Kozier & Erb's fundamentals of nursing : concepts, practice, and process [Tenth edition] 9780133974362, 0133974367, 1292106107, 9781292106106, 9781292106113

Table of contents :
Content: Historical and contemporary nursing practice --
Evidence-based practice and research in nursing --
Nursing theories and conceptual frameworks --
Legal aspects of nursing --
Values, ethics, and advocacy --
Health care delivery systems --
Community nursing and care continuity --
Home care --
Electronic health records and information technology --
Critical thinking and clinical reasoning --
Assessing --
Diagnosing --
Planning --
Implementing and evaluating --
Documenting and reporting --
Health promotion --
Health, wellness, and illness --
Culturally responsive nursing care --
Complementary and alternative healing modalities --
Concepts of growth and development --
Promoting health from conception through adolescence --
Promoting health in young and middle-aged adults --
Promoting health in older adults --
Promoting family health --
Caring --
Communicating --
Teaching --
Leading, managing, and delegating --
Vital signs --
Health assessment --
Asepsis --
Safety --
Hygiene --
Diagnostic testing --
Medications --
Skin integrity and wound care --
Perioperative nursing --
Sensory perception --
Self-concept --
Sexuality --
Spirituality --
Stress and coping --
Loss, grieving, and death --
Activity and exercise --
Sleep --
Pain management --
Nutrition --
Urinary elimination --
Fecal elimination --
Oxygenation --
Circulation --
Fluid, electrolyte, and acid-base balance.

Citation preview

Kozier & Erb’s Fundamentals of Nursing

Concepts, Process, and Practice

For these Global Editions, the editorial team at Pearson has collaborated with educators across the world to address a wide range of subjects and requirements, equipping students with the best possible learning tools. This Global Edition preserves the cutting-edge approach and pedagogy of the original, but also features alterations, customization, and adaptation from the North American version.

Global edition

Global edition

Global edition

Kozier & Erb’s Fundamentals of Nursing

Tenth edition

Concepts, Process, and Practice Tenth edition

Berman Snyder Frandsen

This is a special edition of an established title widely used by colleges and universities throughout the world. Pearson published this exclusive edition for the benefit of students outside the United States and Canada. If you purchased this book within the United States or Canada, you should be aware that it has been imported without the approval of the Publisher or Author.

Audrey Berman • Shirlee J. Snyder • Geralyn Frandsen

Pearson Global Edition

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Brief Contents UNIT 1 The Nature of Nursing  27 Chapter 1 Historical and Contemporary Nursing Practice 28

Chapter 2 Evidence-Based Practice and Research in Nursing  52

Chapter 3 Nursing Theories and Conceptual Frameworks  63 Chapter 4 Legal Aspects of Nursing  73 Chapter 5 Values, Ethics, and Advocacy  99 UNIT 2 Chapter 6 Chapter 7 Chapter 8 Chapter 9

Contemporary Health Care  114 Health Care Delivery Systems  115 Community Nursing and Care Continuity  131 Home Care  144 Electronic Health Records and Information Technology 155

UNIT 3 Chapter 10 Chapter 11 Chapter 12 Chapter 13 Chapter 14 Chapter 15

The Nursing Process  169

UNIT 4 Chapter 16 Chapter 17 Chapter 18 Chapter 19

Health Beliefs and Practices  269

Critical Thinking and Clinical Reasoning  170 Assessing 181 Diagnosing 201 Planning 215 Implementing and Evaluating  234 Documenting and Reporting  247

Health Promotion  270 Health, Wellness, and Illness  288 Culturally Responsive Nursing Care  302 Complementary and Alternative Healing Modalities 321

UNIT 5 Life Span Development  337 Chapter 20 Concepts of Growth and Development  338 Chapter 21 Promoting Health from Conception Through Adolescence 354

Chapter 22 Promoting Health in Young and Middle-Aged Adults  379 Chapter 23 Promoting Health in Older Adults  390 Chapter 24 Promoting Family Health  412

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UNIT 6 Chapter 25 Chapter 26 Chapter 27 Chapter 28

Integral Aspects of Nursing  423 Caring 424 Communicating 437 Teaching 464 Leading, Managing, and Delegating  488

UNIT 7 Assessing Health  502 Chapter 29 Vital Signs  503 Chapter 30 Health Assessment  539 UNIT 8 Chapter 31 Chapter 32 Chapter 33 Chapter 34 Chapter 35 Chapter 36 Chapter 37

Integral Components of Client Care  627

UNIT 9 Chapter 38 Chapter 39 Chapter 40 Chapter 41 Chapter 42 Chapter 43

Promoting Psychosocial Health  929

UNIT 10 Chapter 44 Chapter 45 Chapter 46 Chapter 47 Chapter 48 Chapter 49 Chapter 50 Chapter 51 Chapter 52

Promoting Physiological Health  1035

Asepsis 628 Safety 666 Hygiene 695 Diagnostic Testing  744 Medications 776 Skin Integrity and Wound Care  854 Perioperative Nursing  891

Sensory Perception  930 Self-Concept 948 Sexuality 960 Spirituality 980 Stress and Coping  998 Loss, Grieving, and Death  1015

Activity and Exercise  1036 Sleep 1092 Pain Management  1112 Nutrition 1153 Urinary Elimination  1200 Fecal Elimination  1236 Oxygenation 1267 Circulation 1313 Fluid, Electrolyte, and Acid–Base Balance  1334

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KOZIER & ERB’S

FUNDAMENTALS OF NURSING Concepts, Process, and Practice

TENTH EDITION GLOBAL EDITION

Audrey Berman, PhD, RN Professor Dean, Nursing Samuel Merritt University Oakland, California

Shirlee J. Snyder, EdD, RN Former Dean and Professor, Nursing Nevada State College Henderson, Nevada

Geralyn Frandsen, EdD, RN Professor of Nursing Maryville University St. Louis, Missouri

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Pearson Education Limited Edinburgh Gate Harlow Essex CM20 2JE England and Associated Companies throughout the world Visit us on the World Wide Web at: www.pearsonglobaleditions.com © Pearson Education Limited 2016 The rights of Audrey Berman, Shirlee Snyder, and Geralyn Frandsen to be identified as the authors of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act 1988. Authorized adaptation from the United States edition, entitled Kozier & Erb’s Fundamentals of Nursing: Concepts, Practice, and Process, 10th ­edition, ISBN 978-0-13-397436-2, by Audrey Berman, Shirlee Snyder, and Geralyn Frandsen, published by Pearson Education © 2016. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the prior written permission of the publisher or a license permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency Ltd, Saffron House, 6–10 Kirby Street, London EC1N 8TS. All trademarks used herein are the property of their respective owners. The use of any trademark in this text does not vest in the author or publisher any trademark ownership rights in such trademarks, nor does the use of such trademarks imply any affiliation with or endorsement of this book by such owners. Notice: Care has been taken to confirm the accuracy of information presented in this book. The authors, editors, and the publisher,­ however, cannot accept any responsibility for errors or omissions or for consequences from application of the information in this book and make no warranty, express or implied, with respect to its contents. The authors and publisher have exerted every effort to ensure that drug selections and dosages set forth in this text are in accord with ­current recommendations and practice at time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package inserts of all drugs for any change in indications of dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. ISBN 10: 1-292-10610-7 ISBN 13: 978-1-292-10610-6 (Print) ISBN 13: 978-1-292-10611-3 (PDF) British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library 10 9 8 7 6 5 4 3 2 1 Typeset in 9 Minion Pro by S4Carlisle Publishing Services Printed and bound by CTPS in China.

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Dedication Audrey Berman dedicates this tenth edition to everyone who ever played a part in its creation: to Barbara Kozier and Glenora Erb who started it all and taught me the ropes; to the publishers, editors, faculty authors, contributors, reviewers, and adopters who improved every edition; to the students and their clients who made all the hard work worthwhile; and to all my family and colleagues who allowed me the time and space to make these books my scholarly contribution to the profession. Shirlee Snyder dedicates this edition to her husband, Terry J. Schnitter, for his unconditional love and support; and to all of the nursing students and nurse educators she has worked with and learned from during her nursing career. Geralyn Frandsen dedicates this edition to her husband and fellow nursing colleague Gary. He is always willing to answer questions and provide editorial support. She also dedicates this edition to her children Claire and Joe and future son-in-law, John Conroy.

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About the Authors Audrey Berman, PhD, RN A San Francisco Bay Area native, Audrey Berman received her BSN from the University of California–San Francisco and later returned to that campus to obtain her MS in physiological nursing and her PhD in nursing. Her dissertation was entitled Sailing a Course Through Chemotherapy: The Experience of Women   with Breast Cancer. She worked in oncology at Samuel Merritt Hospital prior to beginning her teaching career in the diploma program at Samuel Merritt Hospital School of Nursing in 1976. As a faculty member, she participated in the transition of that program into a baccalaureate degree and in the development of the master of science and doctor of nursing practice programs. Over the years, she has taught a variety of medical–surgical nursing courses in the prelicensure programs. She currently serves as the dean of nursing at Samuel Merritt University and is the 2014–2016 president of the California Association of Colleges of Nursing. Dr. Berman has traveled extensively, visiting nursing and health care institutions in Australia, Botswana, Brazil, Germany, Israel, Japan, Korea, the Philippines, the Soviet Union, and Spain. She serves on the board of directors for the Bay Area Tumor Institute and the East Bay American Heart Association. She is a member of the American Nurses Association and Sigma Theta Tau and is a site visitor for the Commission on Collegiate Nursing Education. She has twice participated as an NCLEX-RN item writer for the National Council of State Boards of Nursing. She has presented locally, nationally, and internationally on topics related to nursing education, breast cancer, and technology in health care. Dr. Berman authored the scripts for more than 35 nursing skills videotapes in the 1990s. She was a coauthor of the sixth, seventh, eighth, ninth, and tenth editions of Fundamentals of Nursing and the fifth, sixth, seventh, and eighth editions of Skills in Clinical Nursing. Shirlee J. Snyder, EdD, RN Shirlee J. Snyder graduated from Columbia Hospital School of Nursing in Milwaukee, Wisconsin, and subsequently received a bachelor of science in nursing from the University of Wisconsin–Milwaukee. Because of an interest in cardiac nursing and teaching, she earned a master of science in nursing with a minor in cardiovascular clinical specialist and teaching from the University of Alabama in Birmingham. A move to California resulted in becoming a faculty member at Samuel Merritt Hospital School of Nursing in Oakland, California. Shirlee was fortunate to be involved in the phasing out of the diploma and ADN programs and development of a baccalaureate

intercollegiate nursing program. She held numerous positions during her 15-year tenure at Samuel Merritt College, including curriculum coordinator, assistant director–instruction, dean of instruction, and associate dean of the Intercollegiate Nursing Program. She is an associate professor alumnus at Samuel Merritt College. Her interest and experiences in nursing education resulted in Shirlee obtaining a doctorate of education focused on curriculum and instruction from the University of San Francisco. Dr. Snyder moved to Portland, Oregon, in 1990 and taught in the ADN program at Portland Community College for 8 years. During this teaching experience she presented locally and nationally on topics related to using multimedia in the classroom and promoting ethnic and minority student success. Another career opportunity in 1998 led her to the Community College of Southern Nevada in Las Vegas, Nevada, where Dr. Snyder was the nursing program director with responsibilities for the associate degree and practical nursing programs for 5 years. During this time she coauthored the fifth edition of Kozier & Erb’sTechniques in Clinical Nursing with Audrey Berman. In 2003, Dr. Snyder returned to baccalaureate nursing education. She embraced the opportunity to be one of the nursing faculty teaching the first nursing class in the baccalaureate nursing program at the first state college in Nevada, which opened in 2002. From 2008 to 2012, she was the dean of the School of Nursing at Nevada State College in Henderson, Nevada. She is currently retired. Dr. Snyder enjoyed traveling to the Philippines (Manila and Cebu) in 2009 to present all-day seminars to approximately 5,000 nursing students and 200 nursing faculty. She is a member of the American Nurses Association and Sigma Theta Tau. She has been a site visitor for the National League for Nursing Accrediting Commission and the Northwest Association of Schools and Colleges. Geralyn Frandsen, EdD, RN Geralyn Frandsen graduated in the last class from DePaul Hospital School of Nursing in St. Louis, Missouri. She earned a bachelor of science in nursing from Maryville College. She attended Southern Illinois University at Edwardsville, earning a master of science degree in nursing with specializations in community health and nursing education. Upon completion, she accepted a faculty position at her alma mater Maryville College, which has since been renamed Maryville University. In 2003 she completed her doctorate in higher education and leadership at Saint Louis University. Her dissertation was Mentoring Nursing Faculty in Higher Education. Her review of literature was incorporated in the Maryville University Guide to Promotion and Tenure. In service to the university, she has been a member and chair of the promotion and tenure committee for the past 10 years. She is a tenured full professor and currently serves as assistant director

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About the Authors

of the Catherine McCauley School of Nursing at Maryville. When educating undergraduate and graduate students, she utilizes a variety of teaching strategies to engage her students. When teaching undergraduate pharmacology she utilizes a team teaching approach, placing students in groups to review content. Each student is also required to bring a completed ticket to class covering the content to be taught. The practice of bringing a ticket to class was introduced to her by Dr. Em Bevis, who is famous for the Toward a Caring Curriculum. Dr. Frandsen has authored textbooks in pharmacology and nursing fundamentals. In the ninth edition of Kozier & Erb’s Fundamentals of Nursing she contributed the chapters on Safety, Diagnostic Testing, Medications, Perioperative Nursing, and Fecal Elimination. In 2013 she

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was the fundamentals contributor for Ready Point and My Nursing Lab. She has authored both the Nursing Fundamentals: Pearson Reviews and Rationales and, in 2007, Pharmacology Reviews and Rationales. Dr. Frandsen has completed the End-of-Life Nursing Education Consortium train-the-trainer courses for advanced practice nurses and the doctorate of nursing practice. She is passionate about end-oflife care and teaches a course to her undergraduate students. She also teaches undergraduate pharmacology and advanced pharmacotherapeutics. Her advanced pharmacotherapeutics class is taught at the university and online. Dr. Frandsen is a member of Sigma Theta Tau International, the American Nurses’ Association, and serves as a site visitor for the Commission on Collegiate Nursing Education.

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Acknowledgments We wish to extend a sincere thank you to the talented team involved in the tenth edition of this book: the contributors and reviewers who provide content and very helpful feedback; the nursing students, for their questioning minds and motivation; and the nursing instructors, who provided many valuable suggestions for this edition. We would like to thank the editorial team, especially Kelly Trakalo, executive acquisitions editor, for her continual support, Melissa Bashe, Program Manager, Pearson Nursing, and most of all Teri Zak, development editor, for keeping our noses to the grind-

stone and especially for her dedication and attention to detail that promoted an excellent outcome once again. Many thanks to the production team of Michael Giaccobe, production liaison, and Roxanne Klaas, production editor, for producing this book with precision, and to the design team led by Maria Siener and Maria Guglielmo, art directors, for providing a truly beautiful design for this textbook. Audrey Berman Shirlee Snyder Geralyn Frandsen

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Thank You We would like to extend our heartfelt thanks to our colleagues from schools of nursing across the country who have given their time generously to help us create this learning package. These individuals helped us develop this textbook and supplements by reviewing chapters, art, and media, and by answering a myriad of questions right up until the time of publication. Kozier & Erb’s Fundamentals of Nursing, Tenth Edition, has benefited immeasurably from their efforts, insights, suggestions, objections, encouragement, and inspiration, as well as from their vast experience as teachers and nurses. Thank you again for helping us set the foundation for nursing excellence.

Contributors to the Tenth Edition Sherrilyn Coffman, PhD, RN Professor, Associate Dean Nevada State College Chapter 25: Caring

Reviewers of the Tenth Edition Mary Anderson, RN, MSN Chicago State University Chicago, IL Kathy Anglin, MSN, RN Texarkana College Texarkana, TX Barbara Celia, EdD, RN Drexel University Philadelphia, PA Sarah Dempsey, MSN, RN Maryville University St. Louis, MO Mary Ann Gaster, MEd, MSN Central Carolina Community College Pittsboro, NC

Elizabeth Johnston Taylor, PhD, RN Associate Professor, Loma Linda University Research Director, Mary Potter Hospice Wellington South, New Zealand Chapter 41: Spirituality

Susan Growe, MSN, RN, OCN Nevada State College Henderson, NV

Florence Miller, MSN, MPH Chicago State University Chicago, IL

Helena Gunnell, MEd, BSN, RN Jones County Community College Ellisville, MS

Sharon M. Nowak, MSN Jackson College Jackson, MI

Sandy Gustafson, MA, RN Hibbing Community College Hibbing, MN

Martha Olson MSN, MS, RN Iowa Lakes Community College Emmetsburg, Iowa

Elizabeth Long, DNP, APRN, GNP-BC Lamar University Beaumont, TX

Laura Warner, MSN, RN Ivy Tech Community College Greenfield, IN

Colleen Marzilli, DNP, MBA, RN University of Texas at Tyler Tyler, TX

Cindy Zeller, MSN, CPNP Frederick Community College Frederick, MD

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Preface The practice of nursing continues to evolve . . . the practice of caring is timeless. Nurses today must grow and evolve to meet the demands of a dramatically changing health care system. They need skills in science, technology, communication, and interpersonal relations to be effective members of the collaborative health care team. They need to think critically and be creative in implementing nursing strategies to provide safe and competent nursing care for clients of diverse cultural backgrounds in increasingly varied settings. They need skills in teaching, leading, managing, and the process of change. They need to be prepared to provide home- and community-based nursing care to clients across the life span—especially to the increasing numbers of older adults. They need to understand legal and ethical principles, holistic healing modalities, and complementary therapies. And, they need to continue their unique client advocacy role, which demands a blend of nurturance, sensitivity, caring, empathy, commitment, and skill founded on a broad base of knowledge. Kozier & Erb’s Fundamentals of Nursing, Tenth Edition, addresses the concepts of contemporary professional nursing. These concepts include but are not limited to caring, wellness, health promotion, disease prevention, holistic care, critical thinking and clinical reasoning, multiculturalism, nursing theories, nursing informatics, nursing research, ethics, and advocacy. In this edition, every chapter has been reviewed and revised. The content has been updated to reflect the latest nursing evidence and the increasing emphasis on aging, wellness, safety, interprofessional practice, and home- and community-based care.

ORGANIZATION The detailed table of contents at the beginning of the book makes its clear organization easy to follow. Continuing with a strong focus on nursing care, the tenth edition of this book is divided into 10 units. Unit 1, The Nature of Nursing, clusters five chapters that provide comprehensive coverage of introductory concepts of nursing. In Unit 2, Contemporary Health Care, four chapters cover contemporary health care topics such as health care delivery systems, community-based care, home care, and informatics. In Unit 3, The Nursing Process, six chapters introduce students to this important framework with each chapter dedicated to a specific step of the nursing process. Chapter 10 applies critical thinking, clinical reasoning, and the nursing process. A Nursing in Action case study is used as the frame of reference for applying content in all phases of the nursing process in Chapter 11, Assessing; Chapter 12, Diagnosing; Chapter 13, Planning; and Chapter 14, Implementing and Evaluating. Chapter 15 covers documenting and reporting. Starting in this unit and incorporated throughout the book, we refer to the NANDA International diagnoses. In Unit 4, Health Beliefs and Practices, four chapters cover healthrelated beliefs and practices for individuals and families from a variety of cultural backgrounds.

Unit 5, Lifespan Development, consists of five chapters that discuss life span and development from conception to older adults. Unit 6, Integral Aspects of Nursing, discusses topics such as caring; communicating; teaching; and leading, managing, and delegating. These topics are all crucial elements for providing safe, competent nursing care. Unit 7, Assessing Health, addresses vital signs and health assessment skills in two separate chapters, so beginning students can understand normal assessment techniques and findings. Chapter 29, Vital Signs, begins to introduce students to the clinical procedures that they need to learn to perform. In Unit 8, Integral Components of Client Care, the focus shifts to those components of client care that are universal to all clients, including asepsis, safety, hygiene, diagnostic testing, medications, wound care, and perioperative care. Unit 9, Promoting Psychosocial Health, includes six chapters that cover a wide range of areas that affect one’s health. Sensory perception, self-concept, sexuality, spirituality, stress, and loss are all things that a nurse needs to consider to properly care for a client. Unit 10, Promoting Physiological Health, discusses a variety of physiological concepts that provide the foundations for nursing care. These include activity and exercise; sleep; pain; nutrition; elimination; oxygenation; circulation; and fluid, electrolyte, and acid–base balance.

WHAT’S NEW TO THE TENTH EDITION • QSEN linkages. The delivery of high-quality and safe nursing practice is imperative for every nurse. The QSEN competencies were developed to address the gap between nursing education and practice. There are expectations for each of the six QSEN competencies and these expectations relate to knowledge, skills, and attitudes. Nursing students are expected to achieve these competencies during nursing school and use them in their professional role as RNs. This edition has incorporated QSEN competencies and specified expectations in QSEN features. The content in these QSEN features will guide students to learn and maintain safety and quality in their provision of nursing care. • Culturally Responsive Care highlights diversity and special considerations in nursing care. • Evidence-Based Practice focuses on evidence-informed practice to highlight relevant research and its implications for nursing care. • Home Care Assessment focuses on educating the client, family, and community to recognize what is needed for care in the home. • Home Care Considerations focus on teaching the client and care­giver the proper care at home. • Safety Alerts correlate to the National Patient Safety Goals and identify other crucial safety issues. • Updated photo program with more than 150 new photos

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Preface •

•

•

•

Clinical reasoning. The practice of nursing requires critical thought and clinical reasoning. Clinical reasoning is the cognitive processes a nurse utilizes to gather and analyze client data, evaluate the relevance of the information, and implement nursing interventions to improve the client’s well being. Interprofessional practice. The concept of interprofessional practice is identified in specific skills. It reinforces to the student that other members of the health care team may also be performing the specified skill. Men in nursing. This edition has increased information about men in nursing from a historical and current perspective in ­Chapter 1. Standards of care. This edition continues to value and update standards of care as evidenced by the latest National Patient Safety Goals, Infusion Nursing Society Standards of Practice, ANA Scope and Standards of Practice, 2014 Hypertension Guidelines; IHI Pressure Ulcer Prevention Guidelines, ANA Safe Patient Handling and Mobility Interprofessional National Standards, OSHA/ CDC BBP and Infection Prevention Standards, and Cancer Screening Guidelines.

