around the urethral orifice is observed for drainage and excoriation. Urine cultures provide the most accurate means of assessing a patient for infection.

Gerontologic Considerations The older patient with an indwelling catheter may not exhibit the typical signs and symptoms of infection. Therefore, any subtle change in physical condition or mental status must be considered a possible indication of infection and promptly investigated because sepsis may occur before the infection is diagnosed. Figure 46-4 summarizes the sequence of events leading to infection and leakage of urine that often follow long-term use of an indwelling catheter in an older patient.

Preventing Infection Certain principles of care are essential to prevent infection in patients with a closed urinary drainage system (Chart 46-9). The catheter is a foreign body in the urethra and produces a reaction in the urethral mucosa with some urethral discharge. Vigourous cleansing of the meatus while the catheter is in place is discouraged because the cleansing action can move the catheter back and forth, increasing the risk of infection. To remove obvious encrustations from the external catheter surface, the area can be washed gently with soap during the daily bath. The catheter is anchored as securely as possible to prevent it from moving in the urethra. Encrustations arising from urinary salts may serve as a nucleus for stone formation; however, using silicone catheters results in significantly less crust formation. A liberal fluid intake, within the limits of the patient’s cardiac and renal reserve, and an increased urine output must be ensured to flush the catheter and to dilute urinary substances that might form encrustations. Urine cultures are obtained as prescribed or indicated when monitoring the patient for infection; many catheters have an aspiration (puncture) port from which a specimen can be obtained. Bacteriuria is considered inevitable in patients with indwelling catheters; therefore, controversy remains about the usefulness of taking cultures and treating asymptomatic bacteriuria, because overtreatment may lead to resistant strains of bacteria. Continual observation for fever, chills, and other signs and symptoms of systemic infection is necessary; these symptoms are generally treated aggressively.

Minimizing Trauma Trauma to the urethra can be minimized by the following: • Using an appropriate-sized catheter • Lubricating the catheter adequately with a water-soluble lubricant during insertion


Management of Patients With Urinary Disorders

Physiology/Pathophysiology CAUSES Catheterization

Bacterial ascension

Manipulations of catheter Change of catheter Irrigation Unintentional removal

Bacterial colonization Permanent bacteriuria

Bacterial invasion


Damaged mucosa

Bladder infection

Damaged and inflamed mucosa

Detrusor irritation

Detrusor spasms

Inflammatory cells Red blood cells Fibrin Other glutinous products



Adherence to the catheter

CLINICAL SIGNS Encrustation Obstruction Distention Leakage

URINALYSIS Leukocytes Erythrocytes Urothelial cells

FIGURE 46-4. Pathophysiology and manifestations of bladder infection in long-term catheterized older patients.

• Inserting the catheter far enough into the bladder to prevent trauma to the urethral tissues when the retention balloon of the catheter is inflated Manipulation of the catheter is the most common cause of trauma to the bladder mucosa in the catheterized patient. Infection then inevitably occurs when urine invades the damaged mucosa. The catheter is secured properly to prevent it from moving, causing traction on the urethra, or being unintentionally removed, and care is taken to ensure that the catheter position permits leg movement. In male patients, the drainage tube (not the catheter) is taped laterally to the thigh to prevent pressure on the urethra at the penoscrotal junction, which can eventually lead to formation of a urethrocutaneous fistula. In female patients, the drainage tubing attached to the catheter is taped to the thigh to prevent tension and traction on the bladder. Special care should be taken to ensure that any patient who is confused does not remove the catheter with the retention balloon still inflated, as this could cause bleeding and considerable injury to the urethra.



Urinary Tract Function

CHART 46-9

Preventing Infection in the Catheterized Patient • Use scrupulous aseptic technique during insertion of the

• Never irrigate the catheter routinely. If the patient is prone

• • •

catheter. Use a preassembled, sterile, closed urinary drainage system. Insert the catheter far enough into the bladder to prevent trauma to the urethral tissues when the retention balloon of the catheter is inflated. To prevent contamination of the closed system, never disconnect the tubing. The drainage bag must never touch the floor. The bag and collecting tubing are changed if contamination occurs, if urine flow becomes obstructed, or if tubing junctions start to leak at the connections. If the collection bag must be raised above the level of the patient’s bladder, clamp the drainage tube. This prevents backflow of contaminated urine into the patient’s bladder from the bag. Ensure a free flow of urine to prevent infection. Improper drainage occurs when the tubing is kinked or twisted, allowing pools of urine to collect in the tubing loops. To reduce the risk of bacterial proliferation, empty the collection bag at least every 8 hours through the drainage spout—more frequently if there is a large volume of urine. Avoid contamination of the drainage spout. A receptacle in which to empty the bag is provided for each patient.