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FEATURES For years, Kozier & Erb’s Fundamentals of Nursing has been a gold standard that helps students embark on their careers in nursing. This new edition retains many of the features that have made this textbook the number-one choice of nursing students and faculty. The walk-through at the beginning of the textbook illustrates these features. A significant addition to this edition is the inclusion of QSEN features that address the competencies and expectations for quality nursing care. Another important feature is the inclusion of a section on Interprofessional Practice within specific skills. In addition, Evidence-Based Practices boxes replace the Research Notes in recognition that research is not the only way in which nurses determine best practices.

Supplements That Inspire Success for the Student and the Instructor Pearson is pleased to offer a complete suite of resources to support teaching and learning, including: • • •

TestGen Test Bank Lecture Note PowerPoints Clicker PowerPoints

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data from a large national sample. Individual risk reports are based on statistics for the population group that match the individual’s surveyed characteristics. The HRA includes a summary of the person’s health risks and lifestyle behaviors with educational suggestions on how to reduce the risk. 1. An opportunity for clients to assess the impact of their present Many HRA instruments are available today in paper-andlifestyle on their health pencil formats or as computerized forms. Recently, HRAs have be2. A basis for decisions related to desired behavior and lifestyle gun to reflect a broader approach to health as companies use the changes. HRA as a means to begin a health promotion and risk reduction program. Occupational health nurses can identify risk factors and Spiritual Health Assessment subsequently plan interventions aimed at decreasing illness, absenSpiritual health is the ability to develop one’s inner nature to its fullest teeism, and disability. potential, including the ability to discover and articulate one’s basic HRAs are helpful for assessing individual and group health risks. 486 Unit 7 ● Assessing Health purpose in life; to learn how to experience love, joy, peace, and fulThey are not, however, substitutes for medical care and are not approfillment; and to learn how to help ourselves and others achieve their priate for all individuals. For example, people with chronic illnesses fullest potential (Pender et al., 2011, p. 104). Spiritual beliefs can affect such as cancer or heart disease may notTemperature obtain accurate risk assessLIFESPAN CONSIDERATIONS a person’s interpretation of events in his or her life and, therefore, an ments. Certain populations (e.g., very young, older adults, some so• Avoid the tympanic route in a child with active ear infections or Unit 7 ● Assessing Health INFANTS assessment of spiritual well-being is a part of evaluating the person’s 508 ciocultural groups) may not be fully represented in the population • The body temperature of newborns is extremely labile, and tympanic membrane drainage tubes. for more information. overall health. See Chapter 41 databases and, therefore, the warm HRAand maydry notto project accurate risk • The oral route may be used for children over age 3, but newborns must be kept prevent an hypothermia. Evidence-Based Practice Are to Pulse Oximeter Readings Accurate If Measured • Using the axillary nonbreakable, electronic thermometers are recommended. site, you need hold the infant’s arm against assessment. • For a rectal temperature, place the childEVIDENCE-BASED the chest (Figure 29–10 ■). on a Restrained Arm? prone across yourPRACTICE SELF-CARE ALERT • The axillary route may not be as accurate as other routes for lap or in a side-lying position with the knees flexed. Insert the Health Beliefs Review thermometer 2.5 cm (1 in.) into the rectum. detecting fevers in children. value measured from a finger of an arm that had been physically The aim of this study by Korhan, Yönt, and Khorshid (2011) was to There are two physical arts that blend spirituality and health: t’ai chi Clients’ health beliefs need tovalues be particularly those • The tympanic route is fast andclarified, convenient. Placeathe infantonbeliefs restrained was found to be 93.40 and the mean oxygen saturation compare the pulse oximetry obtained from finger reand yoga. T’ai chi promotes muscle relaxation through movement. OLDER ADULTS supine andhow stabilize the head. Pull the pinna straight back and that determine theysides perceive control ofclinical their own health care •value measured from a fingertend of antoarm that had been strained or unrestrained of the body. In settings such Yoga promotes mobility and flexibility. Older adults’ temperatures be lower thannot those ofphysically slightly downward. Remember that is pulled upward was found as intensive physical maythe bepinna indicated to the to restrained status. Locuscare, of control is restraints a measurable concept that canlessen be used middle-aged adults.to be 95.53. for that children overwill 3 years of age andand adults, but downward forthe chances displace tubes monitors. However, • Older adults’ temperatures are strongly influenced by both environpredictchildren whichclients people are most likely to change their behavior (see IMPLICATIONS younger than age 3. Direct the probe tip anteriorly and Social Support Systems Review most important in using physical restraints is impaired mental and internal temperature changes. Their thermoregulation Chapter 17 far enough )complication . Several instruments that assess insert to seal the canal.are Theavailable tip will not touch the a per- The results of this study indicate that nurses should use a finger of circulation. Thus, oxygen saturation from body parts in which circontrol processes are not asrestrained efficient aswhen when evaluating they were younger, Understanding the social context in which a person lives and works arm that is not physically oxygen sattympanic membrane. son’s health-belief measures. AssessmentThe of clients’ health beliefs pro- an and they are at higher risk for both hypothermia and hyperthermia. culation is impaired can be inaccurate. research sample conis important in health promotion. Individuals and groups, through • Avoid the tympanic route in a child with active ear infections or values. The use of physical restraints is carefully evaluated vides the nurse with an indication of how much the clients believe •uration Older adults can develop significant buildup of ear cerumen sisted of 30 hospitalized clients. A significant difference was found tympanic membrane drainage tubes. because there are many possible adverse effects of their use. This interpersonal relationships, can provide comfort, assistance, encour(earwax) that may interfere with tympanic thermometer readings. between the oxygen saturation values obtained from abehaviors. finger they or control health through personal Sev- study provides one additional physiological consideration: that as• can Theinfluence tympanic membrane route may be more accurate in of an agement, and information. Social support fosters successful coping • Older adults are more likely to have hemorrhoids. Inspect the arm had have beentemperature restrained and a finger of anbe, arm that eral that cultures aphysically strong belief in fate: “Whatever will will be.” sessment determining in febrile infants. datataking gathered fromtemperature. a restrained limb may not be accurate. anus before a rectal and promotes satisfying and effective living. had been physically restrained. The oxygen saturation • not When using a belief, temporal artery thermometer, touching only the If people hold this they do not feelmean that they can do anything • Older adults’ temperatures may not be a valid indication of Social support systems contribute to health by creating an enforehead or behind the ear is needed. the seriousness of the pathology of a disease. They may have • The rectal route is least desirable in infants. vironment that encourages healthy behaviors, promotes self-esteem pneumonia or a urinary tract infection and have only a slight Oxygen Saturation and wellness, and provides feedback that the person’s actions will Measuring temperature elevation. Other symptoms, such as confusion and CHILDREN PATIENT-CENTERED CARE Culturally Responsive Care restlessness, may be displayed and need follow-up to determine • Tympanic or temporal artery sites are preferred. lead to desirable outcomes. Examples of social support systems in- PURPOSES • For the tympanic route, have the child held on an adult’s lap if there is an underlying process. clude family, peer support groups (including computer-based sup- • To • To detect the presence of hypoxemia before visible signs Cultural Aspects ofheld Social Support estimate arterial oxygen saturation with thethe child’s headblood gently against the adult for support. 222 Unit 3 ● The Nursing Process port groups), community-organized religious support systems (e.g., develop the pinnatostraight back and upward for children overof age 3 It isPull important understand how various subgroups U.S. ■ churches), and self-help groups (e.g., Mended Hearts, Weight Watch(Figure ). society may29–11 define social support. ASSESSMENT Communication ers). Culturally Responsive Care addresses aspects of social support SAFETY ALERT! SAFETY • In the African American community, the family and church Assess The record as the providers vehicle byofwhich within the context of culture. haveserves been major socialdifferent support.health profession- • • The best location for a pulse oximeter sensor based on the Vital signs, skin color and temperature, nail bed color, and Take safety measures before faxing support confidential information. fax • Hispanic/Latino als client’s who interact with a client communicate each other. Americans and Asianwith Americans viewThis the preThe nurse can begin a social system review byAasking tissue perfusion of extremities as baseline data age and physical condition. Unless contraindicated, the cover sheet should contain instructions that the faxed material is to be family as being a major social support vents fragmentation, repetition, and delays insystem. client care. the client to do the following: • Adhesive allergy finger is usually selected for adults. and such habits as smoking, alcohol consumption, and drug use. Other categories may be included. Several tools are available to assess lifestyle. The goals of lifestyle assessment tools are to provide the following:

Features of the Tenth Edition NEW AND ENHANCED FEATURES

SKILL 29–7

SPECIAL FEATURES provide the opportunity to link QSEN competencies and to think critically to make a connection to nursing practice. These features provide guidance on maintaining safety and quality of nursing care.

given only to the named recipient. Consent is needed from the client to•faxList information. thatpersonal personally identifiable information individualsMake who sure provide support. (e.g., client name, Social Security number) has been removed. Finally, • Indicate the relationship of each person (e.g., family member, felcheck that the fax number is correct, check the number on the display workerafter or colleague, social acquaintance). of thelow machine dialing, and check the number a third time before • Identify which button. individuals have been a source of support for 5 or pressing the “send”

•

• Asian Americans respect older adults and use shame and The client’s overall condition including risk factors for harmony in giving and receiving support.

development of hypoxemia (e.g., respiratory or cardiac disease) • Native Americans Planning ClientliveCare in social networks that foster mutual and hemoglobin level

assistance and support. Each health professional uses data from the client’s record to plan

Figure 29–11 ■ Pull the pinna of the ear back and up for placement of a tympanic thermometer in a child over 3 years

ENHANCED PHOTO PROGRAM shows procedural steps and the latest equipment.

SKILL 29–3

Nursing Practice ed. (p. 220),for by N. J. Pender, may order careFrom forHealth that Promotion client. Ain primary care, 6th provider, example, Equipment PLANNING C.Figure L. Murdaugh, and M.■A. Axillary Parsons, thermometer 2011, Upper Saddle River, NJ: for Prentice Hall. of age; back and down for children under age 3. 29–10 a child. a specific antibiotic after establishing thatplacement the client’ s temperature Many hospitals and clinics have pulse oximeters readily available for is • Nail polish remover as needed more years. • use with other vital signs equipment (or even as an integrated part Alcohol wipe steadily rising and that laboratory tests reveal the presence of a cerFor purposes of education and research, most agencies allow • Sheet or towel of themicroorganism. electronic bloodNurses pressure facilities data may to have a tain usedevice). baselineOther and ongoing evalustudent and graduate health professionals access to client records. • Pulse oximeter PATIENT-CENTERED CARE Home Care Considerations Temperature limited supply of oximeters, and the nurse may need to request it ate the effectiveness of the nursing care plan. The records are used in client conferences, clinics, rounds, client from the central supply department. • Teach the client accurate use and reading of the type of ther■ • Pacifier thermometers ( Figure 29–12 ) may be used in the studies, and written papers. The student or graduate is bound by a mometer to be used. Examine the thermometer used by the home setting for children under 2 years old. The manufacturer’s strict ethical code and legal responsibility to hold all information in Auditing DELEGATION INTERPROFESSIONAL PRACTICE client in Health the home forAgencies safety and proper functioning. Facilitate instructions must be followed carefully since many require confidence. It is the responsibility of the student or health profesAn audittheis replacement a review of client records for qualitywith assurance purposes of mercury thermometers nonmercury adding 0.5°F in order to estimate rectal temperature. Application of See the pulse oximeter sensor and recording the SpO Measuring oxygen saturation may be within the scope of practice ones. page 482 for instructions regarding of2 sional to protect the client’s privacy by not using a name or any state(see Chapter 14 ). Accrediting agencies such as management Theof Joint Comvalue may be delegated to UAP. The interpretation of the oxygen for many health care providers. For example, in addition to nurses, amay broken mercury thermometer. ments in the notations that would identify the client. mission review client records to determine if a particular health saturation value the andclient/caregiver determinationtaking of appropriate are • Observe respiratory therapists may check the client’s oxygen saturation and readingresponses a temperature. agency meeting its importance stated standards. done byis the nurse.the before, during, and after treatment. Although these therapists may Reinforce of reporting the site and type of therEnsuring Confidentiality mometer used and the value of using the same site and therverbally communicate their findings and plan to the health care team mometer consistently. of Computer Records members, the nurse must also know where to locate their documenResearch • Discuss means of keeping the thermometer clean, such as tation in the client’s medical record. Because of the increased use of EHRs (see Chapter 9 ), health The information contained a record be contamination. a valuable source of warm water and soap,inand avoidingcan cross care agencies have developed policies and procedures to ensure the thatThe the client has water-soluble lubricant of if using a with data •forEnsure research. treatment plans for a number clients privacy and confidentiality of client information stored in computrectal thermometer. the health problems can yield information helpful in treating 492 UnitIMPLEMENTATION 7 ●same Assessing Health • Instruct the client or family member to notify the health care ers. In addition, the Security Rule of HIPAA became mandatory in Preparation other clients. provider if the temperature is is 38.5°C (101.3°F) or higher. • If using an extremity, apply the sensor only if the proximal 2005. This rule governs the security of electronic PHI. The following Check that the oximeter equipment functioning normally. • When making a home visit, take a thermometer with you in case pulse and capillary refill at the point closest to the site are are some suggestions for ensuring the confidentiality and security of Assessing an Apical Pulse Performance the clients do not have a functional thermometer of their own. Education present. If the client has low tissue perfusion due to periph• Check computerized records: that the client knows howintroduce to record self the temperature. 1. Prior to performing the procedure, and verify eral vascular disease or therapy using vasoconstrictive in health disciplines often use client records as educational PURPOSESStudents Provideidentity a recording if indicated. the client’s usingchart/table agency protocol. Explain to the client use a nasal sensor or a reflectance sensor • To obtain tools. • 1. A personal password is required to enter and sign off computer A record can frequently provide a comprehensive view of the the heart rate adult to with ancontrol irregular determine whether medications, the cardiac rate is within normal range • Discuss environmental modifications that should what you of arean going do, why it is necessary, and howTo hebe or on the forehead. Avoid using lower extremities that have a peripheralclient, pulse and the rhythm is regular made during illness or extreme climate conditions (e.g., heating, files. Do not share this password with anyone, including other the illness, effective treatment strategies, and factors that affect she can participate. Discuss how the results will be used in compromised circulation and extremities • To establish baseline • data evaluation with cardiac, renal disease and that are used for ■ A pacifierorthermometer. Figure 29–12 pulmonary, air conditioning, clothing and bedding). To monitor clients planning further careappropriate or treatments. health team members. the outcome of for thesubsequent illness. infusions or otherheart invasive monitoring. those receiving medications to improve action Chapter 11 • Assessing 157hand hygiene and observe appropriate infection 2. Perform 2. After logging on, never leave a computer terminal unattended. 5. Prepare the site. prevention procedures. • Clean the site with an alcohol wipe before applying the sensor. 3. Do not leave client information displayed on the monitorASSESSMENT where Reimbursement Margaret O’Brien is a 33-year-old 3. Provide for client privacy. • It may be necessary to remove a female client’s dark nail Assess nursing student. others She is married and it. may see ASSESSING Nurse Medina’s Documentation also appropriate helps a facility reimbursement 4. physical Choose a sensor for receive the client’s weight, •size,from and the • Clinical has a 13-year-old daughter and Factors that may alter polish. pulse rate (e.g., emotional status, activity signs of cardiovascular alterations such as dyspnea reveals that Margaret’s vital 4. Shred all unneeded computer-generated worksheets.assessment desired location. Because weight obtain limits ofpayment sensors through overlap, Media federal government. For a facility signs are temperature, 39.4°C (103°F); 5-year-old son. She is admitted to level, and medicationsRationale: that affect heart rate such digoxin, with accurate measure(difficult respirations), fatigue/weakness, pallor, to cyanosis (bluish Nail polish mayasinterfere pulsean 92 beats/min; respirationspediatric 28/min; could be used for contain a small adult. the hospital with an elevated 5. Know the facility’s policy and procedure for correcting entry beta-blockers, or calcium channel blockers) discoloration of the skin andsensor mucous membranes), palpitations, care, client’ s clinical record must the correct diagnosisments although the data about this are inconsistent. and blood pressure, 122/80 mmHg. Nurse temperature, a productive cough, • If the client is allergic to adhesive, use a clip or sensor Medina observes that Mrs. O’Brien’s skin error. syncope (fainting), or impaired peripheral tissue perfusion as • Alternatively, position the sensor on the side of the finger related without group (DRG) codes and reveal that the appropriate care has and rapid, labored respirations. is dry, her cheeks are flushed, and she is adhesive. evidenced by skin discoloration and cool temperature rather than perpendicular to the nail bed. Follow agency procedures for documenting sensitive material, While taking6.a nursing history, experiencing chills. Auscultation beenreveals given.

inspiratory crackles with diminished breath Mary Medina, RN, finds that such as a diagnosis of AIDS. sounds in the right lung. Codable diagnoses, such as DRGs, are supported by accuMargaret has had a “chest cold” for PLANNING technology (IT) personnel must install a firewall to 2 weeks, and7. has Information been rate, thorough recording by nurses. This not only facilitates reINTERPROFESSIONAL PRACTICE DELEGATION experiencing shortness of protect the server from unauthorized access. imbursement from the federal government, but also facilitates DIAGNOSING After analysis, breath upon exertion. Nurse Medina formulates a an apical pulse may be within the scope of practice for Due to the degree of skill and knowledge required, companies UAP are generally Yesterday she developed an reimbursement from insurance and otherAssessing third-party nursing diagnosis: Ineffective elevated temperature and many health care providers. For example, in addition to nurses, not responsible assessing apical pulses. Airway Clearancefor related payers. Ifto additional care, treatment, or length of stay becomes began to experience accumulated mucus respiratory therapists may check the client’s apical pulse before, obstructing airways. “pain” in her “lungs”. necessary for the client’s welfare, thorough charting will helpand jus-after treatment, and physicians often check the apiClient records are kept for a number of purposes including communiduring,

PURPOSES OF CLIENT RECORDS

tify these needs. cation, planning client care, auditing health agencies, research,Equipment educa• Clock or watch with a sweep second hand or digital seconds tion, reimbursement, legal documentation, and health care analysis. indicator • •

CLINICAL ALERT!

cal pulse when assessing the chest during examinations. Although these providers may verbally communicate their findings and plan to other health care team members, the nurse must also know where to locate their documentation in the client’s medical record.

Legal Documentation

Stethoscope Antiseptic wipes

The client’s record is a legal document and is usually admissible in court as evidence. In some jurisdictions, however, the record is considered inadmissible as evidence when the client objects, because information the client gives to the primary care provider is confidential.

PLANNING Nurse Medina and • Ifcollaborate using a toDUS: thegoals transducer probe, the stethoscope headset, Margaret establish An accurate client health record provides details about the (e.g., carerestore atransmission cli-effective breathing gel, and tissues/wipes and lung ventilation); set ent has received and the client’s overall response to care.pattern Accurate outcome criteria (e.g., have a symmetrical respiratory excursion of at documentation provides the staff with a means for accountability and IMPLEMENTATION 4 cm, and so on); and develop a reflection on the delivery of client care (Prideaux, 2011). Toleast enhance carePreparation plan that includes, but is not the accuracy in documenting care, Paans, Sermeus, Nieweg, and limited to,van coughing and check that the equipment is functioning normally. If using a DUS, exercises q3h, fluid der Schans (2010) identified the PES structure as a guidelinedeep-breathing for ofnursintake 3,000 mL daily, and daily Performance ing care. The letter P represents the client’s problem or diagnosis. The postural drainage.

Health Care Analysis

1. Prior to performing the procedure, introduce self and verify

INTERPROFESSIONAL PRACTICE reinforces interactions with other members of the health care team.

Margaret agrees to practice the etiology or cause of the problem is represented by E,IMPLEMENTING and S represents Information from records may Explain assist health the client’s identity using agency protocol. to the care clientplanners to identify deep-breathing exercises q3h during the day. In the signs and symptoms the nurse should be assessing. The usewhat of youagency are why itasisoverutilized necessary, and how he or addition, she verbalizes awareness of thegoing needneeds, to to do,such and underutilized hospital serthis structure enhances nurses’ ability to exercise clinical increase reasoning. her fluid intake andcan to plan her morning Discuss how the results will be used in she participate.

vices. Records can be used to establish the costs of various services

activities to accommodate postural drainage.

EVALUATING Upon assessment of respiratory excursion, Nurse Medina detects failure of the client to achieve maximum ventilation. She and Margaret reevaluate the care plan and modify it to increase coughing and deep-breathing exercises to q2h.

Figure 11–1

• Continued

10

planning further care or treatments. 2. Perform hand hygiene and observe appropriate infection prevention procedures. 3. Provide for client privacy. 4. Position the client appropriately in a comfortable supine position or in a sitting position. Expose the area of the chest over the apex of the heart. 5. Locate the apical impulse. This is the point over the apex of the heart where the apical pulse can be most clearly heard. • Palpate the angle of Louis (the angle between the manubrium, the top of the sternum, and the body of the sternum). It is palpated just below the suprasternal notch and is felt as a prominence (see Figure 29–14). • Slide your index finger just to the left of the sternum, and palpate the second intercostal space. ❶

CLINICAL ALERT! When “left” and “right” are used to describe the nurse’s hand placement on the client, the terms refer to the client’s right or left side, not the nurse’s. # 153613

Cust: Pearson Au: Berman Pg. No. 157 & Erb’s Fundamentals of Nursing 10e

C/M/Y/K

Shirlee Snyder.

Place your middle or next finger in the third intercostal space, and continue palpating downward until you locate the fifth intercostal space. ❷ • Move your index finger laterally along the fifth intercostal space toward the MCL. ❸ Normally, the apical impulse is palpable at or just medial to the MCL (see Figure 29–14). 6. Auscultate and count heartbeats. • Use antiseptic wipes to clean the earpieces and diaphragm of the stethoscope. Rationale: The diaphragm needs to be cleaned and disinfected if soiled with body substances. Both earpieces and diaphragms have been shown to harbor pathogenic bacteria (Muniz, Sethi, Zaghi, Ziniel, & Sandora, 2012). •

DESIGN SERVICES OF

S4CARLISLE Short / Normal # 153613   Cust: Pearson   Au: Berman  Pg. No. 10 A02_BERM6106_10_GE_FM.indd 10 Title: Kozier & Erb’s Fundamentals of Nursing   10e M14_BERM4362_10_SE_CH11.indd 157 Title: Kozier

❶ Second intercostal space.

Publishing Services

12/08/14 6:32 PM

C/M/Y/K Short / Normal

DESIGN SERVICES OF

S4CARLISLE Publishing Services

20/04/15 10:37 am

HALLMARK FEATURES This tenth edition maintains the best aspects of previous editions to provide the most valuable learning experience.

19

Complementary and Alternative Healing Modalities

LEARNING OUTCOMES

LEARNING OUTCOMES help identify critical concepts.

After completing this chapter, you will be able to: 1. Describe the basic concepts of alternative practices. 2. Give examples of healing environments. 3. Describe the basic principles of health care practices such as Ayurveda, traditional Chinese medicine, Native American healing, and curanderismo. 4. Explain how herbs are similar to many prescription drugs. 5. Discuss the principles of naturopathic medicine. 6. Identify the role of manual healing methods in health and illness.

KEY TERMS

KEY TERMS provide a study tool for learning new vocabulary. Page numbers are included for easy reference.

acupressure, 327 acupuncture, 327 allopathic medicine, 321 alternative medicine, 321 animal-assisted therapy, 332 aromatherapy, 325 Ayurveda, 323 balance, 322 bioelectromagnetics, 332 biofeedback, 330 biomedicine, 321 chiropractic, 326

UNIT

4

In this unit, we have explored concepts related to health, health promotion, wellness, illness, culture and heritage, and complementary and alternative healing modalities. These topics heighten awareness of the individualistic nature of the relationship between the nurse and the client and the importance of assessing the breadth of factors that affect health decisions and behaviors. In the case described below, you will see how one person demonstrates complicated, interrelated, personal definitions of health and illness influenced by her medical condition, her heritage, and her demographic characteristics (e.g., age and family structure). These definitions and perspectives in turn influence her choices for care and support—including the role of her nurses.

AGE: 55

CURRENT MEDICAL DIAGNOSIS: Still’s Disease

Medical History: Manuela has experienced some type of health challenge for most of her adult life. She was diagnosed with adultonset Still’s disease (AOSD) at about age 35 after several years of tests to try to determine exactly what syndrome her symptoms reflected. She complained of joint pain, rash, and fevers, which came and went, and she had an enlarged spleen and liver. This disease has many similarities with rheumatoid and autoimmune diseases, but those conditions were all removed from consideration because the tests were negative. AOSD is a chronic condition for which there is no known cure. In addition to joint deterioration, it can progress to affect the lungs and heart. Initial treatment consists of steroids and nonsteroidal anti-inflammatory drugs (NSAIDS). If those are ineffective, other medications such as gold and chemotherapeutics are used; however, they have severe side effects such as kidney damage and bone marrow suppression. The condition worsens when the person is under physical or emotional stress. Manuela

underwent a hip replacement about 4 years ago and recently has had several hospitalizations for respiratory failure. Personal and Social History: Manuela has never married and has lived near or with her parents or siblings for all her life. She has many friends, drives, and has an active social life when she is feeling well. She uses the computer extensively for communication, especially when having visitors or talking by phone is too exhausting. She must follow a strict diet of food and liquids that are easy to swallow and digest. She is a spiritual person but not overly religious. She is quick to laugh and generally has an optimistic outlook, but expresses awareness that her life could end at any time—certainly long before her full life expectancy. Manuela is a college graduate but has been able to work only part time for most of her life. Recently, she was declared permanently disabled, which allows her access to financial and other support systems. She is creative in adapting her living situation to her disabilities and unwilling to give up her beloved pet dog.

Questions American Nurses Association Standard of Professional American Nurses Association Standard of Practice #3 is Performance #13 is Collaboration: Nurses work with the client, Outcomes Identification: The nurse consults with the client and family, and other health care providers in planning, implementing, family in formulating measureable goals consistent with the client’s and evaluating care. culture, values, and environment. As you learned in Chapter 16 , 4. Which health care team members other than physicians Manuela’s needs fall into the category of tertiary prevention in which and nurses would likely be important to include in Manuela’s rehabilitation and movement toward optimal levels of functionality care plan? within the individual’s constraints are the focus. American Nurses Association Standard of Professional 1. What are some outcomes for Manuela that would reflect Performance #9 is Research. this focus? ● The Nursing Process 218 2.Unit 3 5. What evidence might you have or seek to support the use Do you need to know her personal definitions of health and of alternative or complementary treatment modalities in health beliefs (Chapter 17 ) before you can work with her to Manuela’s care? set expected outcomes? American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver American Nurses Association Standard of Practice #5b is Spring, MD: Author. Health Teaching and Health Promotion: The nurse customizes the NURSING CARE PLAN For Margaret O’Brien Modified Implementation See SuggestedFollowing Answers to End-of-Unit Meeting the Standards Questions on student resource client’s teaching to promote a healthy environment. website. andsituation Evaluation—continued 3. What are some aspects of Manuela’s that you would consider incorporating into a teaching plan to maximize a safe environment for her? Nursing Diagnosis: Ineffective Airway Clearance related to viscous secretions and shallow chest expansion secondary to

volume, pain, and fatigue

Desired Outcomes*/ Indicators • Freely expresses concerns and possible solutions about work and parenting roles

Evaluation Statements Partially met. Discussed only briefly on 3–11 shift. Not done on 11–7 shift because of client’s need to rest. (Evaluated 8/27/14, JW)

310

Nursing Interventions** As client can tolerate, encourage to express and expand on her concerns about her child and her work. Explore alternatives as needed.

qi, 323 qi gong, 330 reflexology, 327 spirituality, 322 t’ai chi, 330 traditional Chinese medicine (TCM), 323 Western medicine, 321 yoga, 328

homeopathy, 325 horticultural therapy, 332 humanist, 322 hypnotherapy, 329 imagery, 329 integrative medicine, 321 massage therapy, 327 meditation, 329 music therapy, 331 naturopathic medicine, 326 pilates, 330 prayer, 330

complementary medicine, 321 conventional medicine, 321 curanderismo, 324 detoxification, 332 Eastern medicine, 321 energy, 322 faith, 330 guided imagery, 329 hand-mediated biofield therapies, 327 herbal medicine, 324 holism, 322

systems of ancient people, including Egyptians, Chinese, Asian IndiINTRODUCTION ans, Greeks, and Native Americans. Other therapies, such as bioelecWestern medicine is an approach to health that focuses on the use tromagnetics and chiropractic, evolved in the United States during of science in the diagnosis and treatment of health problems. This is the past two centuries. Still others, such as some of the mind–body in contrast to Eastern medicine, which places greater emphasis on approaches, are on the frontier of scientific knowledge and underprevention and natural healing. The differences between Western standing. The CAM therapies described in this chapter are only some and Eastern medicine are not about geographic location since both of the many used by clients. Nurses must learn about the ones being Eastern and Western health practitioners exist in almost every part used by the clients in their specific practice settings. of the world. Most of nursing education in the United States, Canada, Complementary medicine refers to the use of CAM together Europe, and Australia has been under the umbrella of Western mediwith conventional medicine. Most use of CAM by Americans is cine. Thus, nurses from these parts of the world are familiar and complementary. Alternative medicine refers to use of CAM in comfortable with biomedical beliefs, theories, practices, strengths, place of conventional medicine. Integrative medicine combines and limitations. In this chapter the terms conventional medicine, treatments from conventional medicine and CAM for which there is biomedicine, and allopathic medicine are used to describe Westsome high-quality evidence of safety and effectiveness. It is also called ern medical practices. Fewer nurses have studied Eastern medicine integrated medicine. and as a result may lack information or even harbor misinformation The public interest in complementary and alternative therapies about these healing practices. is extensive and growing. One has only to look at the proliferation of The term complementary and alternative medicine (CAM) popular health books, health food stores, Chapter and clinics heal- 203 ● Planning 13offering includes as many as 1,800 other therapies practiced all over the world. ing therapies to realize this. In 1998, the National Institutes of Health Many of these have been handed down over thousands of years, both established the National Center for Complementary and Alternative orally and as written records. They are based on the Eastern medical BOX 13–2 Benefits of Standardized Interventions

Meeting the Standards

CLIENT: Manuela

7. Describe the goals that yoga, meditation, hypnotherapy, guided imagery, qi gong, and t’ai chi have in common. 8. Identify types of detoxification therapies. 9. Discuss uses of animals, prayer, and humor as treatment modalities. 10. Teach clients the uses of and safety precautions regarding complementary and alternative therapies.

• • • • •

Enhances communication among nurses and among nurses and nonnurses. Makes it possible for researchers to determine the effectiveness and cost of nursing treatments. Helps communicate the nature of nursing to the public. Helps demonstrate the impact that nurses have on health care. Makes it easier for nurses to select appropriate interventions by reducing the need for memorization and recall. Facilitates the teaching of clinical decision making.

321

Contributes to the development and use of computerized clinical records. Assists in effective planning for staff and equipment needs. Aids in development of a system of payment for nursing services. • Promotes full and meaningful participation of nurses in the multidisciplinary team. • • •

MEETING THE STANDARDS end of unit activities provide the opportunity to think through themes and competencies presented across chapters in a unit and think critically to link theory to nursing practice. •

From Nursing Process & Critical Thinking, 5th ed. (p. 253), by J. M. Wilkinson, 2012, Upper Saddle River, NJ: Prentice Hall. Adapted with permission.

LIFESPAN CONSIDERATIONS Nursing Care Plan

OLDER ADULTS When a client is in an extended care facility or a long-term care facility, interventions and medications often remain the same day after day. It is important to review the care plan on a regular basis, because changes in the condition of older adults may be subtle and go unnoticed. This applies to both changes of improvement or deterioration. Either one should receive attention so that appropriate revisions can be made in expected outcomes and interventions. Outcomes need to be realistic with consideration given to the client’s physical condition, emotional condition, support systems, and

NURSING CARE PLAN

deficient fluid

Explanation for Continuing or Modifying Nursing Interventions It is important that this assessment be made right away, so child care can be arranged if needed.

NURSING CARE PLANS help you approach care from the nursing Note whether husband returns as scheduled. If he does not, perspective. institute care plan for actual Interrupted Family Process. (Do on 8/27, day shift) (8/27/14, JW)

*The NOC # for desired outcomes is listed in brackets following the appropriate outcome. **In this care plan, a line has been drawn through portions the nurse wished to delete; additions to the care plan are shown in italics.

mental status. Outcomes often have to be stated and expected to be completed in very small steps. For instance, clients who have had a cerebrovascular accident may spend weeks learning to brush their own teeth or dress themselves. When these small steps are successfully completed, it gives the client a sense of accomplishment and motivation to continue working toward increasing selfcare. This particular example also demonstrates the need to work collaboratively with other departments, such as physical and occupational therapy, to develop the nursing care plan.

Margaret O’Brien

Nursing Diagnosis: Ineffective Airway Clearance related to viscous secretions and shallow chest expansion secondary to deficient fluid volume, pain, and fatigue Desired Outcomes*/Indicators

Nursing Interventions

Rationale

Respiratory Status: Gas Exchange [0402], as evidenced by Absence of pallor and cyanosis (skin and mucous membranes) • Use of correct breathing/coughing technique after instruction

Monitor respiratory status q4h: rate, depth, effort, skin color, mucous membranes, amount and color of sputum. Monitor results of blood gases, chest x-ray studies, and incentive spirometer volume as available. Monitor level of consciousness.

To identify progress toward or deviations from goal. Ineffective Airway Clearance leads to poor oxygenation, as evidenced by pallor, cyanosis, lethargy, and drowsiness.

Auscultate lungs q4h. Vital signs q4h (TPR, BP, pulse oximetry, pain).

Inadequate oxygenation and pain cause increased pulse rate. Respiratory rate may be decreased by narcotic analgesics. Shallow breathing further compromises oxygenation.

Instruct in breathing and coughing techniques. Remind to perform, and assist q3h.

To enable client to cough up secretions. May need encouragement and support because of fatigue and pain.

Administer prescribed expectorant; schedule for maximum effectiveness. Maintain Fowler’s or semi-Fowler’s position. Administer prescribed analgesics. Notify primary care provider if pain not relieved.

Helps loosen secretions so they can be coughed up and expelled. Gravity allows for fuller lung expansion by decreasing pressure of abdomen on diaphragm. Controls pleuritic pain by blocking pain pathways and altering perception of pain, enabling client to increase thoracic expansion. Unrelieved pain may signal impending complication.

•

• •

Productive cough Symmetric chest excursion of at least 4 cm

Within 48–72 hours: Lungs clear to auscultation Respirations 12–22/min; pulse, less than 100 beats/min

• • •

Inhales normal volume of air on incentive spirometer

Applying Critical Thinking 1. From reviewing Margaret O’Brien’s nursing care plan, what general conclusions can you make about the desired outcomes for Ineffective Airway Clearance and Anxiety? 2. Despite some of the outcomes being only partially met or not met, no new interventions were written for several outcomes. What reasons might there be for this? 3. For the nursing diagnosis of Anxiety, most of the outcomes are fully met. Would you delete this diagnosis from the care plan at this time? Why or why not? 4. Since the Evaluation Statements column is generally not used on written care plans, where would auditors or individuals conducting quality assessments find these data?

Continued on page 204

See Critical Thinking Possibilities on student resource website.

APPLYING CRITICAL THINKING questions come at the end of select sample Nursing Care Plans to Chapter 14 Review encourage further reflection and analysis. CHAPTER HIGHLIGHTS • Implementing is putting planned nursing interventions into action. • Successful implementing and evaluating depend in part on the

quality of the preceding phases of assessing, diagnosing, and planning. • Reassessing occurs simultaneously with the implementing phase of the nursing process. • Cognitive, interpersonal, and technical skills are used to implement nursing strategies. • Before implementing an order, the nurse reassesses the client to be sure that the order is still appropriate. • The nurse must determine A02_BERM6106_10_GE_FM.indd 11 whether assistance is needed to perform a nursing intervention knowledgeably, safely, and comfortably

11

• After the care plan has been implemented, the nurse evaluates

the client’s health status and the effectiveness of the care plan in achieving client goals. • The desired outcomes formulated during the planning phase serve

as criteria for evaluating client progress and improved health status. • The desired outcomes determine the data that must be collected

to evaluate the client’s health status. • Reexamining the client care plan is a process of making decisions

about problem status and critiquing each phase of the nursing process. • Professional standards of care hold that nurses are responsible and accountable for implementing and evaluating the plan of care.

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Unit 5

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Life Span Development

CONCEPT MAP Overview of Growth and Development Psychosocial Theories and Theorists

CONCEPT MAPS provide visual representations of the nursing process, nursing care plans, and the relationships between difficult concepts.

Growth and Development Theories

Psychosocial Development

theorist

theorist

theorist

theorist

theorist

Freud

Erikson

Havighurst

Peck

Gould

personality develops in five overlapping stages from birth to adulthood

stages reflect positive and negative aspects of the critical life periods

believed

adult development

adult development

5 stages: • Oral • Anal • Phallic • Latency • Genital

• Three developmental tasks during old age: • Ego differentiation vs. work-role • Body transcendence vs. body preoccupation • Ego transcendence vs. ego preoccupation

• Growth & development occurs during 6 age periods (infancy to later maturity) • Each age period has developmental tasks • Achieving the developmental tasks helps the individual transition to the next developmental period

8 stages: • Trust vs. Mistrust • Autonomy vs. Shame & Doubt • Initiative vs. Guilt • Integral Components of Client Care 632 Unit •8 Industry vs. Inferiority • Identity vs. Role Confusion • Intimacy vs. Isolation Sterile Gloves • Generativity vs. Stagnation Sterile gloves may be applied by the open method or • Integrity vs. Despair

7 stages: • 1: 16–18 years • 2: 18–22 years • 3: 22–28 years • 4: 28–34 years • 5: 34–43 years • 6: 43–50 years • 7: 50–60 years

Sterile gloves are available to protect the nurse from contact with the closed blood and body fluids. Latex and nitrile gloves are more flexible than method. The open method is most frequently used outside the opervinyl, mold to the wearer’s hands, and allow freedom of movement. ating room because the closed method requires that the nurse wear a Since latex should be avoided due to possible allergies, wear nitrile sterile gown. Gloves are worn during many procedures to enable the gloves when performing tasks (a) that demand flexibility, (b) that nurse to handle sterile items freely and to prevent clients at risk (e.g., place stress on the material (e.g., turning stopcocks, handling sharp those43–50). with open wounds) from becoming by microorgan• Stage 6 (ages instruments or tape), and (c) that involve a high risk of exposure to Personalities are seen as set. infected Time is accepted Temperament Theories on unsterile gloves orinthe nurse’ s hands. with friends and pathogens. gloves should be chosen to stress as finite. isms Individuals are interested social activities Early research on Vinyl temperament, conducted in for the tasks 1950sunlikely by Stella Sterile gloves are packaged with a cuff about 5 cm (2 in.) and the glove material, requiring minimal precision, and with minimal spouse and desire both sympathy and affection fromofspouse. Chess and Alexander Thomas, identified nine temperamental with 50–60). the palmsThis facing the package iswith opened. The packrisk of exposure to pathogens. • Stage 7 (ages is aupward period when of transformation, a realqualities seen in children’ s behavior (Table 20–3). Temperament is usually indicates the size the glove (e.g.,issize or 7 1/2inor small, Skill 31–4 describes to apply andofremove gloves by ization ofage mortality and a concern forofhealth. There an 6increase multidimensional leading to thehow development a child’sterile s personmedium, large).in negativism. The spouse is seen as a valuable the open method. has a role in the development of anxiety, warmth and a decrease ality traits. Temperament companion (Gould, 1972, pp. 525–527). depression, attention deficit disorder, and other types of behavior

SETTING THE FOUNDATION FOR CLINICAL COMPETENCE!

SKILL 31–4

Applying and Removing Sterile Gloves (Open Method) PURPOSES • To enable the nurse to handle or touch sterile objects freely without contaminating them

•

To prevent transmission of potentially infective organisms from the nurse’s hands to clients at high risk for infection

ASSESSMENT Review the client’s record and orders to determine exactly what procedure will be performed that requires sterile gloves. Check the client record and ask about latex allergies. Use nonlatex gloves whenever possible. PLANNING Think through the procedure, planning which steps need to be completed before the gloves can be applied. Determine what additional supplies are needed to perform the procedure for this client. Always have an extra pair of sterile gloves available.

INTERPROFESSIONAL PRACTICE

DELEGATION

Equipment • Packages of sterile gloves

Sterile gloves are used many health care providers. All providers should be comfortable pointing out to each other when any break in sterile technique is detected.

Sterile procedures are not delegated to UAP. IMPLEMENTATION Preparation Ensure the sterility of the package of gloves. Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary. 2. Perform hand hygiene and observe other appropriate infection prevention procedures (see Skills 31–1, 31–2, and 31–3). 3. Provide for client privacy. 4. Open the package of sterile gloves. • Place the package of gloves on a clean, dry surface. Rationale: Any moisture on the surface could contaminate the gloves. • Some gloves are packed in an inner as well as an outer package. Open the outer package without contaminating the gloves or the inner package. See Skill 31–3. • Remove the inner package from the outer package. • Open the inner package as in step 4 of Skill 31–3 or according to the manufacturer’s directions. Some manufacturers provide a numbered sequence for opening the flaps and folded tabs to grasp for opening the flaps. If no tabs are provided, pluck the flap so that the fingers do not touch the inner surfaces. Rationale: The inner surfaces, which are next to the sterile gloves, will remain sterile. 5. Put the first glove on the dominant hand. • If the gloves are packaged so that they lie side by side, grasp the glove for the dominant hand by its folded cuff

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edge (on the palmar side) with the thumb and first finger of the nondominant hand. Touch only the inside of the cuff. ❶ Rationale: The hands are not sterile. By touching only the inside of the glove, the nurse avoids contaminating the outside. or • •

If the gloves are packaged one on top of the other, grasp the cuff of the top glove as above, using the opposite hand. Insert the dominant hand into the glove and pull the glove on. Keep the thumb of the inserted hand against the palm of the hand during insertion. ❷ Rationale: If the thumb is kept

STEP-BY-STEP SKILLS An easy-to-follow format helps students understand techniques and practice sequences. • Includes a complete Equipment list for easy preparation. • Clearly labeled Delegation boxes assist you in assigning tasks appropriately. • Easy-to-find rationales give you a better understanding of why things are done. • Critical steps are visually represented with full-color photos and illustrations.

❶ Picking up the first sterile glove.