Retraining the Bladder When an indwelling urinary catheter is in place, the detrusor muscle does not actively contract the bladder wall to stimulate emptying, because urine is continuously draining from the bladder. As a result, the detrusor may not immediately respond to bladder filling when the catheter is removed, resulting in either urine retention or urinary incontinence. This condition, known as postcatheterization detrusor instability, can be managed with bladder retraining (Chart 46-10). Immediately after the indwelling catheter is removed, the patient is placed on a timed voiding schedule, usually every 2 to 3 hours. At the given time interval, the patient is instructed to void. The bladder is then scanned using a portable ultrasonic bladder scanner. If 100 mL or more of urine remains in the bladder, straight catheterization may be performed for complete bladder emptying. After a few days, as the nerve endings in the bladder wall become aware of bladder filling and emptying, bladder function usually returns to normal. If the person has had an indwelling catheter in place for an extended period, bladder retraining will take longer; in some cases, function may never return to normal, and long-term intermittent catheterization may become necessary.

Assisting With Intermittent Self-Catheterization Intermittent self-catheterization provides periodic drainage of urine from the bladder. By promoting drainage and eliminating excessive residual urine, intermittent catheterization protects the kidneys, reduces the incidence of UTIs, and improves continence. It is the treatment of choice in patients with spinal cord injury and other neurologic disorders, such as multiple sclerosis, when the ability to empty the bladder is impaired. Self-catheterization promotes independence,

• • • • •

• •

to obstruction from clots or large amounts of sediment, use a three-way system with continuous irrigation. Never disconnect the tubing to obtain urine samples, to irrigate the catheter, or to ambulate or transport the patient. Never leave the catheter in place longer than is necessary. Avoid routine catheter changes. The catheter is changed only to correct problems such as leakage, blockage, or encrustations. Avoid unnecessary handling or manipulation of the catheter by the patient or staff. Carry out hand hygiene before and after handling the catheter, tubing, or drainage bag. Wash the perineal area with soap and water at least twice a day; avoid a to-and-fro motion of the catheter. Dry the area well, but avoid applying powder because it may irritate the perineum. Monitor the patient’s voiding when the catheter is removed. The patient must void within 8 hours; if unable to void, the patient may require catheterization with a straight catheter. Obtain a urine specimen for culture at the first sign of infection.

results in few complications, and enhances self-esteem and quality of life. When teaching the patient how to perform selfcatheterization, the nurse must use aseptic technique to minimize the risk of cross-contamination. However, the patient may use a “clean” (nonsterile) technique at home, where the risk of cross-contamination is reduced. Either antibacterial liquid soap or povidone-iodine (Betadine) solution is recommended for cleaning urinary catheters at

CHART 46-10

Bladder Retraining after Indwelling Catheterization • Instruct the patient to drink a measured amount of fluid • • • • • •

from 8 AM to 10 PM to avoid bladder overdistention. Offer no fluids (except sips) after 10 PM. At specific times, ask the patient to void by applying pressure over the bladder, tapping the abdomen, or stretching the anal sphincter with a finger to trigger the bladder. Immediately after the voiding attempt, catheterize the patient to determine the amount of residual urine. Measure the volumes of urine voided and obtained by catheterization. Palpate the bladder at repeated intervals to assess for distention. Instruct the patient who has no voiding sensation to be alert for any signs that indicate a full bladder, such as perspiration, cold hands or feet, or feelings of anxiety. Lengthen the intervals between catheterizations as the volume of residual urine decreases. Catheterization is usually discontinued when the volume of residual urine is less than 100 mL.


home. The catheter is thoroughly rinsed with tap water after soaking in the cleaning solution. It must dry before reuse. It should be kept in its own container, such as a plastic food-storage bag. In teaching the patient, the nurse emphasizes the importance of frequent catheterization and emptying the bladder at the prescribed time. The average daytime clean intermittent catheterization schedule is every 4 to 6 hours and just before bedtime. If the patient is awakened at night with an urge to void, catheterization may be performed after an attempt is made to void normally. The female patient assumes a Fowler’s position and uses a mirror to help locate the urinary meatus. She inserts the lubricated catheter 7.5 cm (3 in) into the urethra, in a downward and backward direction. The male patient assumes a Fowler’s or sitting position, lubricates the catheter, retracts the foreskin of the penis with one hand while grasping the penis and holding it at a right angle to the body. (This manoeuvre straightens the urethra and makes it easier to insert the catheter.) He inserts the catheter 15 to 25 cm until urine begins to flow. After removal, the catheter is cleaned, rinsed, and wrapped in a paper towel or placed in a plastic bag or case. Patients who follow this routine should consult a primary health care provider at regular intervals to assess urinary function and detect complications. If the patient cannot perform intermittent self-catheterization, a family member may be taught to carry out the procedure at regular intervals during the day. An alternative to self-catheterization that requires an extensive surgical procedure is creation of the Mitrofanoff umbilical appendicovesicostomy, which provides easy access to the bladder. In this procedure, the bladder neck is closed and the appendix is used to create access to the bladder from the skin surface through a submucosal tunnel created with the appendix. One end of the appendix is brought to the skin surface and used as a stoma, and the other end is tunnelled into the bladder. The appendix serves as an artificial urinary sphincter when an alternative is necessary to empty the bladder. A surgically prepared continent urine reservoir with a sphincter mechanism is required in cases of bladder cancer and severe interstitial cystitis (inflammation of the bladder wall). Various types of urological stomas may be used when a radical cystectomy (surgical removal of the bladder) is necessary.