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s signed by the nurse making nd title; for example, “Susan J. gencies have a signature sheet nurses can use their initials. rse has his or her own code, identified. re often used, but nurses need gn their names:

When a recording mistake is made, draw a single line through it to identify it as erroneous with your initials or name above or near the line (depending on agency policy). Do not erase, blot out, or use correction fluid. The original entry must remain visible. When using computerized charting, the nurse needs to be aware of the agency’s policy and process for correcting documentation mistakes. See Figure 15–10 ■ for an example. Write on every line but never between lines. If a blank appears in a notation, draw a line through the blank space so that no additional information can be recorded at any other time or by any other person, sign the 268andUnit 4 ●notation. Health Beliefs and Practices CLINICAL ALERT! Spiritual and religious beliefs can significantly affect health be-

CLINICAL ALERTS highlight special STANDARDS OF LIVING An individual’s standard of living (reflecting occupation, income, and information useful for clinical education) is related to health, morbidity, and mortality. Hygiene, foodsettings. habits, and the ability to seek health care advice and follow Jews perform circumcision on the eighth day of a male baby’s life. health regimens vary among high-income and low-income groups. The influence of spirituality and religion is discussed further in Low-income families must prioritize use of their finances, often Chapter 15 ● Documenting and Reporting 233 Sequence Chapter 41events . in the order in which they occur; for example, rechoosing food and housing over health care.29 They difficulty Document ● may Chapter Vital have Signs 481 obtaining time off from work and transportation to health care facord assessments, then the nursing interventions, and then the client’s PRACTICE GUIDELINES SELF-CARE cilities. Because their present problems are so great and all efforts are responses. UpdateALERT orNursing delete problems as needed.for Clients Interventions Nursing Interventions for Clients SELF-CARE ALERTS focus actions Long-Term Documentation exerted toward survival, they may lack an on orientation toward actions BOX 29–2 BOX 29–3Care Feverdoes not always translate into action. with Hypothermia Knowledge of healthwith behaviors that help prevent illness. • Complete the assessment and screening forms (MDS) and planof • Document and report any change in the client’s condition to the nurses can perform to take care The nurse should be self-reflective and consider both the personal of care within the time period specified by bodies. areas have primary environmental conditions ofregulatory impoverished a care provider and the client’s family within 24 hours. • professional • • The Monitor vitaladvantages signs. Provide a warm environment. and of examining and minimizing one’s own • Document all measures implemented in response to a change Keep a record of any visits and of phone calls family, and serve asfrom effective role • Assess •themselves skinofcolor and temperature. Provide dryothers clothing. bearing on and overall health. neighborhoods are overcrowded barriers to ways becoming a positive role model. friends, regardingSlum the client. in the client’s condition. • Make sure that progress notes address the client’s progress in • Monitor white blood cell count, hematocrit value, and other • •in Write nursing summaries notes that comply tend with to be Apply warm blankets.and progress and a state offor deterioration. Sanitation services inadmodels and colleagues. the frequency and clients standards required by regulatory bodies. relation to the goals or outcomes defined in the plan of care. • Keep pertinent laboratory reports for indications of infection or limbs close to body. • Review equate, streets with and common. Fires and andstrewn revise the plangarbage, of care every 3 pests monthsare or whenever • Cover the client’s scalp with a cap or turban. dehydration. External Variables the may client’sbe health status changes. violence frequent. Recreational facilities are limited, forcing • Remove excess blankets when the client feels warm, but • Supply warm oral or intravenous fluids. External variables affecting health include the physical environment, children to warming play in streets • Apply provide extra warmth when the client feels chilled. pads.and alleys. standards of living, family and cultural beliefs, and social support • Provide adequate nutrition and fluids (e.g., 2,500–3,000 mL/ PRACTICE GUIDELINES Occupational roles also predispose people to certain illnesses. networks. day) to meet the increased metabolic demands and prevent ForHome instance, some industrial workers may be exposed to carcinoHealth Care Documentation dehydration. genic agents.hypothermia, High-pressure social or occupational roles predispose with• severe a hyperthermia blanket (an electronically ENVIRONMENT • Report changes in the plan of care to the primary care provider • Measure intake and output. Complete a comprehensive nursing assessment and develop to stress-related Such roles may also encourage overeating controlled provides a specified temperature) is applied, a plan blanket of carediseases. to that meet Medicare and other third-party payer and document that these were reported. Medicare and • Reduce physical activity to limitaware heat production, especially and People are becoming increasingly of their environment requirements. Some agencies use the certification and plan of Medicaid will reimburse only for the skilled services provided or social use of drugs or excessive alcohol. and warm intravenous fluids are given. Wet clothing, which increases thetheir flush health stage. and level of wellness. Geographic locahow during it affects treatment form as the client’s official plan of care. that are reported to the primary care provider. • Administer antipyretics (drugs that reduce the level of fever) as heat• loss because of note the high conductivity of water, should • Encourage the client or home caregiver to record data when Write a progress at each client visit, noting any changes in be replaced tion determines climate, and climate affects health. For instance, FAMILY AND CULTURAL BELIEFS the client’s condition, nursing interventions performed (including appropriate. ordered. CLINICAL MANIFESTATIONS boxes with dry clothing. See Box 29–3 for nursing interventions for• clients malaria and oral malaria-related conditions occurmembranes more frequently education and instructional brochures and materials provided to Write a discharge summary for the primary care provider • Provide hygiene to keep the mucous moist. in The family passes on patterns ofclient dailyresponses living and lifestyles to offspring. who have hypothermia. the client and home caregiver), to nursing care, to approve the discharge and to notify the reimbursers that a aquick resource toPollution learn tropical rather than sponge temperate climates. of the water, air, • are Provide tepid bath to increase heat loss through For example, a man who was abused as a child may physically abuse and vital signs as indicated. services have been discontinued. Include all services provided, conduction. and soil affects the health of cells. Pollution can occur naturally (e.g., • Provide a monthly progress nursing summary to the attending the client’s health status at discharge, outcomes achieved, and key signs and symptoms of his own children. Physical orthe emotional abuse may cause long-term • Provide dry clothing recommendations for further care. primary care provider and toTemperature reimburser to confirm the need and bed linens. Assessing Body lightning-caused fires produce smoke, which pollutes the air). Some healthtoproblems. Emotional health depends on a social environment continue services. illness. The most acommon for inmeasuring bodyandtemperature are oral, man-made substances in the environment, such as asbestos, are concopy of thesites care plan the client’s home update it that•isKeep free of excessive tension and does not isolate the person from the client’s condition changes. rectal,asaxillary, tympanic membrane, and skin/temporal artery. Each sidered carcinogenic (i.e., they cause cancer). Tobacco is “hazardous others. A climate of open communication, sharing, and love fosters of the sites has advantages and disadvantages (Table 29–1). to one’s health, ” with rates of cancer higher among both smokers CLINICAL MANIFESTATIONS the fulfillment of the person’s optimum potential. The body temperature may be measured orally. If a client has themselves, and those who live or work near people who smoke in Culture and social interactions also influence how a person perPM PRACTICE GUIDELINES provide been taking cold or hot food or fluids 361 or smoking, the nurse should their environment. Date and Time Chapter 22 ● Promoting Health in Young and Middle-Aged Adults Hypothermia ceives, experiences, and copes with health and illness. Each culture Document the date and time of each This isorally essential 2400 wait 30 minutes before taking therecording. temperature to ensure that An environmental hazard is pulse, radiation. improper or exces• Decreased body temperature, and The respirations instant-access summaries of has about andalso these are often from parents notideas only for legalhealth, reasons safety. transmitted Record the time 1300 2300 12 the temperature of thebut mouthforisclient not affected by the temperature of sive use of medical for example, can harm many of the body’s • Severe shiveringx-rays, (initially) the conventional (e.g., 9:00 am or 3:15 ) or according toinchildren. Peoplemanner of certain cultures maypmperceive home remedies Developmental Assessment Guidelines 1 11 1200 clinical do’s and don’ts. • Feelings of cold and chills the food, fluid, or warm smoke. organs. Another common source of radiation is the sun’s ultraviolet the 24-hour (militaryasclock), which to avoids about 0100 ortotribal healthclock customs superior andconfusion more dependable than 1100 AM • Middle-Aged Pale, cool, waxy skin The Adult Rectal temperature are■considered to be very accurate. rays. Light-skinned people are more susceptible to the harmful efam or pmreadings (Figure 15–9 ). 1400 thewhether healtha time carewas practices of North American society. For example, 2200 a • Frostbite (discolored, blistered nose, fingers, toes) 2 • Enjoy Rectal temperatures Infects theseofthree areas, does the middle-aged adultmolecules do new freedom to be independent. are contraindicated for clients who are undergo- 10 the developmental sun than are dark-skinned people. Ozone in the 0200 1000 person ofroles Asian origin prefer to use • following? Hypotension • Accept changes the in family (e.g., havingmay teenage children and herbal remedies and acuTiming ing rectal surgery, have diarrhea or diseases of the rectum, are immunoatmosphere absorb most of the harmful sun radiation but the manu• Decreased urinary output aging parents).puncture treats policy pain about rather analgesic medications. Cultural Follow theto agency’ thethan frequency of documenting, and PHYSICAL DEVELOPMENT suppressed, a clotting disorder, • Interact facture ofofcertain products releases chemicals that damage the ozone effectively and share have companionable activities withor lifehave significant hemorrhoids. Lackweight muscle coordination • •Exhibit within normal range for age and sex. adjustvalues, the frequency as a client’ s condition example, rules, and beliefs give people aindicates; sense offor being stable and2100 able 0900 partner. 0300 3 1500 9 • layer, •Manifest Disorientation The axilla is often the preferred site for measuring temperature vital signsthe (e.g., blood pressure) withinrays normal for the earth’ increasing amount of harmful thatrange reach s surclient whose blood pressure is changing requires frequent • Expand and renew previous interests. toapredict outcomes. The challenging of oldmore beliefs and values by and sex. •ageDrowsiness progressing tolimiting coma the production of these in newborns because it is accessible and safe. Axillary temperatures ● face. International legislation documentation than a client whose blood pressure is constant. As 496 Unit 7 Assessing Health • chemiPursue charitable and altruistic activities. • Manifest visual and hearing abilities within normal range. second-generation cultural groups may give rise to conflict, instabil• Have a meaningful philosophy life. should documenting be done as soon as clinicians possible afterrecommend an area rule, lower thanof rectal temperatures. Some re• cals canappropriate lessen damage to the layer. Exhibit knowledge andozone attitudes about sexuality (e.g., 0400 ity, and insecurity, in turn contributing to illness. and cul- 8 0800 or OF intervention. No recording should be doneHeritage before about menopause). DEVELOPMENT INassessment ACTIVITIES DAILYaxillary LIVING 4 checking an elevated temperature with one taken from anThe main component of acid rain is sulfur dioxide, produced by DRUG CAPSULE 1600 • Verbalize any changes in eating, elimination, or exercise. • Follow preventive providing nursingon care. health practice. tural influences health are discussed in detail in Chapter 18 . 2000 thissmelters results in frostbite. Frostbite most commonly occurs are in hands, other site to confirm the degree of elevation. Nurses should check ore and related industries. The other components nitro0700 0500 PSYCHOSOCIAL DEVELOPMENT Cardiac Glycoside or Digitalis Glycoside Digoxin (Lanoxin) 0600 feet, nose, and ears.emissions, brought down by the air when it rains, agency protocol when taking the temperature of newborns, infants, 7 5 oxides. These • gen Accept aging body. SOCIAL SUPPORT NETWORKS Legibility • Assess for signs CAPSULE boxes CLIENT WITH CARDIAC MEDICATIONS of digoxin toxicity: nausea, vomiting, • Feel comfortable and respectDRUG 1900 self. involves 6 anorexia,1700 Managing hypothermia toddlers, children. Adult clients fortowhom axillary method of blurred All THAT entries must beHEART legible and (family, easy to read prevent are thought to damage forests, lakes, andremoving rivers. the client from the Having a and support network friends, orthe ainterpretaconfidant) anddiarrhea, job AFFECT RATE or “yellow” vision, unusual tiredness and 1800 tionCardiac errors.glycosides Hand printing or easilycontractility, understood handwriting iswhom other increase cardiac which increases carweakness. cold An andenvironmental rewarming thehazard client’s that body. For the client with mild hypotemperature assessment isavoid appropriate include those for is a receiving more attention isof an provide brief overview satisfaction helps people illness. Support persons also help the diac permissible. output. As a result, to the kidneysabout is increased, which usually Followperfusion the agency’ s policies handwritten CLIENT15–9 AND ■ FAMILY TEACHING thermia, in thethe body is rewarmed by” applying the client temperature sites are contraindicated. increase “greenhouse effect. The glassblankets; roof of afor greenhouse Figure The 24-hour clock. individual confirm that illness with support increases the production of urine.exists. CardiacPeople glycosides alsoinadequate decrease recording. drug information, nursing • Explain the reason for taking digoxin and the importance of heart rate by prolonging cardiac conduction, especially at the AV node. permits the sun’ s radiation to penetrate, butfor theMiddle-Aged resulting heat does BOX 22–4 Health Promotion Guidelines Adults networks sometimes allow themselves to become increasingly illmedical be- checkups that may include laboratory work to evaluate Digoxin is commonly used for the clinical management of heart the effects and dosage of the drug. not escape back throughresponsibilities, the glass. Carbon dioxideand in the client earth’s atPermanence agency’ s policies about the type of pen and ink used for recording. In fore confirming the illness and and seeking therapy. Support people also failure, atrial fibrillation, atrial flutter, paroxysmal atrial tachycardia. • Teach the client and/or family how to check the radial or carotid SAFETY HEALTH TESTS AND SCREENING TABLEacts 29–1 Advantages Disadvantages of Sites Used forthe Body Temperature Measurements All reinforcement, entries onmotivation the client’ s record are made innight dark ink so thatwell the reregards changesInform are made withatthe mosphere like the glass roof of aand greenhouse, and as carbon di• Annual physical • Motor provide for an ill person to become again. NURSING RESPONSIBILITIES pulsetoforEHRs, a full minute. themintoaccordance take the pulse thesoftware examination vehicle safety especially when driving at teaching to help you cord is permanent and changes can be identified. Dark ink reproguidelines. It iseach important fortothe nurse to the understand policies and • same time day and write it on calendar.the Provide Take the apical pulse for 1 minute before administering the • • Immunizations as recommended, such as aand tetanus booster emissions, Workplace oxide levels increase due to industrial automobile the safety measures pulse parameters andcare tell them when regarding it is appropriate to call the dose. If the apical pulse is 60 beats/min or anotherFollow specificthe • Disadvantages duces well on microfilm in< duplication processes. procedures of the health institution documentation. Site Advantages for influenza every 10 years, and currentunderstand recommendations Home safety measures: keeping hallways and stairways lighted of surface temperature of the earth may also be implications increasing. health care provider. parameter set by the health care provider, vaccine and uncluttered, using smoke detectors, using nonskid mats do not administer Accessible and convenient are pesticides Thermometers can the break bitten. • Caution the client not to stop taking the digoxin without doseifand retake the pulseMODELS in 1 hour. If pulse remains < 60, • Oral and handrails HEALTH in the bathrooms Regular assessments (e.g., every 6 months) Otherdental sources of environmental contamination BELIEF pharmacotherapy in different call the prescriber. Note: If the initial resting pulse is significantly approval of the health care provider. Inaccurate if client has just ingested hot or cold food or fluid or smoked. • Tonometry for signs of glaucoma and other eye diseases every and chemicals used to control weeds and plant diseases. These con- ANDSeveral models of health beliefs and have been the client to avoid over-the-counter drugs, except on NUTRITION EXERCISE • Caution 88 (35 in.) or Less cm (35 in.) — — —

—

Overweight 25.0–29.9

Increased

High

Obesity

30.0–34.9 I 35.0–39.9 II

High Very high

Very high Very high

Extreme obesity

40.0+

III

Extremely high Extremely high

*Disease risk for type 2 diabetes, hypertension, and cardiovascular disease. +

More than 7.5″ (191 mm)

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= 24.9

Box 47–2 provides an interpretation of the results. Another measure of body mass is percent body fat. Because BMI uses only height and weight, it can give misleading results for certain groups of clients such as athletes, frail older adults, and children. The most accurate percentage of body fat can be measured by underwater weighing and dual-energy x-ray absorptiometry (DEXA), but these methods are time consuming and expensive (Roth, 2014). Other indirect, but more practical measures include waist circumference (see Box 47–2), skinfold testing, and bioelectrical impedance analysis.

*Determine body-frame size by measuring the client’s wrist circumference and applying to the table below. Add 10% for large body-frame size, and subtract 10% for small body-frame size.

Height Less Than 5′2″ (Less Than 155 cm) Small Less than 5.5″ (140 mm) Medium 5.5″–5.75″ (140– 146 mm) Large More than 5.75″ (146 mm)

1height in meters22

72 kilograms

Approximating Ideal Body Weight

Female Wrist Measurements

weight in kilograms

1.7 * 1.7 meters

BODY WEIGHT AND BODY MASS STANDARDS

1157

Increased waist circumference can also be a marker for increased risk even in individuals of normal weight. From Aim for a Healthy Weight, National Heart, Lung, and Blood Institute, n.d., Washington, DC: U.S. Department of Health & Human Services. Retrieved from http://www.nhlbi.nih .gov/health/public/heart/obesity/lose_wt/bmi_dis.htm

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Unit 10

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Promoting Physiological Health

FACTORS AFFECTING NUTRITION

Although the nutritional content of food is an important consideration when planning a diet, an individual’s food preferences and habits are often a major factor affecting actual food intake. Habits about eating are influenced by developmental considerations, gender, ethnicity and culture, beliefs about food, personal preferences, religious practices, lifestyle, economics, medications and therapy, health, alcohol consumption, advertising, and psychological factors.

Development

People in rapid periods of growth (i.e., infancy and adolescence) have increased needs for nutrients. Older adults, on the other hand, may need fewer calories and also need some dietary changes in view of their risk for coronary heart disease, osteoporosis, and hypertension.

Sex

Nutrient requirements are different for men and women because of body composition and reproductive functions. The larger muscle mass of men translates into a greater need for calories and proteins. Because of menstruation, women require more iron than men do prior to menopause. Pregnant and lactating women have increased caloric and fluid needs.

Ethnicity and Culture

Ethnicity often determines food preferences. Traditional foods (e.g., rice for Asians, pasta for Italians, curry for Indians) are eaten long after other customs are abandoned. Nurses should not use a “good food, bad food” approach, but rather should realize that variations of intake are acceptable under different circumstances. The only “universally” accepted guidelines are (a) to eat a wide variety of foods to furnish adequate

nutrients and (b) to eat moderately to maintain body weight. Food preference probably differs as much among individuals of the same cultural background as it does between cultures. Not all Italians like pizza, for example, and many undoubtedly enjoy Mexican food.

Beliefs About Food

Beliefs about effects of foods on health and well-being can affect food choices. Many people acquire their beliefs about food from television, magazines, and other media. Some people are reducing their intake of animal fats in response to evidence that excessive consumption of animal fats is a major risk factor in vascular disease, including heart attack and stroke. Food fads that involve nontraditional food practices are relatively common. A fad is a widespread but short-lived interest or a practice followed with considerable zeal. It may be based either on the belief that certain foods have special powers or on the notion that certain foods are harmful. Food fads appeal to the individual seeking a miracle cure for a disease, the person who desires superior health, or someone who wants to delay aging. Some fad diets are harmless, but others are potentially dangerous. Determining the needs a fad diet fills for the client enables the nurse both to support these needs and to suggest a more nutritious diet.

Personal Preferences

People develop likes and dislikes based on associations with a typical food. A child who loves to visit his grandparents may love pickled crabapples because they are served in the grandparents’ home. Another child who dislikes a very strict aunt grows up to dislike the chicken casserole she often prepared. People often carry such preferences into adulthood.

Culturally Responsive Care Common Variations in Nutritional Practices and Preferences Many religions and cultures have historically followed specific dietary guidelines. These practices may or may not be applicable to the ­client under your care; they are generalizations. It is important to e ­ xercise caution and not to convert a generalization into an expectation of what a particular client’s behaviors and preferences will be. Nurses must always ask individual clients about their dietary practices and preferences when considering some of the common variations. VARIATIONS IN RESTRICTIONS • Pork, beef, shellfish, or red meats lightly-cooked (rare) may not be permitted. Certain combinations of foods may be prohibited. In some cultures, foods must be prepared in a certain manner and with specific, approved equipment. • Alcohol or caffeine-containing beverages may be prohibited. • Some religions and cultures observe fasting practices each year. This may consist of a lunar month of fasting during ­daylight hours for some, 40 days of fasting for others, periodic cleansing fasts, or other fasting traditions.

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PATIENT-CENTERED CARE Foods coming from a source that “has a face” are not eaten (vegan). These foods plus foods such as dairy, eggs, or fish may be eaten, but mammal flesh is prohibited (various ­vegetarian practices). • Clients with glucose or lactose intolerance may restrict or ­eliminate these foods. •

VARIATIONS IN PREFERENCES • Beverages may be preferred after, not during, the meal. • Rice, tortillas, pasta, and other grain products may be used instead of bread. • Soy sauce may be used instead of salt. • The main meal of the day may be at noontime rather than in the evening. • Room temperature or hot water may be preferred instead of ice water. • The use of spices varies by culture. • Some cultures may serve basic foods on a daily basis (meat and potatoes, rice and beans); others prefer to eat a wide variety of foods and food styles.

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Individual likes and dislikes can also be related to familiarity. Children often say they dislike a food before they sample it. Some adults are very adventuresome and eager to try new foods. Others prefer to eat the same foods repeatedly. Preferences in the tastes, smells, flavors (blends of taste and smell), temperatures, colors, shapes, and sizes of food influence a person’s food choices. Some people may prefer sweet and sour tastes to bitter or salty tastes. Textures play a great role in food preferences. Some people prefer crisp food to limp food, firm to soft, tender to tough, smooth to lumpy, or dry to soggy.

Religious Practices

Religious practice also affects diet. Some Roman Catholics avoid meat on certain days, and some Protestant faiths prohibit meat, tea, coffee, or alcohol. Both Orthodox Judaism and Islam prohibit pork. Orthodox Jews observe kosher customs, eating certain foods only if they are inspected by a rabbi and prepared according to dietary laws. The nurse must plan care with consideration of such religious dietary practices.

Lifestyle

Certain lifestyles are linked to food-related behaviors. People who are always in a hurry probably buy convenience grocery items or eat restaurant meals. People who spend many hours at home may take time to prepare more meals “from scratch.” Individual differences also influence lifestyle patterns (e.g., cooking skills, concern about health). Some people work at different times, such as evening or night shifts. They might need to adapt their eating habits to this and also make changes in their medication schedules if they are related to food intake. Muscular activity affects metabolic rate more than any other factor; the more strenuous the activity, the greater the stimulation of the metabolism. Mental activity, which requires only about 4 Kcal per hour, provides very little metabolic stimulation.

Economics

What, how much, and how often a person eats are frequently affected by socioeconomic status. For example, people with limited income, including some older adults, may not be able to afford meat and fresh vegetables. In contrast, people with higher incomes may purchase more proteins and fats and fewer complex carbohydrates. Not all individuals have the financial resources for extensive food preparation and storage facilities. The nurse should not assume that clients have their own stove, refrigerator, or freezer. In some low-income areas, food costs at small local grocery stores can be significantly higher than at large chain stores farther away.

Medications and Therapy

The effects of drugs on nutrition vary considerably. They may alter appetite, disturb taste perception, or interfere with nutrient absorption or excretion. Nurses need to be aware of the nutritional effects of specific drugs when evaluating a client for nutritional problems. The nursing history interview should include questions about the medications the client is taking. Conversely, nutrients can affect drug utilization. Some nutrients can decrease drug absorption; others enhance absorption. For example, the calcium in milk hinders absorption of the antibiotic tetracycline but enhances the absorption of the antibiotic erythromycin. Older adults are at particular risk for drug– food interactions due to the number of medications they may take,

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age-related physiological changes affecting medication actions (e.g., decrease in lean-to-fat ratio, decrease in renal or hepatic function), and disease-restricted diets. Selected drug and nutrient interactions are shown in Table 47–1. Therapies prescribed for certain diseases (e.g., chemotherapy and radiation for cancer) may also adversely affect eating patterns and nutrition. Normal cells of the bone marrow and the gastrointestinal (GI) mucosa are naturally very active and particularly susceptible to antineoplastic agents. Oral ulcers, intestinal bleeding, or diarrhea resulting from the toxicity of the antineoplastic agents used in chemotherapy can seriously diminish a person’s nutritional status. The effects of radiotherapy depend on the area that is treated. Radiotherapy of the head and neck may cause decreased salivation, taste distortions, and swallowing difficulties; radiotherapy of the abdomen and pelvis may cause malabsorption, nausea, vomiting, and diarrhea. Many clients undergoing radiotherapy feel profound fatigue and anorexia (loss of appetite).

Health

An individual’s health status greatly affects eating habits and nutritional status. Missing teeth, ill-fitting dentures, or a sore mouth makes chewing food difficult. Difficulty swallowing (dysphagia) due to a painfully inflamed throat or a stricture of the esophagus can prevent a person from obtaining adequate nourishment. Disease processes and surgery of the GI tract can affect digestion, absorption, metabolism, and excretion of essential nutrients. GI and other diseases also create nausea, vomiting, and diarrhea, all of which can adversely affect a person’s appetite and nutritional status. Gallstones, which can block the flow of bile, are a common cause of impaired lipid digestion. Metabolic processes can be impaired by diseases of the liver. Diseases of the pancreas can affect glucose metabolism or fat digestion. Autoimmune and genetic disorders such as celiac disease and irritable bowel syndrome may be worsened when eating foods containing wheat or gluten. Between 30 million and 50 million Americans have lactose intolerance (also called lactose maldigestion), a shortage of the enzyme lactase, which is needed to break down the sugar in milk. Certain populations are more widely affected, especially African Americans, American Indians, Ashkenazi Jews, and Asian Americans, although they may not always show symptoms (DeBruyne & Pinna, 2014).

Alcohol Consumption

The calories in alcoholic drinks include both those of the alcohol itself and of the juices or other beverages added to the drink. These can constitute large numbers of calories, for example, 150 calories for a regular 12-ounce beer, and 160 calories for a “screwdriver” (1.5 ounces vodka plus 4 ounces orange juice). Drinking alcohol can lead to weight gain through adding these calories to the regular diet plus the effect of alcohol on fat metabolism. A small amount of the alcohol is converted directly to fat. However, the greater effect is that the remainder of the alcohol is converted into acetate by the liver. The acetate released to the bloodstream is used for energy instead of fat and the fat is then stored. Excessive alcohol use contributes to nutritional deficiencies in several ways. Alcohol may replace food in a person’s diet, and it can depress the appetite. Excessive alcohol can have a toxic effect on the intestinal mucosa, thereby decreasing the absorption of nutrients.

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TABLE 47–1   Selected Drug–Nutrient Interactions Drug

Effect On Nutrition

Acetylsalicylic acid (aspirin)

Decreases serum folate and folacin nutrition. Increases excretion of vitamin C, thiamine, potassium, amino acids, and glucose. May cause nausea and gastritis.

Antacids containing aluminum or magnesium hydroxide

Decrease absorption of phosphate and vitamin A. Inactivate thiamine. May cause deficiency of calcium and vitamin D. Increase excretion of sodium, potassium, chloride, calcium, magnesium, zinc, and riboflavin.

Thiazide diuretics

May cause anorexia, nausea, vomiting, diarrhea, or constipation. Decrease absorption of vitamin B12. May cause diarrhea, nausea, or vomiting.

Potassium chloride

Increases excretion of potassium, magnesium, and calcium. May cause anorexia, nausea, or vomiting. Is incompatible with protein hydrolysates.

Laxatives

May cause calcium and potassium depletion. Mineral oil and phenolphthalein (Ex-Lax) decrease absorption of vitamins A, D, E, and K.

Antihypertensives

Hydralazine may cause anorexia, vomiting, nausea, and constipation. Methyldopa increases need for vitamin B12 and folate. May cause dry mouth, nausea, vomiting, diarrhea, and constipation.

Anti-inflammatory agents

Colchicine decreases absorption of vitamin B12, carotene, fat, lactose, sodium, potassium, protein, and cholesterol. Prednisone decreases absorption of calcium and phosphorus.

Antidepressants

Amitriptyline increases food intake (large amounts may suppress intake).

Antineoplastics

Can cause nausea, vomiting, anorexia, malabsorption, and diarrhea.

Nutrient

Effect on Drugs

Grapefruit

Can cause toxicity when taken with a variety of medications including amiodarone, carbamazepine, cisapride, cyclosporine, diazepam, nifedipine, saquinavir, statins, terfenadine, verapamil.

Vitamin K

Can decrease the effectiveness of warfarin (Coumadin).

Tyramine (found in aged cheeses, tap beer, dried sausages, fermented soy, sauerkraut)

In combination with monoamine oxidase inhibitor (MAOI) medications, e.g., isocarboxazid (Marplan), isoniazid, linezolid, phenelzine, tranylcypromine, creates sudden increase in epinephrine leading to headaches, increased pulse and blood pressure, and possible death.

Milk

Interferes with absorption of tetracycline antibiotics.

The need for vitamin B increases, because it is used in alcohol metabolism. Alcohol can impair the storage of nutrients and increase nutrient catabolism and excretion. Several studies have shown health benefits of moderate alcohol consumption. Examples include reduced risk of cardiovascular disease, strokes, dementia, diabetes, and osteoporosis. However, any benefits of alcohol must be weighed against the many harmful effects, and the possibility of alcohol abuse.

Advertising

Food producers try to persuade people to change from the product they currently use to the brand of the producer. Popular actors are often used in television, radio, Internet, and print to influence consumers’ choices. Advertising is thought to influence people’s food choices and eating patterns to a certain extent. Of note is that such products as alcoholic beverages, coffee, frozen foods, and soft drinks are more heavily advertised than such products as bread, vegetables, and fruits. Convenience foods (frozen or packaged and easy to prepare) and take-out (fast) foods are heavily advertised. Children’s television show commercials often promote snack foods, candy, soda, and sugared cereals over fresh, healthy foods. Australia, Canada, Sweden, and

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Great Britain have adopted regulations prohibiting food advertising on programs targeting audiences of young children. There has been an increase in advertising that targets older adults in particular and encourages use of herbs and supplements. Some products are nutritionally safe, whereas others are not and can cause interactions with medications they might be taking or cause unexpected side effects. The cost of some of these supplements is also usually high, is generally not covered by health insurance, and may take money that the person could spend for healthier food.

Psychological Factors

Although some people overeat when stressed, depressed, or lonely, others eat very little under the same conditions. Anorexia and weight loss can indicate severe stress or depression. Anorexia nervosa and bulimia are severe psychophysiological conditions seen most frequently in female adolescents.

NUTRITIONAL VARIATIONS THROUGHOUT THE LIFE CYCLE

Nutritional requirements vary throughout the life cycle. Guidelines follow for the major developmental stages.

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Neonate to 1 Year

The neonate’s fluid and nutritional needs are met by breast milk or formula. Fluid needs of infants are proportionately greater than those of adults because of a higher metabolic rate, immature kidneys, and greater water losses through the skin and the lungs. Therefore, fluid balance is a critical factor. Under normal environmental conditions, infants do not need additional water beyond that obtained from breast or bottle formula feedings; however, neonates in very warm environments may require additional fluids. The total daily nutritional requirement of the newborn is about 80 to 100 mL of breast milk or formula per kilogram of body weight. The newborn infant’s stomach capacity is about 90 mL, and feedings are required every 2 1/2 to 4 hours. The newborn infant is usually fed “on demand.” Demand ­feeding means that the child is fed when hungry rather than on a set time schedule. This method tends to decrease the problem of overfeeding or underfeeding the infant. The newborn who is hungry usually cries and exhibits tension in the entire body. During feeding, the infant sucks readily and needs burping after each ounce of formula or after 5 minutes of breast-feeding. Infants demonstrate satisfaction by slowing their sucking activity or by falling asleep. Infants should not be coaxed into finishing the feeding. This could lead to discomfort or overfeeding. When feeding is completed, healthy infants can be placed in a supine position for sleep during the first 6 months of life to reduce the risk of sudden infant death syndrome (SIDS). Regurgitation, or spitting up, during or after a feeding is a common occurrence during the first year. Although this may concern parents, it does not usually result in nutritional deficiency. Demonstration of adequate weight gain should reassure parents that the infant is receiving adequate nutrition. Adding solid food to the diet usually takes place between 4 and 6 months of age. Six-month-old infants can consume solid food more readily because they can sit up, can hold a spoon, and have decreased sucking and tongue protrusion reflexes. Solid foods (strained or pureed) are generally introduced in the following order: cereals (rice before oat and wheat), fruits, vegetables (yellow before green), and strained meats. Foods are introduced one at a time, usually with only one new food introduced every 5 days to ensure that the infant tolerates the food and demonstrates no allergy to it. This sequence can vary according to cultural preferences. With the eruption of teeth at about 7 to 9 months, the infant is ready to chew and can experience different textures of food. At this time, the infant enjoys finger foods, such as skinless fruit cut into small pieces to prevent choking, dry cereal, or toast. Because honey can contain spores of Clostridium botulinum and this has been a source of infection (and death) for infants, children less than 12 months old should not be fed honey. According to the Centers for Disease Control and Prevention (CDC) (2011), honey is safe for persons 1 year of age and older. At about 6 months of age, infants require iron supplementation to prevent iron deficiency anemia. Iron deficiency anemia is a form of anemia (decrease in red blood cells) caused by inadequate supply of iron for synthesis of hemoglobin. Cow’s milk is low in iron and, thus, iron-fortified cereals or formulas are usually recommended by 6 months of age and are continued until the child reaches 18 months. Weaning from the breast or bottle to the cup takes place gradually and is usually achieved by 12 to 24 months of age. It is recommended that infants be breast-fed exclusively for 6 months and then until 1 year

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of age or longer as desired (American Academy of Pediatrics, 2012). Some infants have difficulty giving up the bottle, particularly at naptime or bedtime. Parents should be warned that having the bottle in bed could lead to bottle mouth syndrome. The term describes decay of the teeth caused by constant contact with sweet liquid from the bottle. Some dentists advocate brushing or cleaning the infant’s teeth to prevent bottle mouth syndrome, especially for the infant who requires a bottle only at naptime or bedtime. Weaning from the bottle can be facilitated by diluting the formula with water increasingly until the infant is drinking plain water. By the age of 1, most infants can be completely fed on table food, and milk intake is about 20 ounces per day.

Toddler

Because of a maturing GI tract, toddlers can eat most foods and adjust to three meals each day. Toddlers’ fine motor skills are sufficiently well developed for them to learn how to feed themselves. Before the age of 20 months, most toddlers require help with glasses and cups because their wrist control is limited. By age 3, when most of the deciduous teeth have emerged, the toddler can bite and chew adult table food. Developing independence may be exhibited through the toddler’s refusal of certain foods. Meals should be short because of the toddler’s brief attention span and environmental distractions. Often toddlers display their liking of rituals by eating foods in a certain order, cutting foods a specific way, or accompanying certain foods with a particular drink. The toddler is less likely to have fluid imbalances than the infant. The toddler’s GI function is more mature, and the percentage of fluid body weight is lower. A healthy toddler weighing 15 kg (33 lb) needs about 1,250 mL of fluid per 24 hours. During the toddler stage, the caloric requirement is 1,000 to 1,400 Kcal/day. From 1 to 2 years of age, the toddler may eat a combination of prepared toddler foods and some table foods. Parents should be instructed to read labels carefully and be aware that table foods offer more variety and are less expensive and more nutritious than prepared toddler foods. The need for adequate iron, calcium, and vitamins C and A, which are common toddler deficiencies, should also be discussed. The following suggestions may help parents meet the child’s ­nutritional needs and promote effective parent–child interactions: (a) Make mealtime a pleasant time by avoiding tensions at the table and discussions of bad behavior; (b) offer a variety of simple, attractive foods in small portions, and avoid meals that combine foods into one dish, such as a stew; (c) do not use food as a reward or punish a child who does not eat; (d) schedule meals, sleep, and snack times that will allow for optimum appetite and behavior; and (e) avoid the routine use of sweet desserts.

Preschooler

The preschooler eats adult foods. Parents should become informed about the diet of their child in day care or preschool settings so that they can ensure that the child’s total nutritional needs are being met. Children at this age are very active and may rush through meals to return to playing. Active children often require snacks between meals. Cheese, fruit, yogurt, raw vegetables, and milk are good choices. The 4-year-old still requires parents’ help in cutting meat and may spill milk when pouring from a large container. Parents also need to teach the preschooler how to use utensils and should provide them with the opportunity to practice (e.g., buttering bread). However, 4- and 5-year-olds often use their fingers to pick up food. Children at this age may enjoy helping in the kitchen, and both girls and boys should be encouraged to do so.

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The preschooler is even less at risk than the toddler for fluid imbalances. The average 5-year-old weighing 20 kg (45 lb) requires at least 75 mL of liquid per kilogram of body weight per day, or 1,500 mL every 24 hours.

School-Age Child

School-age children require a balanced diet including approximately 1,600 to 2,200 Kcal/day. They can eat three meals a day and one or two nutritious snacks. Children need a protein-rich food at breakfast to sustain the prolonged physical and mental effort required at school. Children who skip breakfast become inattentive and restless by late morning and have decreased problem-solving ability. Undernourished children become fatigued easily and face a greater risk of infection, resulting in frequent absences from school. The average healthy 8-year-old weighing 30 kg (66 lb) requires about 1,750 mL of fluid per day. Many school-age children have only one meal a day with their family, at dinner. Mealtime should be a social time enjoyed by all, and parents should encourage good eating habits. Parents should be aware that children learn many of their food habits by observing their parents. Eating a balanced diet should be the norm for both parent and child. The school-age child generally eats lunch at school. The child may bring lunch from home or get lunch at the school. Many dietary problems stem from this independence in food choices. Children may trade their food, not eat lunch at all, or buy sweets or junk food with their lunch money. Parents should discuss with the child the foods that they should eat and continue to provide a balanced diet in the home setting. Poor eating habits may cause obesity. Childhood obesity is an increasing problem. More than 18% of American children ages 6 to 18 are overweight (at or above the 95% for BMI) (Ogden, Carroll, Kit, & Flegal, 2012). Obesity in school-age children tends to result in adult obesity and all the related health risks. It is both caused by and results in decreased activity and psychosocial problems. Obese children may be ridiculed and discriminated against by peers. Such behavior reinforces low self-esteem. The CDC’s Division of Adolescent and School Health has established many programs to address both prevention and treatment of childhood obesity. The goal of treatment for children who are overweight is to reduce weight gain, allowing their weight to increase more slowly than their height. Counseling and teaching for parents should include the following: • • • •

Reviewing the child’s eating habits, including snacks Altering meal content Using rewards other than food Promoting regular exercise.

Adolescent

The adolescent’s need for nutrients and calories increases, particularly during the growth spurt. In particular, the need for protein, calcium, vitamin D, iron, and B vitamins increases during adolescence. An adequate diet for an adolescent is 1 quart of milk per day and appropriate amounts of meat, vegetables, fruits, breads, and cereals. Calcium intake during adolescent years (1,200 to 1,500 mg/day) may help decrease osteoporosis (a decrease in bone density) in later life. Peak bone mineralization occurs on average at 12.5 years in girls and 14.0 years in boys when 40% of total adult bone mass is accumulated. The majority of adolescents do not get enough calcium (Roth, 2014). Many parents observe that teenagers, particularly boys, seem to eat all the time. Teenagers have active lifestyles and irregular eating

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patterns. They tend to diet or snack frequently, often eating high-­ calorie foods such as soft drinks, ice cream, and fast foods. Parents and nurses can promote better lifelong eating habits by encouraging teenagers to eat healthy snacks. Parents can provide healthy snacks such as fruits and cheese and limit the junk food available in the home. The teenager’s food choices relate to physical, social, and emotional factors and impulses and may not be influenced by teaching. Nurses need to advise parents to help adolescents take responsibility for their decisions in many areas of life, and to avoid conflicts that relate to food. Common problems related to nutrition and self-esteem among adolescents include obesity, anorexia nervosa, and bulimia. Obesity continues to be a problem in the adolescent period. Depression is not unusual among adolescents who are obese. Treatment of obesity in this age group includes education on nutrition and assessment of psychosocial problems that may produce overeating. Under social pressure to be slim, some adolescents severely limit their food intake to a level significantly below that required to meet the demands of normal growth. Sometimes, the adolescent may develop an eating disorder, such as anorexia or bulimia. These disorders are considered to be related to the need for control. Anorexia nervosa is characterized by a prolonged inability or refusal to eat, rapid weight loss, and emaciation in individuals who continue to believe they are fat. People with anorexia may also induce vomiting and use laxatives and diuretics to remain thin. Bulimia is an uncontrollable compulsion to consume enormous amounts of food (binge) and then expel it by self-induced vomiting or by taking laxatives (purge). These illnesses are most effectively treated in the early stages by psychotherapy. Hospitalization may be necessary when the effects of starvation become life threatening.

Young Adult

Many young adults are aware of the food groups but may not be knowledgeable about how many servings of each group they need or how much a serving constitutes. The nurse should provide the young adult client with resources such as a chart or list that contains the foods and the amounts needed in each category. Young adult females need to maintain adequate iron intake. Many women do not ingest sufficient dietary iron each day. To prevent iron deficiency anemia, menstruating females should ingest 18 mg of iron daily. The nurse should instruct the female client to include iron-rich foods, such as organ meats (liver and kidneys), eggs, fish, poultry, leafy vegetables, and dried fruits, in her daily diet. Go to nursing.pearsonhighered.com to download the Nutritional Reference Guide. In addition, the World Health Organization (WHO) recommends folate/folic acid supplements for all women of childbearing ability. Because folate can prevent neural tube defects in the fetus but must be taken prior to and during the early portion of the pregnancy, the United States and more than 50 other countries have mandated folic acid supplementation of enriched grain products. Calcium is needed in young adulthood to maintain bones and help decrease the chances of developing osteoporosis in later life. Along with calcium, the person must have adequate vitamin D, necessary for the calcium to enter the bloodstream. Vitamin D is made in the skin on exposure to the sun. If the person does not get sufficient sun exposure (15 minutes three times each week), supplements may be indicated. Obesity may occur during the young adult years as the active teen becomes the sedentary adult but does not decrease caloric intake. The young adult who is overweight or obese is at risk for hypertension, a major health problem for this age group.

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DRUG CAPSULE

Mineral  ferrous sulfate (Slow-Fe, Feosol), ferrous gluconate (Fergon) CLIENT WITH IRON DEFICIENCY ANEMIA Iron is required for the formation of red blood cells. When iron stores are low, the body cannot produce enough red blood cells and anemia can develop. Symptoms of iron deficiency anemia include fatigue, listlessness, anorexia, and pallor. Although iron deficiency anemia is not the only kind of anemia, it is possibly the most common and one of the easiest to treat. Immediate and timed-release forms are available. NURSING RESPONSIBILITIES • Administer on an empty stomach, 1 hour before or 2 hours after meals, with a full glass of water. If the client experiences gastric upset, administer with or after food. The immediate-release formulation is administered up to three times per day. • Vitamin C increases absorption of iron from the stomach. Some preparations contain both iron and vitamin C. • Administer at least 2 hours apart from antacids, ciprofloxacin, tetracycline, and several other medications. Consult a drug handbook for possible drug interactions. • Liquid forms should be diluted in a glass of water or juice and sipped through a straw to prevent staining of the teeth. • Shake suspension forms well before each use; take with a full glass of water.

Hypertension and obesity are 2 of more than 40 risk factors identified in the development of cardiovascular (CV) disease. Preventing these risk factors and lowering the risk of CV disease are critical. Low-fat and/or low-cholesterol diets play a significant role in both the prevention and treatment of CV disease.

Middle-Aged Adult

The middle-aged adult should continue to eat a healthy diet, following the recommended portions of the food groups, with special attention to protein and calcium intake, and limiting cholesterol and caloric intake. Two or three liters of fluid should be included in the daily diet. Postmenopausal women need to ingest sufficient calcium and vitamin D to reduce osteoporosis, and antioxidants such as vitamins A, C, and E may be helpful in reducing the risks of heart disease in women. Although iron supplements are no longer needed, the amount in a multivitamin is not harmful. Middle-aged adults who gain weight may not be aware of some common facts about this age period. Decreased metabolic activity and decreased physical activity mean a decrease in caloric need. The nurse’s role in nutritional health promotion is to counsel clients to prevent obesity by reducing caloric intake and participating in regular exercise. Clients should also be warned that being overweight is a risk factor for many chronic diseases, such as diabetes and hypertension, and for problems of mobility, such as arthritis. For the client who requires additional resources, a variety of programs is frequently available. Most programs use behavior modification techniques and group support to assist clients in reaching their goals. Clients should seek medical advice before considering any major changes in their diets. During late middle age, gastric juice secretions and free acid gradually decline. Some individuals may complain of “heartburn” (acid indigestion) or an increase in belching. They may determine that certain foods disagree with them. Clients should be advised to develop sensible eating habits and avoid fried or fatty foods.

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Iron comes in different dose strengths and may require adjustment for optimal effect.

CLIENT AND FAMILY TEACHING • Take the medication on an empty stomach, 1 hour before or 2 hours after meals, with a full glass of water. If upset stomach occurs, take with or after food, but not with coffee, tea, eggs, or milk because these decrease absorption. Do not lie down for 30 minutes after taking the tablet or capsule. • Sustained-release capsules and tablets must be swallowed whole. Do not crush or chew them because side effects may be increased. • Common side effects may include nausea, stomach cramps, vomiting, and constipation. These should decrease within a few days even while continuing the iron. • Stools will turn green-black, and this is normal. • Do not stop taking the medication, even if you feel stronger. • Do not take iron without consulting the primary care provider if you have a history of intestinal problems. • Store at room temperature, away from moisture and sunlight. Keep away from children. Accidental overdose can be fatal. Note: Prior to administering any medication, review all aspects with a current drug handbook or other reliable source.

Older Adults

The older adult requires the same basic nutrition as the younger adult. However, fewer calories are needed by older adults because of the lower metabolic rate and the decrease in physical activity. Some older adults may need more carbohydrates for fiber and bulk, but most nutrient requirements remain relatively unchanged. Such physical changes as tooth loss and impaired sense of taste and smell may affect eating habits. Decreased saliva and gastric juice secretion may also affect a person’s nutrition. Psychosocial factors may also contribute to nutritional problems. Some older adults who live alone do not want to cook for themselves or eat alone. They may adopt poor dietary habits. Other factors, such as lack of transportation, poor access to stores, and inability to prepare the food also affect nutritional status. Loss of spouse, anxiety, depression, dependence on others, and lowered income all affect eating habits (Table 47–2). Guidelines to include high-nutrient foods compatible with the nutritional needs of older adults are summarized in Client Teaching and in the Nutritional Reference Guide. Go to nursing.pearsonhighered.com to download the Nutritional Reference Guide. Also see Lifespan Considerations on pages 1138–1139.

STANDARDS FOR A HEALTHY DIET

Various daily food guides have been developed to help healthy people meet the daily requirements of essential nutrients and to facilitate meal planning. Food group plans emphasize the general types or groups of foods rather than the specific foods, because related foods are similar in composition and often have similar nutrient values. For example, all grains, whether wheat or oats, are significant sources of carbohydrate, iron, and the B vitamin thiamine. Food guides currently used include Dietary Guidelines for Americans and the U.S. Department of Agriculture’s (USDA’s) Food Guidance System (MyPlate, MyPyramid, food guide pyramids).

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TABLE 47–2   Problems Associated with Nutrition in Older Adults Problems Difficulty chewing

Nursing Interventions Encourage regular visits to the dentist to have dentures repaired, refitted, or replaced. Chop fruits and vegetables finely; shred green, leafy vegetables; select ground meat, poultry, or fish.

Lowered glucose tolerance

Eat more complex carbohydrates (e.g., breads, cereals, rice, pasta, potatoes, and legumes) rather than sugar-rich foods.

Decreased social interaction, loneliness

Promote appropriate social interaction at meals, when possible. Encourage the client and family to take an interest in food preparation and serving, perhaps as an ­activity they can do together. Encourage family or caregivers to present the food at a dining table with place mats, tablecloths, and napkins to trigger eating associations for the older adult. If food preparation is not possible, suggest community resources, such as Meals-on-Wheels. Suggest picnics in the yard or inviting friends over for meals.

Loss of appetite and senses of smell and taste

Eat essential, nutrient-dense foods first; follow with desserts and low-nutrient-density foods. Review dietary restrictions, and find ways to make meals appealing within these guidelines. Eat small meals frequently instead of three large meals a day.

Limited income

Suggest using generic brands and coupons. Substitute milk, dairy products, and beans for meat. Avoid convenience foods if able to cook. Buy foods that are on sale and freeze for future use. Suggest community resources and nutrition programs.

Difficulty sleeping at night

Have the major meal at noon instead of in the evening. Avoid tea, coffee, or other stimulants in the evening.

CLIENT TEACHING

Nutrition for Older Adults •

•

Include each food group on the Food Pyramid/MyPlate. For ­example, a 65-year-old female of average height and weight who performs less than 30 minutes of exercise per day requires 1,600 Kcal consisting of the following: Grains Vegetables Fruits Milk, yogurt, and cheese Meat and beans

5 ounces 2 cups 1.5 cups 3 cups 5 ounces

Reduce caloric intake. Caloric needs generally decrease in older adults often because of decreased activity. Older adults need to consume nutrient-dense foods and avoid foods that are high in calories but have few nutrients. • Reduce fat consumption. Use leaner cuts of meat, and limit portions to 4 to 6 oz per day. (But be sure intake of meat is sufficient, because older adults often consume inadequate amounts of these foods.) Broil, boil, or bake foods instead of frying them. Use low-fat milk and cheese; limit intake of butter, margarine, and salad dressings. • Reduce consumption of empty calories. Substitute fruit or puddings made with low-fat milk in place of pastry, cookies, and rich desserts.

•

•

•

•

•

Reduce sodium consumption for clients who have hypertension or other cardiac problems. Avoid canned soups, ketchup, and mustard. Avoid salted, smoked, cured, and pickled meats (e.g., ham and bacon), poultry, and fish. Do not add salt when cooking foods or at the table. Ensure adequate calcium intake (at least 800 mg) to prevent bone loss. Milk, cheese, yogurt, cream soups, puddings, and frozen milk products are good sources. Go to nursing .pearsonhighered.com to download the Nutritional Reference Guide and see the Major Food Sources of Calcium table. Ensure adequate vitamin D intake. Vitamin D is essential to maintain calcium homeostasis. Include some milk, because other dairy products are not usually fortified with vitamin D. If milk cannot be tolerated because of a lactose deficiency, provide vitamin supplements. Ensure adequate iron intake. Iron intake in older people may be compromised by such factors as increased incidence of GI disturbance, chronic diarrhea, regular aspirin use, and possible reduction in meat consumption. Go to nursing.pearsonhighered .com to download the Nutritional Reference Guide and see the Major Food Sources of Iron table. Consume fiber-rich foods to prevent constipation and minimize use of laxatives. Go to nursing.pearsonhighered.com to download the Nutritional Reference Guide and see the Fiber-Rich Foods table. Because fiber-rich foods provide bulk and a feeling of fullness, they help people control their appetites and lose weight.

LIFESPAN CONSIDERATIONS Nutrition CHILDREN • Children learn eating habits from their parents. It is the parents’ responsibility to be good nutritional role models, both in terms of what they eat and how they incorporate food into their lifestyle. • During the preschool and early school-age years, children learn lifelong eating habits. It is the parents’ responsibility to provide the child with adequate amounts of nutritious foods in an environment that is relaxed and comfortable for eating. It is the

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child’s responsibility to decide what and how much of the nutritious foods to eat. Parents should be counseled that eating can become a source of conflict if the parent tries to tell the child what and how much to eat, or if the child tries to tell the parent what foods should be eaten. Children’s access to “junk food” should be limited, but completely forbidding a food may also create conflict. • Adolescents who are vegan or vegetarians are at risk for some nutritional deficits.

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LIFESPAN CONSIDERATIONS Nutrition—continued OLDER ADULTS Most older adults take several medications. Considerations for potential problems include the following: • Some foods interact adversely or decrease the effectiveness of certain medications, such as foods high in vitamin K and the anticoagulant warfarin (Coumadin). Older adults should not change their diet significantly without consulting the health care provider since drug dosage may have been based on the older adult’s previous dietary intake. • Some medications increase appetite, such as glucocorticoids. • Some medications decrease appetite by their actions or by causing an unpleasant taste. • Certain tablets should not be crushed to be given by mouth or by gastric tubes, such as enteric-coated or slow-release medications. Conditions such as neuromuscular disorders and dementia can make it difficult for older adults to eat or to be fed. Safety should

Dietary Guidelines for Americans

This guide is published by the USDA every 5 years, and the 2010 ­edition contains recommendations for the total diet that allows food choices that result in a nutrient-rich and calorie-balanced intake. Key points of the latest dietary guidelines follow: • • • •

•

• •

Shift to more plant-based foods such as vegetables, fruits, grains, beans, and nuts. Significantly reduce foods with added sugars and solid fats. Engage in regular physical activity. Consume foods, including milk products, each day that increase commonly insufficient nutrients: vitamin D, calcium, potassium, and fiber. Keep daily total fat intake within 20% to 35% of total calories, less than 7% from saturated fatty acids and less than 300 mg cholesterol. (See also Client Teaching for ways to reduce fat intake.) Consume less than 1,500 mg of sodium per day. If you drink alcohol, do so in moderation (one drink per day for women and two drinks per day for men).

These dietary recommendations are intended to help achieve the nutritional goals stated in Healthy People 2020 (U.S. Department of Health and Human Services, 2013). Those goals include 22 specific nutritional objectives, such as the following: • • • •

Reduce the incidence of obese adults (target = 30.5%) and children (target = 14.5%). Increase the proportion of persons ages 2 years and older who consume no more than 2,300 mg of sodium daily. Prevent inappropriate weight gain in youth and adults. Reduce consumption of calories from solid fats and added sugars in the population ages 2 years and older (target = 29.8%).

THE FOOD GUIDE PYRAMID AND MYPLATE The Food Guide Pyramid is a graphic aid developed by the USDA as a guide in making daily food choices. On the pyramid, the food groups—grains, vegetables, fruits, milk, and meat and beans—are drawn from the base of the pyramid to the apex. This indicates that activity, moderation, personalization, proportionality, variety, and gradual improvement are the keys to good nutrition (Figure 47–1 •).

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always be a priority concern with attention paid to prevent aspiration. All health care personnel and family caregivers should be taught proper techniques to reduce this risk. Effective techniques include: • Use the chin-tuck method when feeding clients with dysphagia. Have them flex the head toward the chest when swallowing to decrease the risk of aspiration into the lungs. • Use foods of prescribed consistency. Many older adults can swallow foods with thicker consistency more easily than thin liquids. • Try to focus on food preferences—the family can help provide this information. • Try to maintain mealtime as a positive social occasion with conversations and extra attention to having a pleasant environment. Economic factors may influence older adults’ nutritional status if they cannot afford food, especially if a prescribed diet requires expensive supplements. Inexpensive or convenience foods such as canned soups are often high in fat and sodium.

CLIENT TEACHING

Reducing Dietary Fat • • • • • • • • • • • •

Cook meat by grilling, baking, broiling, or microwaving rather than frying. Substitute popcorn or pretzels for such snacks as potato chips, cheese puffs, and corn chips. Read labels. Some crackers, for example, are high in fat; ­others are not. Limit desserts high in fat, such as candy, ice cream, cake, and cookies. Substitute hard candies for chocolate bars. Use skim or reduced-fat milk instead of whole milk, for ­drinking as well as in recipes. Use less butter or margarine on breads. Remove fat from meat and skin from chicken before cooking. Eat less meat; eat more fish. Use less dressing, or use low-fat dressings, on salads. Eat plant sources of protein (e.g., kidney, lima, and navy beans). Use nuts as a source of protein, but since they are high in fat, use to replace meat rather than in addition.

There are many variations of the standard food pyramid. Examples include the pyramid for young children, the Healthy Eating Pyramid from the Harvard School of Public Health, an Asian food pyramid, and a pyramid for older adults. Food guide pyramids or other shaped diagrams exist for many cultures, and Georgia State University has translated the original pyramid into more than 36 languages. In May 2011, First Lady Michelle Obama introduced the MyPlate icon as a simpler reminder of how to implement the dietary guidelines. This depiction, and the website that accompanys it, promote getting more fruits and vegetables, whole grains, and low-fat dairy foods into the diet (Figure 47–2 •). Although it may replace the pyramid in many settings, both diagrams are consistent with the Dietary Guidelines. Using and following the guide does not guarantee that a person will consume the necessary levels of all essential nutrients. For example, someone who chooses cooked and low-fiber fruits and vegetables might not have an adequate intake of dietary fiber even though the recommended number of servings is eaten. However, the

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Anatomy of MyPyramid One size doesn't fit all USDA's new MyPyramid symbolizes a personalized approach to healthy eating and physical activity. The symbol has been designed to be simple. It has been developed to remind consumers to make healthy food choices and to be active every day. The different parts of the symbol are described below.

Activity Activity is represented by the steps and the person climbing them, as a reminder of the importance of daily physical activity.

Proportionality Proportionality is shown by the different widths of the food group bands. The widths suggest how much food a person should choose from each group. The widths are just a general guide, not exact proportions. Check the Web site for how much is right for you.

Moderation Moderation is represented by the narrowing of each food group from bottom to top. The wider base stands for foods with little or no solid fats or added sugars. These should be selected more often. The narrower top area stands for foods containing more added sugars and solid fats. The more active you are, the more of these foods can fit into your diet.

Variety Variety is symbolized by the 6 color bands representing the 5 food groups of the Pyramid and oils. This illustrates that foods from all groups are needed each day for good health.

Gradual Improvement Gradual improvement is encouraged by the slogan. It suggests that individuals can benefit from taking small steps to improve their diet and lifestyle each day.

U.S. Department of Agriculture Center for Nutrition Policy and Promotion April 2005 CNPP-16

GRAINS

VEGETABLES

FRUITS

OILS

Personalization Personalization is shown by the person on the steps, the slogan, and the URL. Find the kinds and amounts of food to eat each day at MyPyramid.gov.

MILK

MEAT& BEANS

USDA is an equal opportunity provider and employer.

Figure 47–1  •  The anatomy of the Food Guide Pyramid. From U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2005.

food guide is easy to follow, and people who eat a variety of foods from each group, in the suggested amounts, are likely to come close to recommended nutrient levels.

Recommended Dietary Intake

Figure 47–2  •  MyPlate illustrates the five food groups using a familiar mealtime visual, a place setting. From U.S. Department of Agriculture, 2013.

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The Committee on the Scientific Evaluation of Dietary Reference Intakes of the Institute of Medicine publishes dietary reference intakes (DRIs) tables, which contain four sets of reference values: estimated average requirements (EARs), recommended dietary allowances (RDAs), adequate intakes (AIs), and tolerable upper intake levels (ULs). Definitions of these terms are found in Box 47–3. The values for RDAs and AIs in the tables are modified for different age groups and according to gender. The effect of illness or injury (increasing the need for nutrients) and the variability among individuals within any given subgroup are not taken into account in the DRIs. Consumers most commonly learn recommended dietary intake information from the U.S. Food and Drug Administration (FDA) nutrition labels. Food labeling is required for most prepared foods, such as breads, cereals, canned and frozen foods, snacks, desserts, and drinks. Nutrition labeling for raw produce (fruits and vegetables) and fish is voluntary. Everyone must learn how to read and interpret these labels. In Figure 47–3 •, the section at the top of the label ❶ indicates serving size and number of servings in the container. The remaining

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BOX 47–3   Definitions for Dietary Reference Value Tables Dietary reference intakes (DRIs) are the standards for nutrient recommendations that include the following values: • Estimated average requirement (EAR): the average daily nutrient intake value estimated to meet the requirement of half the healthy individuals in a particular life stage and gender group • Recommended dietary allowance (RDA): the average daily nutrient intake level sufficient to meet the nutrient requirement of nearly all (97% to 98%) healthy individuals in a particular life stage and gender group • Adequate intake (AI): used when RDA cannot be determined; a recommended average daily nutrient intake level based on

observed or experimentally determined approximations or estimates of nutrient intake for a group (or groups) of healthy people that are assumed to be adequate • Tolerable upper intake level (UL): the highest average daily nutrient intake level likely to pose no risk of adverse health effects to almost all individuals in a particular life stage and gender group. As intake increases above the UL, the potential risk of adverse health effects increases. Source: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (p. 3), by the National Academy of Sciences, 2005, Washington, DC: National Academies Press. Reprinted with permission. Retrieved from http://www.nal.usda .gov/fnic/DRI//DRI_Energy/energy_full_report.pdf

Sample label for Macaroni & Cheese

Start Here

Nutrition Facts Serving Size 1 cup (228g) Servings Per Container 2 Amount Per Serving

Check Calories

Calories 250

Calories from Fat 110 % Daily Value*

Limit these Nutrients

Get Enough of these Nutrients

Total Fat 12g Saturated Fat 3g Trans Fat 3g Cholesterol 30mg Sodium 470mg Total Carbohydrate 31g

18% 15% 10% 20% 10%

Dietary Fiber 0g Sugars 5g Protein 5g

0%

Vitamin A Vitamin C Calcium Iron

4% 2% 20% 4%

Quick Guide to % DV • 5% or less is Low • 20% or more is High

* Percent Daily Values are based on a 2,000 calorie diet. Your Daily Values may be higher or lower depending on your calorie needs.

Footnote

Total Fat Sat Fat Cholesterol Sodium Total Carbohydrate Dietary Fiber

Calories: Less than Less than Less than Less than

2,000 65g 20g 300mg 2,400mg 300g 25g

2,500 80g 25g 300mg 2,400mg 375g 30g

Figure 47–3  •  The Nutrition Facts label. From How to Understand and Use the Nutrition Facts Label, by the U.S. FDA/Center for Food Safety & Applied Nutrition, 2004. Retrieved from http://www.fda.gov/Food/IngredientsPackagingLabeling/ LabelingNutrition/ucm274593.htm

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information on the label indicates the values for each serving. If the person consumes a container that has more than one serving, the person must multiply the values to determine the real nutrient content. The next section ❷ indicates the number of total calories and calories from fat per serving. Based on a 2,000-calorie diet, a serving with 40 calories is considered low, 100 calories moderate, and 400 calories high. Section ❸ has those nutrients that should be minimized: fats, cholesterol, and sodium. A “% Daily Value” (DV) of 5% or less is low, and 20% or more is high. When adding the % DV from all foods eaten in one day, the goal is to keep the total below 100%. Packaged foods must list trans-fat content. Trans-fats are created when unsaturated oils are hydrogenated to create a solid form and are used in frying foods, margarine, and many snack products. They are also present in meat and dairy fats. Trans-fats have been shown to increase cholesterol and contribute to heart disease. The next section ❹ includes fiber, vitamins, and minerals commonly insufficient in American diets. When adding the percent values from all foods eaten in one day, the goal is for the total DV of each of these to be at least 100%. The footnote ❺ indicates the approximate DVs for fat cholesterol, sodium, total carbohydrate, and fiber for 2,000- and 2,500-calorie diets. The 2,000-calorie values are used for the % DV numbers in the upper sections ❻. Note that the % DV on this label has not yet been revised to reflect the 2010 dietary guidelines. If the label on a food is missing, consumers can retrieve the information from several websites.

Vegetarian Diets

People may become vegetarians for economic, health, religious, ethical, or ecologic reasons. There are two basic vegetarian diets: those that use only plant foods (vegan) and those that include milk, eggs, or dairy products. Some people eat fish and poultry but not beef, lamb, or pork; others eat only fresh fruit, juices, and nuts; and still others eat plant foods and dairy products but not eggs. Go to nursing .pearsonhighered.com to download the Nutritional Reference Guide to see the Types of Vegetarian Diets table. Vegetarian diets can be nutritionally sound if they include a wide variety of foods and if proper protein and vitamin and mineral supplementation are provided. Because the proteins found in plant foods are incomplete proteins, vegetarians must eat complementary protein foods to obtain all of the essential amino acids. A plant protein can be complemented by combining it with a different plant protein. The combination produces a complete protein (Box 47–4). Obtaining complete proteins is especially important for growing children and pregnant and lactating women, whose protein needs are high. Generally, legumes (starchy beans, peas, lentils) have complementary relationships with grains, nuts, and seeds. Complementary foods must be eaten in the same meal. Diets such as the fruitarian diet do not provide sufficient amounts of essential nutrients and are not recommended for long-term use. Foods of animal origin are the best source of vitamin B12. Therefore, vegans need to obtain this vitamin from other sources: brewer’s yeast, foods fortified with vitamin B12, or a vitamin supplement. Because iron from plant sources is not absorbed as efficiently as iron from meat, vegans should eat iron-rich foods (e.g., green leafy vegetables, whole grains, raisins, and molasses) and iron-­enriched foods. They should eat a food rich in vitamin C at each meal to enhance iron absorption. Calcium deficiency is a concern only for strict vegetarians. It can be prevented by including in the diet soybean

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BOX 47–4

Combinations of Plant Proteins That Provide Complete Proteins

Grains plus legumes = complete protein. Legumes plus nuts or seeds = complete protein. Grains, legumes, nuts, or seeds plus milk or milk products (e.g., cheese) = complete protein. Grains Brown rice Barley Corn meal Millet Oats/oatmeal Rye Whole wheat

Legumes Black beans Kidney beans Lima beans Soybeans Lentils Tofu Black-eyed peas Split peas

Nuts and Seeds Almonds Brazil nuts Cashews Pecans Walnuts Pumpkin seeds Sesame seeds Sunflower seeds

Examples

Black-eyed peas and rice Lentil soup and whole-wheat bread Beans and tortillas Lima beans and sesame seeds Cereal with milk Macaroni with cheese

milk and tofu (soybean curd) fortified with calcium and leafy green vegetables.

ALTERED NUTRITION

Malnutrition is commonly defined as the lack of necessary or appropriate food substances, but in practice includes both undernutrition and overnutrition. Overnutrition refers to a caloric intake in excess of daily energy requirements, resulting in storage of energy in the form of adipose tissue. As the amount of stored fat increases, the individual becomes overweight or obese. A person is said to be overweight when the BMI is between 25 and 29.9 kg/m2 and obese when the BMI is >30 kg/m2 (National Heart, Lung, and Blood Institute, n.d.). Excess body weight increases the stress on body organs and predisposes people to chronic health problems such as hypertension and diabetes mellitus. Obesity that interferes with mobility or breathing is referred to as morbid obesity. Obese individuals may also manifest undernourishment in important nutrients (e.g., essential vitamins or minerals) even though excess calories are ingested. Undernutrition refers to an intake of nutrients insufficient to meet daily energy requirements because of inadequate food intake or improper digestion and absorption of food. An inadequate food intake may be caused by the inability to acquire and prepare food, inadequate knowledge about essential nutrients and a balanced diet, discomfort during or after eating, dysphagia, anorexia, nausea, vomiting, and so on. Improper digestion and absorption of nutrients may be caused by an inadequate production of hormones or enzymes or by medical conditions resulting in inflammation or obstruction of the GI tract. Inadequate nutrition is associated with marked weight loss, generalized weakness, altered functional abilities, delayed wound healing, increased susceptibility to infection, decreased immunocompetence, impaired pulmonary function, and prolonged length of hospitalization. In response to undernutrition, carbohydrate reserves, stored as

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liver and muscle glycogen, are mobilized. However, these reserves can only meet energy requirements for a short time (e.g., 24 hours) and then body protein is mobilized. Protein-calorie malnutrition (PCM), seen in starving children of underdeveloped countries, is now also recognized as a significant problem of clients with long-term deficiencies in caloric intake (e.g., those with cancer and chronic disease). Characteristics of PCM are depressed visceral proteins (e.g., albumin), weight loss, and visible muscle and fat wasting. Protein stores in the body are generally divided into two compartments: somatic and visceral. Somatic protein consists largely of skeletal muscle mass; it is assessed most commonly by conducting anthropometric measurements such as the mid-arm circumference (MAC) and the mid-arm muscle area (MAMA). (See the Anthropometric Measurements section on page 1144.) Visceral protein includes plasma protein, hemoglobin, several clotting factors, hormones, and antibodies. It is usually assessed by measuring serum protein levels such as albumin and transferrin, discussed in the Biochemical (Laboratory) Data section of Assessing, which follows.

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NURSING MANAGEMENT

Assessing A nutritional assessment identifies clients at risk for malnutrition and those with poor nutritional status. In most health care facilities, the responsibility for nutritional assessment and support is shared by the primary care provider, the dietitian, and the nurse. A comprehensive nutritional assessment is often performed by a nutritionist or a dietitian, and the primary care provider. Components of a nutritional assessment are shown in Table 47–3 and may be remembered as ABCD data: anthropometric, biochemical, clinical, and dietary.

Nutritional Screening Because a comprehensive nutritional assessment is time consuming and expensive, various levels and types of assessment are available. Nurses perform a nutritional screen. A nutritional screen is an assessment performed to identify clients at risk for malnutrition or those who are malnourished. For clients who are found to be at moderate or high risk for malnutrition (Box 47–5), follow-up is provided in the

TABLE 47–3   Components of a Nutritional Assessment Anthropometric data

Biochemical data

Clinical data

Dietary data

Screening Data

Additional In-Depth Data

•

Height Weight • Ideal body weight • Usual body weight • Body mass index

•

•

•

•

Hemoglobin Serum albumin • Total lymphocyte count

•

•

•

•

Skin Hair and nails • Mucous membranes • Activity level

•

•

•

• •

Triceps skinfold (TSF) Mid-arm circumference (MAC) • Mid-arm muscle area (MAMA)

Serum transferrin level Urinary urea nitrogen • Urinary creatinine excretion

24-hour food recall Food frequency record

Hair analysis Neurologic testing

Selective food frequency record Food diary • Diet history • •

BOX 47–5   Summary of Risk Factors for Nutritional Problems DIET HISTORY • Chewing or swallowing difficulties (including ill-fitting dentures, dental caries, and missing teeth) • Inadequate food budget • Inadequate food intake • Inadequate food preparation facilities • Inadequate food storage facilities • Intravenous fluids (other than total parenteral nutrition for 10 or more days) • Living and eating alone • Physical disabilities • Restricted or fad diets MEDICAL HISTORY • Adolescent pregnancy or closely spaced pregnancies • Alcohol or substance abuse • Catabolic or hypermetabolic condition: burns, trauma • Chronic illness: end-stage renal disease, liver disease, AIDS, pulmonary disease (e.g., COPD), cancer

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Fluid and electrolyte imbalance GI problems: anorexia, dysphagia, nausea, vomiting, diarrhea, constipation • Neurologic or cognitive impairment • Oral and GI surgery • Unintentional weight loss or gain of 10% within 6 months • •

MEDICATION HISTORY* • Antacids • Antidepressants • Antihypertensives • Anti-inflammatory agents • Antineoplastic agents • Aspirin • Digitalis • Diuretics (thiazides) • Laxatives • Potassium chloride *The potential effects of some medications on nutrition are shown in Table 47–1 on page 1134.

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form of a comprehensive assessment by a dietitian. Medicare standards for nursing homes require that any resident who experiences unplanned or undesired weight loss of 5% or more in 1 month, 7.5% or more in 3 months, or 10% or more in 6 months receive a full nutritional assessment by a nurse. Nurses carry out nutritional screens through routine nursing histories and physical examinations. Custom-designed screens for a particular population (e.g., older adults and pregnant women) and specific disorders (e.g., cardiac disease) are available. Screening tools such as the Patient-Generated Subjective Global Assessment (PG-SGA; Figure 47–4 •) and the Nutrition Screening Initiative (NSI) can be incorporated into the nursing history. The PGSGA is a method of classifying clients as either well nourished, moderately malnourished, or severely malnourished based on a dietary history and physical examination. It was established primarily for use with cancer clients, but has been widely tested and is appropriate for both inpatient and outpatient clients with various diagnoses. The NSI is an ongoing project of the American Academy of Family Physicians, the American Dietetic Association, the National Council on Aging, and other organizations to promote nutrition screening and improved nutritional care for older adults. The NSI estimates that approximately half of hospitalized, nursing home, and

home care older adults are malnourished. The NSI screens older adults using a nutrition checklist that contains nine warning signs of conditions that can interfere with good nutrition (Box 47–6). Nursing History

As mentioned earlier, nurses obtain considerable nutrition-related data in the routine admission nursing history. Data include but are not limited to the following: • • • • • • • • • •

Age, sex, and activity level Difficulty eating (e.g., impaired chewing or swallowing) Condition of the mouth, teeth, and presence of dentures Changes in appetite Changes in weight Physical disabilities that affect purchasing, preparing, and eating Cultural and religious beliefs that affect food choices Living arrangements (e.g., living alone) and economic status General health status and medical condition Medication history.

Anthropometric Measurements Anthropometric measurements are noninvasive techniques that aim to quantify body composition. A skinfold measurement is

Figure 47–4  •  Scored Patient-Generated Subjective Global Assessment. Faith D. Ottery, 2005, 2006, 2014 email: [email protected] or http://www.pt-global.org Reprinted with permission.

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Figure 47–4  •  Continued

BOX 47–6   Nutritional Screening Tool Read the statement. Circle the number in the Yes column for those that apply to you. Total your nutritional assessment. If you scored 0–2: Good! Recheck your nutritional score in 6 months. If you scored 3–5: You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyle. ­Recheck your score in 3 months. If you scored 6 or above: You are at high nutritional risk. Take this checklist to your doctor, nurse practitioner, or home health nurse. Ask for help to improve your nutritional health. Nutritional Assessment Statements I have an illness or condition that made me change the kind or amount of food I eat. I eat fewer than two meals per day. I eat few fruits, vegetables, or milk products. I have three or more drinks of beer, liquor, or wine almost every day.

Yes 2 3 2 2

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I have tooth or mouth problems that make it hard for me to eat. I do not always have enough money to buy the food I need. I eat alone most of the time. I take three or more different prescribed or overthe-counter drugs a day. Without wanting to, I have lost or gained 10 pounds in the last 6 months. I am not always physically able to shop, cook, or feed myself. Total

2 4 1 1 2 2

_______

From Determine Your Nutritional Health, by the Nutrition Screening Initiative, 2008, Washington, DC: National Council on Aging. Reprinted with permission by the Nutrition Screening Initiative, a project of the American Dietetic Association, funded in part by a grant from Ross Products Division, Abbott Laboratories, Inc.

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TABLE 47–4

Standard Values for Anthropometric Measurements for Adults

Measurement Triceps skinfold

Male 12 mm

Female 20 mm

Mid-arm circumference

32 cm

28 cm

Mid-arm muscle area

54 cm2

30 cm2

From “Overview of Undernutrition,” in The Merck Manual Online, 2012, by R. S. Porter and J. L. Kaplan (Eds.). Retrieved from http://www.merckmanuals.com/professional/ nutritional_disorders/undernutrition/overview_of_undernutrition.html.

*

and the MAC. The MAMA is an estimate of lean body mass, or skeletal muscle reserves. If tables are not available, the nurse uses the following formula to calculate the MAMA from the triceps skinfold and MAC direct measurements: MAMA (cm2) =

Figure 47–5  •  Measuring the triceps skinfold.

3 midarm circumference 1cm2 - 13.14 * TSF cm24 2 4p –10 (males) or –6.5 (females) Standard values for anthropometric measurements for adults are shown in Table 47–4. Changes in anthropometric measurements occur slowly and reflect chronic rather than acute changes in nutritional status. They are used, therefore, to monitor the client’s progress for months to years rather than days to weeks. Ideally, initial and subsequent measurements need to be taken by the same clinician. In addition, measurements obtained need to be interpreted with caution. Fluctuations in hydration status that often occur during illness can influence the accuracy of results. In addition, normal standards often do not account for normal changes in body composition such as those that occur with aging.

Figure 47–6  •  Measuring the mid-arm circumference.

performed to determine fat stores. The most common site for measurement is the triceps skinfold (TSF). The fold of skin measured includes subcutaneous tissue but not the underlying muscle. It is measured in millimeters using special calipers. To measure the TSF, locate the midpoint of the upper arm (halfway between the acromion process and the olecranon process), then grasp the skin on the back of the upper arm along the long axis of the humerus (Figure 47–5 •). Placing the calipers 1 cm (0.4 in.) below the nurse’s fingers, measure the thickness of the fold to the nearest millimeter. The mid-arm circumference (MAC) is a measure of fat, muscle, and skeleton. To measure the MAC, ask the client to sit or stand with the arm hanging freely and the forearm flexed to horizontal. Measure the circumference at the midpoint of the arm, recording the measurement in centimeters, to the nearest millimeter (e.g., 24.6 cm) (Figure 47–6 •). The mid-arm muscle area (MAMA) is then calculated by using reference tables or by using a formula that incorporates the TSF

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Biochemical (Laboratory) Data Laboratory tests provide objective data to the nutritional assessment, but because many factors can influence these tests, no single test specifically predicts nutritional risk or measures the presence or degree of a nutritional problem. The tests most commonly used are serum proteins, urinary urea nitrogen and creatinine, and total lymphocyte count. Serum Proteins

Serum protein levels provide an estimate of visceral protein stores. Tests commonly include hemoglobin, albumin, transferrin, and total iron-binding capacity. A low hemoglobin level may be evidence of iron deficiency anemia. However, abnormal blood loss or a pathologic process such as GI cancer must be ruled out before iron deficiency related to diet is confirmed. Albumin, which accounts for over 50% of the total serum proteins, is one of the most common visceral proteins evaluated as part of the nutritional assessment. Because there is so much albumin in the body and because it is not broken down very quickly (i.e., it has a half-life of 18 to 20 days), albumin concentrations change slowly. A low serum albumin level is a useful indicator of prolonged protein depletion rather than acute or short-term

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changes in nutritional status. However, many conditions besides malnutrition can depress albumin concentration, such as altered liver function, hydration status, and losses from open wounds and burns. Transferrin binds and carries iron from the intestine through the serum. Because it has a shorter half-life than albumin (8 to 9 days), transferrin responds more quickly to protein depletion than albumin. Serum transferrin can be measured directly or by a total ironbinding capacity (TIBC) test, which indicates the amount of iron in the blood to which transferrin can bind. Transferrin levels below normal are found with protein loss, iron deficiency anemia, pregnancy, hepatitis, or liver dysfunction. Prealbumin, also referred to as thyroxine-binding albumin or transthyretin, has the shortest half-life and smallest body pool and is, therefore, the most responsive serum protein to rapid changes in nutritional status. Prealbumin levels of 15 to 35 mg/dL are normal, below 15 indicates clients at risk, and below 11 indicates that aggressive nutritional intervention is needed. Urinary Tests

Urinary urea nitrogen and urinary creatinine are measures of protein catabolism and the state of nitrogen balance. Urea, the chief end product of amino acid metabolism, is formed from ammonia detoxified by the liver, circulated in the blood, and transported to the kidneys for excretion in urine. Urea concentrations in the blood and urine, therefore, directly reflect the intake and breakdown of dietary protein, the rate of urea production in the liver, and the rate of urea removal by the kidneys. The state of nitrogen balance is determined by comparing the nitrogen intake (grams of protein) to the nitrogen output over a 24-hour period. A positive nitrogen balance exists when intake exceeds nitrogen output; a negative nitrogen balance occurs when output exceeds nitrogen intake. Protein intake must be accurately recorded and kidney function must be normal to ensure the validity of a urinary urea nitrogen test. Urinary creatinine reflects a person’s total muscle mass because creatinine is the chief end product of the creatine produced when energy is released during skeletal muscle metabolism. The rate of creatinine formation is directly proportional to the total muscle mass. Creatinine is removed from the bloodstream by the kidneys and excreted in the urine at a rate that closely parallels its formation. The greater the muscle mass, the greater the excretion of creatinine. As skeletal muscle atrophies during malnutrition, creatinine excretion decreases. Urinary creatinine is influenced by protein intake, exercise, age, sex, height, renal function, and thyroid function. Total Lymphocyte Count

Certain nutrient deficiencies and forms of PCM can depress the immune system. The total number of lymphocyte white blood cells decreases as protein depletion occurs.

Clinical Data (Physical Examination) Physical examination reveals some nutritional deficiencies and excesses besides obvious weight changes. Assessment focuses on rapidly proliferating tissues such as skin, hair, nails, eyes, and mucosa but also includes a systematic review comparable to any routine physical

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examination. See Clinical Manifestations and Figure 47–7 • for signs associated with malnutrition. These signs must be viewed as suggestive of malnutrition because the signs are nonspecific. For example, red conjunctiva may indicate an infection rather than a nutritional deficit, and dry, dull hair may be related to excessive exposure to the sun rather than severe protein-energy malnutrition. To confirm malnutrition, clinical findings need to be substantiated with laboratory tests and dietary data. Calculating Percentage of Weight Loss

Accurate assessment of the client’s height, current body weight (CBW), and usual body weight (UBW) is essential. Although the client’s CBW can be compared with an ideal body weight discussed earlier, the IBW is based on healthy people and does not account for changes in the client’s body composition that accompany illness or reflect any changes in weight. The client’s UBW better indicates weight change and the possibility of malnutrition. Calculation and interpretation of the percentage of deviation from UBW and the percentage of weight loss are shown in Box 47–7. An important aspect of weight assessment, obtained during the nursing history, is a description of weight change. The nurse should document any weight loss or gain, the duration of the change, and whether the weight change was intentional or unintentional.

Dietary Data Dietary data includes the client’s usual eating patterns and habits; food preferences, allergies, and intolerances; frequency, types, and quantities of foods consumed; and social, economic, ethnic, or religious factors influencing nutrition. Factors may include, but are not limited to, living and eating companions, ability to purchase and prepare food, availability of refrigeration and cooking facilities, income, and effect of religion and ethnicity on food choices. Four possible methods for collecting dietary data are a 24-hour food recall, a food frequency record, a food diary, and a diet history. For a 24-hour food recall, the nurse asks the client to recall all of the food and beverages the client consumes during a typical 24-hour period when at home. The data obtained are then generally evaluated according to the Food Guide to judge overall adequacy. A food frequency record is a checklist that indicates how often general food groups or specific foods are eaten. Frequency may be categorized as times/day, times/week, times/month, or frequently, seldom, never. This record provides information about the types of foods eaten but not the quantities. When specific foods or nutrients are suspected of being deficient or excessive, the health care professional may use a selective food frequency that focuses, for example, on fat, fruit, vegetable, or fiber intake. A food diary is a detailed record of measured amounts (portion sizes) of all food and fluids a client consumes during a specified period, usually 3 to 7 days. A diet history is a comprehensive time-consuming assessment of a client’s food intake that involves an extensive interview by a nutritionist or dietitian. It includes characteristics of foods usually eaten and the frequency and amount of food consumed. It may include a 24-hour recall, a food frequency record, and a food diary. Medical and psychosocial factors are also assessed to evaluate their impact on

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B

C

A

Figure 47–7  •  Examples of nutritional deficiencies: A, dull, sparse hair and inflammation of the corners of the mouth from protein deficiency; B, rickets from vitamin D or calcium deficiency; C, pallagra, caused by a chronic lack of niacin (vitamin B). A from Centers for Disease Control and Prevention; B from Custom Medical Stock Photo; C from Biophoto Associates/Science Source.

nutritional requirements, food habits, and choices. Data obtained are analyzed by computer and translated into caloric and nutrient intake. Results are compared with the DRIs appropriate for the client’s age, sex, and condition.

Diagnosing NANDA International (Herdman & Kamitsuru, 2014) includes the following diagnostic labels for nutritional problems: • • • •

Imbalanced Nutrition: Less Than Body Requirements Obesity Overweight Readiness for Enhanced Nutrition

Many other NANDA nursing diagnoses may apply to certain individuals, because nutritional problems often affect other areas of human functioning. In this case, the nutritional diagnostic label may be used as the etiology of other diagnoses. Examples include: • Activity Intolerance related to inadequate intake of iron-rich

foods resulting in iron deficiency anemia

• Constipation related to inadequate fluid intake and fiber intake • Chronic Low Self-Esteem related to obesity

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• Risk for Infection related to immunosuppression secondary to in-

sufficient protein intake.

Planning Major goals for clients with or at risk for nutritional problems include the following: • • • • •

Maintain or restore optimal nutritional status. Promote healthy nutritional practices. Prevent complications associated with malnutrition. Decrease weight. Regain specified weight.

Specific nursing activities associated with each of these goals can be selected to meet the individual needs of the client. See the Nursing Care Plan and Concept Map at the end of this chapter.

Planning for Home Care To provide for continuity of care, the nurse must consider the client’s need for assistance with nutrition. Some clients will need help with eating, purchasing food, and preparing meals; others will need instructions about nutrition therapy.

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Implementing

CLINICAL MANIFESTATIONS Malnutrition Area of Examination (Possible Cause)

Signs Associated with Malnutrition

General appearance and vitality

Apathetic, listless, looks tired, easily fatigued

Weight

Overweight or underweight

Skin

Dry, flaky, or scaly; pale or pigmented; presence of petechiae or bruises; lack of subcutaneous fat; edema

Nails

Brittle, pale, ridged, or spoon shaped (iron)

Hair

Dry, dull, sparse, loss of color, brittle (­Figure 47–7A)

Eyes

Pale or red conjunctiva, dryness, soft ­ ornea, dull cornea, night blindness c (­vitamin A deficiency)

Lips

Swollen, red cracks at side of mouth, ­vertical fissures (B vitamins) (Figure 47–7C)

Tongue

Swollen, beefy red or magenta colored (B vitamins); smooth appearance (B vitamins deficiency); decrease or increase in size

Gums

Spongy, swollen, inflamed; bleed easily (vitamin C deficiency)

Muscles

Underdeveloped, flaccid, wasted, soft

GI system

Anorexia, indigestion, diarrhea, constipation, enlarged liver, protruding abdomen

Nervous system

Decreased reflexes, sensory loss, burning and tingling of hands and feet (B vitamins), mental confusion or irritability

Home care planning incorporates an assessment of the client’s and family’s abilities for self-care, financial resources, and the need for referrals and home health services. The Home Care Assessment box covers nutritional problems and needs. A major aspect of discharge planning involves the instructional needs of the client and family (see Client Teaching).

BOX 47–7

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Nursing interventions to promote optimal nutrition for hospitalized clients are often provided in collaboration with the primary care provider who writes the diet orders and the dietitian who informs clients about special diets. The nurse reinforces this instruction and, in addition, creates an atmosphere that encourages eating, provides assistance with eating, monitors the client’s appetite and food intake, administers enteral and parenteral feedings, and consults with the primary care provider and dietitian about nutritional problems that arise. In the community setting, the nurse’s role is largely educational. Nurses promote optimal nutrition at health fairs, in schools, at prenatal classes, and with well or ill clients and support people in their homes. In the home setting, nurses also initiate nutritional screens, refer clients at risk to appropriate resources, instruct clients about enteral and parenteral feedings, and offer nutrition counseling as needed. Nutrition counseling involves more than providing information. The nurse must help clients integrate diet changes into their lifestyle and provide strategies to motivate them to change their eating habits. All dietary instructions must be individually designed to meet the client’s intellectual ability, motivation level, lifestyle, culture, and economic status. Both nutritionists and dietitians help to adapt a diet to suit the client. Simple verbal instructions need to be given and reinforced with written material. Family and support persons must be included in the dietary instruction.

Assisting with Special Diets Alterations in the client’s diet are often needed to treat a disease process such as diabetes mellitus, to prepare for a special examination or surgery, to increase or decrease weight, to restore nutritional deficits, or to allow an organ to rest and promote healing. Diets are modified in one or more of the following aspects: texture, kilocalories, specific nutrients, seasonings, or consistency. Hospitalized clients who do not have special needs eat the regular (standard or house) diet, a balanced diet that supplies the metabolic requirements of a sedentary person (about 2,000 Kcal). Most agencies offer clients a daily menu from which to select their meals for the next day; others provide standard meals to each client on the general diet.

Calculating and Interpreting the Percentage of Deviation from Usual Body Weight and the Percentage of Weight Loss

CALCULATING PERCENTAGE OF USUAL BODY WEIGHT % Usual body weight =

current weight usual body weight

* 100

CALCULATING PERCENTAGE OF WEIGHT LOSS % Weight loss =

usual weight - current weight usual weight

* 100

Mild malnutrition

85–90%

Significant Weight Loss

Severe Weight Loss

Moderate malnutrition

75–84%

5% over 1 mo

Greater than 5% over 1 mo

Severe malnutrition

Less than 74%

7.5% over 3 mo

Greater than 7.5% over 3 mo

10% over 6 mo

Greater than 10% over 6 mo

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Home Care Assessment Nutrition CLIENT/ENVIRONMENT • Self-care abilities: Assess ability to feed self, to purchase food, and to prepare meals. • Adaptive feeding aids required: Determine need for special drinking cups, plates, or feeding utensils. • Instructional needs: Consider nutritional requirements (e.g., Food Guide Pyramid/MyPlate, dietary guidelines, special diet), adaptive aids available, recommended lifestyle variations, and management of enteral/parenteral nutrition. • Physical environment: Assess adequacy of water, electricity, refrigeration, and telephone facilities; and presence of clean, secure area to store and set up enteral/parenteral equipment as needed. FAMILY • Caregiver availability, skills, and willingness: Assess whether primary and secondary individuals are able to assist with food purchase, meal preparation, and feeding and able to comprehend and administer special diets or enteral/parenteral nutrition required. • Family role changes and coping: Consider effect on parenting and spousal roles, financial resources, and social roles.

PATIENT-CENTERED CARE •

Alternate potential primary or respite caregivers: Consider the availability of other caregivers, for example, other family members, volunteers, church members, paid caregivers, or housekeeping services; available community respite care (adult day care, senior centers) and so on.

COMMUNITY • Current knowledge, use, and experience with community resources: Review nutritional counseling services; home health agencies for enteral/parenteral nutrition support; dietitian or nutritionist for planning appropriate meals for prescribed diet, ways to include ethnic food preferences into the diet, and providing written meal plans; medical equipment and supply companies; financial assistance services; and support and ­educational services such as: • Weight management programs (e.g., Weight Watchers) • American Dietetic Association for information on all nutrition topics • National Eating Disorders Association • Meals-on-Wheels.

CLIENT TEACHING

Healthy Nutrition •

• • • • •

Instruct clients about the content of a healthy diet based on the Food Guide Pyramid/MyPlate and Dietary Guidelines for Americans Encourage clients, particularly older clients, to reduce dietary fat (see Client Teaching on reducing dietary fat, page 1139). Instruct strict vegetarians about proper protein complementation and additional vitamin and mineral supplementation. Discuss foods high in specific nutrients required such as protein, iron, calcium, vitamin C, and fiber. Discuss importance of properly fitted dentures and dental care. Discuss safe food preparation and preservation techniques as appropriate.

DIETARY ALTERATIONS • Explain the purpose of the diet. • Discuss allowed and excluded foods. • Explain the importance of reading food labels when selecting packaged foods. • Include family or significant others. • Reinforce information provided by the dietitian or nutritionist as appropriate. • Discuss herbs and spices as alternatives to salt and substitutes for sugar. FOR CLIENTS WHO ARE OVERWEIGHT • Discuss physiological, psychological, and lifestyle factors that predispose to weight gain. • Provide information about desired weight range and recommended calorie intake. • Discuss principles of a well-balanced diet and high- and lowcalorie foods. • Encourage intake of low-calorie, caffeine-free beverages, and plenty of water. • Discuss ways to adapt eating practices by using smaller plates, taking smaller servings, chewing each bite a specified number of times, and putting fork down between bites. • Discuss ways to control the desire to eat by taking a walk, drinking a glass of water, or doing slow deep-breathing exercises.

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Discuss the importance of exercise and help the client plan an exercise program. • Discuss stress reduction techniques. • Provide information about available community resources (e.g., weight-loss groups, dietary counseling, exercise programs, selfhelp groups). •

FOR CLIENTS WHO ARE UNDERWEIGHT • Discuss factors contributing to inadequate nutrition and weight loss. • Discuss recommended calorie intake and desired weight range. • Provide information about the content of a balanced diet. • Provide information about ways to increase calorie intake (e.g., high-protein or high-calorie foods and supplements). • Discuss ways to manage, minimize, or alter the factors contributing to malnourishment. • If appropriate, discuss ways to purchase low-cost nutritious foods. • Provide information about community agencies that can assist in providing food (e.g., Meals-on-Wheels). PREVENTING FOODBORNE ILLNESS • Reinforce hygienic handling of food and dishes: ▪▪ Wash hands before preparing foods. ▪▪ Wash hands and all dishes, utensils, and cutting boards with hot water and soap after contact with raw meats. ▪▪ Defrost frozen foods in the refrigerator. ▪▪ Cook beef, poultry, and eggs thoroughly. Use a cooking thermometer. ▪▪ Refrigerate leftovers promptly (at 40°F [5°C] or less) and keep no more than 3 to 5 days. ▪▪ Wash or peel raw fruits and vegetables. ▪▪ Do not use foods from containers that have been damaged or have opened seals. ▪▪ Follow the rules “keep hot foods hot and cold foods cold” and “when in doubt, throw it out.” • Recommend the client consider a preventive vaccination for hepatitis A. • Instruct clients to seek medical attention for prolonged vomiting, fever, abdominal pain, or severe diarrhea following a meal.

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A variation of the regular diet is the light diet, designed for postoperative and other clients who are not ready for the regular diet. Foods in the light diet are plainly cooked and fat is usually minimized, as are bran and foods containing a great deal of fiber. Diets modified in consistency are often given to clients before and after surgery or procedures or to promote healing in clients with GI distress. These diets include clear liquid, full liquid, soft, and diet as tolerated. In some agencies, GI surgery clients are not permitted red-colored liquids or candy since, if vomited, the color may be confused with blood. Clear Liquid Diet

This diet is limited to water, tea, coffee, clear broths, ginger ale, or other carbonated beverages, strained and clear juices, and plain gelatin. Note that “clear” does not necessarily mean “colorless.” This diet provides the client with fluid and carbohydrate (in the form of sugar), but does not supply adequate protein, fat, vitamins, minerals, or calories. It is a short-term diet (24 to 36 hours) provided for clients after certain surgeries or in the acute stages of infection, particularly of the GI tract. The major objectives of this diet are to relieve thirst, prevent dehydration, and minimize stimulation of the GI tract. Examples of foods allowed in clear liquid diets are shown in Box 47–8. Full Liquid Diet

This diet contains only liquids or foods that turn to liquid at body temperature, such as ice cream (see Box 47–8). Full liquid diets are often eaten by clients who have GI disturbances or cannot tolerate solid or semisolid foods. This diet is not recommended for long-term use because it is low in iron, protein, and calories. In addition, its cholesterol content may be high because of the amount of cow’s milk offered. Clients who must receive only liquids for long periods are usually given a nutritionally balanced oral supplement, such as Ensure or Sustacal. The full liquid diet is monotonous and difficult for clients to accept. Planning six or more feedings per day may encourage a more adequate intake. Soft Diet

The soft diet is easily chewed and digested. It is often ordered for clients who have difficulty chewing and swallowing. It is a low-­residue

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(low-fiber) diet containing very few uncooked foods; however, restrictions vary among agencies and according to individual tolerance. Examples of foods that can be included in a soft or semisoft diet are shown in Box 47–8. The pureed diet is a modification of the soft diet. Liquid may be added to the food, which is then blended to a semisolid consistency. Diet as Tolerated

“Diet as tolerated” is ordered when the client’s appetite, ability to eat, and tolerance for certain foods may change. For example, on the first postoperative day a client may be given a clear liquid diet. If no nausea occurs, normal intestinal motility has returned as evidenced by active bowel sounds and client reports passing gas, and the client feels like eating, the diet may be advanced to a full liquid, light, or regular diet. Modification for Disease

Many special diets may be prescribed to meet requirements for disease processes or altered metabolism. For example, a client with diabetes mellitus may need a diet recommended by the American Diabetes Association, an obese client may need a calorie-restricted diet, a cardiac client may need sodium and cholesterol restrictions, and a client with allergies will need a hypoallergenic diet. Some clients must follow certain diets (e.g., the diabetic diet) for a lifetime. If the diet is long term, the client must understand the diet and also develop a healthy, positive attitude toward it. Assisting clients and support persons with special diets is a function shared by the dietitian or nutritionist and the nurse. The dietitian informs the client and support persons about the specific foods allowed and not allowed and assists the client with meal planning. The nurse reinforces this instruction, assists the client to make changes, and evaluates the client’s responses. Dysphagia

Some clients may have no difficulty with choosing a healthy diet, but be at risk for nutritional problems due to dysphagia. These clients may have inadequate solid or fluid intake, be unable to swallow their medications, or aspirate food or fluids into the lungs—causing pneumonia. Clients at risk for dysphagia include older adults, those who have experienced a stroke, clients with cancer who have

BOX 47–8   Examples of Foods for Clear Liquid, Full Liquid, and Soft Diets Clear Liquid

Full Liquid

Soft

Coffee, regular and decaffeinated Tea Carbonated beverages Bouillon, fat-free broth Clear fruit juices (apple, cranberry, grape) Other fruit juices, strained Popsicles Gelatin Sugar, honey Hard candy

All foods on clear liquid diet plus: Milk and milk drinks Puddings, custards Ice cream, sherbet Vegetable juices Refined or strained cereals (e.g., cream of rice) Cream, butter, margarine Eggs (in custard and pudding) Smooth peanut butter Yogurt

All foods on clear and full liquid diets, plus: Meat: all lean, tender meat, fish, or poultry (chopped, shredded); spaghetti sauce with ground meat over pasta Meat alternatives: scrambled eggs, omelet, poached eggs; cottage cheese and other mild cheese Vegetables: mashed potatoes, sweet potatoes, or squash; ­vegetables in cream or cheese sauce; other cooked vegetables as tolerated (e.g., spinach, cauliflower, asparagus tips), chopped and mashed as needed; avocado Fruits: cooked or canned fruits; bananas, grapefruit and orange sections without membranes, applesauce Breads and cereals: enriched rice, barley, pasta; all breads; cooked cereals (e.g., oatmeal) Desserts: soft cake, bread pudding

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had radiation therapy to the head and neck, and others with cranial nerve dysfunction. Consider dysphagia if the client exhibits the following behaviors: coughs, chokes, or gags while eating; complains of pain when swallowing; has a gurgling voice; requires frequent oral suctioning. Nurses may be the first persons to detect dysphagia and are in an excellent position to recommend further evaluation; implement specialized feeding techniques and diets; and work with clients, family members, and other health care professionals to develop a plan to assist the client with difficulties. If the client condition suggests dysphagia, the nurse should review the history in detail; interview the client or family; assess the mouth, throat, and chest; and observe the client swallowing. Although absence of or a reduced gag reflex indicates the client will have difficulty swallowing, the presence of the gag reflex should not be interpreted to indicate that swallowing will not be impaired. A multidisciplinary group has developed the National Dysphagia Diet (NDD), which delineates standards of food textures (American Dietetic Association, 2002). The four levels of liquid foods are thin, nectar-like, honey-like, and spoon-thick liquids. The four levels of semisolid/solid foods are pureed, mechanically altered, advanced/mechanically soft, and regular/general. In consultation with the dietitian, occupational therapist, swallowing specialist, speech-language pathologist, and/or primary care provider, these levels can be used to determine a consistent approach to a particular client’s dysphagia. For example, a mechanically soft diet may result in lower pneumonia rates than a pureed diet in clients who have had a stroke and a history of aspiration pneumonia. Early detection and intervention can prevent the adverse outcomes of dysphagia in most clients.

Stimulating the Appetite Physical illness, unfamiliar or unpalatable food, environmental and psychological factors, and physical discomfort or pain may depress the appetites of many clients. A short-term decrease in food intake usually is not a problem for adults; over time, however, it leads to weight loss, decreased strength and stamina, and other nutritional problems. Decreased food intake is often accompanied by a decrease in fluid intake, which may cause fluid and electrolyte problems. Stimulating a person’s appetite requires the nurse to determine the reason for the lack of appetite and then deal with the problem. Some general interventions for improving the client’s appetite are summarized in Box 47–9. Assisting Clients with Meals Because clients in health care agencies are frequently confined to their beds, meals are brought to the client. The client receives a tray that has been assembled in a central kitchen. Nursing personnel may be responsible for giving out and collecting the trays; however, in most settings this is done by dietary personnel. Long-term care facilities and some hospitals serve meals to mobile clients in a special dining area. Guidelines for providing meals to clients are summarized in Box 47–10. Individuals who frequently require help with their meals include older adults who are weakened, individuals with disabilities such as visual impairment, those who must remain in a back-lying position,

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BOX 47–9   Improving Appetite •

• • •

• •

•

Provide familiar food that the person likes. Often the relatives of clients are pleased to bring food from home but may need some guidance about special diet requirements. Select small portions so as not to discourage the client. Avoid unpleasant or uncomfortable treatments immediately before or after a meal. Provide a tidy, clean environment that is free of unpleasant sights and odors. A soiled dressing, a used bedpan, an ­uncovered irrigation set, or even used dishes can negatively affect the appetite. Encourage or provide oral hygiene before mealtime. This ­improves the client’s ability to taste. Relieve illness symptoms that depress appetite before mealtime; for example, give an analgesic for pain or an antipyretic for a fever or allow rest for fatigue. Reduce psychological stress. A lack of understanding of ­therapy, the anticipation of an operation, and fear of the unknown can cause anorexia. Often, the nurse can help by discussing feelings with the client, giving information and ­assistance, and allaying fears.

or those who cannot use their hands. The client’s nursing care plan will indicate that assistance is required with meals. The nurse must be sensitive to clients’ feelings of embarrassment, resentment, and loss of autonomy. Whenever possible, the nurse should help clients feed themselves rather than feed them. Some clients become depressed because they require help and because they believe they are burdensome to busy nursing personnel. Although feeding a client is time consuming, nurses should try to appear unhurried and convey that they have ample time. Sitting at the bedside is one way to convey this impression. If the client is to be fed by unlicensed assistive personnel, the nurse must ensure that the same standards are met. When feeding a client, ask in which order the client would like to eat the food. If the client cannot see, tell the client which food is being given. Always allow ample time for the client to chew and swallow the food before offering more. Also, provide fluids as requested or, if the client cannot communicate, offer fluids after every three or four mouthfuls of solid food. Make the time a pleasant one, choosing topics of conversation that are of interest to clients who want to talk. Although normal utensils should be used whenever possible, special utensils may be needed to assist a client to eat. For clients who have difficulty drinking from a cup or glass, a straw often permits them to obtain liquids with less effort and less spillage. Special drinking cups are also available. One model has a spout; another is specially designed to permit drinking with less tipping of the cup than is normally required. Many adaptive feeding aids are available to help clients maintain independence. A standard eating utensil with a built-up or widened handle helps clients who cannot grasp objects easily. Utensils with wide handles can be purchased, or a regular eating utensil can be modified by taping foam around the handle. The foam increases friction and steadies the client’s grasp. Handles may be bent or angled to compensate for limited motion. Collars or bands that prevent the utensil from being dropped can be attached to the end of the handle

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BOX 47–10   Providing Client Meals • • •

• • •

•

•

Offer the client assistance with hand washing and oral hygiene before a meal. If it is permitted, assist the client to a comfortable position in bed or in a chair, whichever is appropriate. Clear the overbed table so there is space for the tray. If the ­client must remain in a lying position in bed, arrange the ­overbed table close to the bedside so the client can see and reach the food. Check each tray for the client’s name, the type of diet, and completeness. Do not leave an incorrect diet for a client to eat. Assist the client as required (e.g., remove the food covers, ­butter the bread, pour the tea, and cut the meat). For a client with a visual impairment, identify the placement of the food as you would describe the time on a clock (­Figure 47–8 •). For instance, the nurse might say, “The ­potatoes are at eight o’clock, the chicken at 12 o’clock, and the green beans at 4 o’clock.” After the client has completed the meal, observe how much and what the client has eaten and the amount of fluid taken. Use a standard tool to estimate the amount eaten in relation to a typical meal. For example, if served a donut and hot chocolate for breakfast, although the client may have eaten both of these, they certainly do not represent 100% of a nutritious breakfast. If the client is on a special diet or is having problems eating, ­record the amount of food eaten and any pain, fatigue, or ­nausea experienced.

•

If the client is not eating, document this so that changes can be made, such as rescheduling the meals, providing smaller, more frequent meals, or obtaining special self-feeding aids. 12 o’clock

9

3

8 o’clock

4 o’clock

6

Figure 47–8  •  For a client who is visually impaired, the nurse can use the clock system to describe the location of food on the plate.

and fit over the client’s hand. Clients requiring pureed or liquid diets are sometimes fed with a feeding syringe. Plates with rims and plastic or metal plate guards enable the client to pick up the food by first pushing it against this raised edge. A suction cup or damp sponge or cloth may be placed under the dish to keep it from moving while the client is eating. No-spill mugs and twohandled drinking cups are especially useful for individuals with impaired hand coordination. Stretch terry cloth and knitted or crocheted glass covers enable the client to keep a secure grasp on a glass. Lidded tip-proof glasses are also available. Figures 47–9 • and 47–10 • show some of these aids.

Special Community Nutritional Services In many places, community programs have been developed to help special groups meet nutritional needs. For older adults who cannot prepare meals or leave their homes, ready-to-eat meals or frozen dinners are delivered to the home by local organizations. Meals-on-Wheels is one such well-known organization.

Figure 47–9  •  Left to right: glass holder, cup with hole for nose, ­two-handled cup holder.

Figure 47–10  •  Dinner plate with guard attached and lipped plate

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facilitate scooping; wide-handled spoon and knife facilitate grip.

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For people who can prepare meals but have physical disabilities and cannot shop for groceries, grocery delivery services are available. For the poor in the United States, the USDA funds the Supplemental Nutrition Assistance Program. Through this program, people with low incomes can use stamps to purchase food at any approved grocery store. The value of the food stamps provided depends on the size and income of the family.

Enteral Nutrition Alternative feeding methods that ensure adequate nutrition include enteral (through the GI system) methods. Enteral nutrition (EN), also referred to as total enteral nutrition (TEN), is provided when the client cannot ingest foods or the upper GI tract is impaired and the transport of food to the small intestine is interrupted. Enteral feedings are administered through nasogastric and small-bore feeding tubes, or through gastrostomy or jejunostomy tubes.

Figure 47–11  •  Left, Single-lumen Levin tube. Right, Double-lumen Salem sump tube with filter on air vent port.

Enteral Access Devices

Enteral access is achieved by means of nasogastric or nasointestinal (nasoenteric) tubes, or gastrostomy or jejunostomy tubes. A nasogastric tube is inserted through one of the nostrils, down the nasopharynx, and into the alimentary tract. Traditional firm, large-bore nasogastric tubes (i.e., those larger than 12 Fr in diameter) are placed into the stomach. Examples are the Levin tube, a flexible rubber or plastic, single-lumen tube with holes near the tip, and the Salem sump tube, with a double lumen (Figure 47–11 •). The larger lumens allow delivery of liquids to the stomach or removal of gastric contents. When the Salem tube is used for suction of gastric contents, the smaller vent lumen (the proximal port is often referred to as the blue pigtail) allows for an inflow of atmospheric air, which prevents a vacuum if the gastric tube adheres to the wall of the stomach. Irritation of the gastric mucosa is thereby avoided. Softer, more flexible and less irritating small-bore feeding tubes (SBFTs), smaller than 12 Fr in diameter, are frequently used for enteral nutrition (Figure 47–12 •). Nasogastric tubes are used for feeding clients who have adequate gastric emptying, and who require short-term feedings. They are not

Figure 47–12  •  A polyurethane feeding tube designed for nasogastric and nasoduodenal feeding with a weighted tip for easier insertion. The feeding port is incompatible with luer lock or IV connections, reducing the risk of accidental connection or infusion. Tubes can be 8Fr-12Fr and 36”-55” long. Courtesy Covidien.

advised for feeding clients without intact gag and cough reflexes since the risk of accidental placement of the tube into the lungs is much higher in those clients. Skill 47–1 provides guidelines for inserting a nasogastric tube. Skill 47–4 later in this chapter outlines the steps for removing a nasogastric tube.

SKILL 47–1

Inserting a Nasogastric Tube PURPOSES • To administer tube feedings and medications to clients unable to eat by mouth or swallow a sufficient diet without aspirating food or fluids into the lungs • To establish a means for suctioning stomach contents to prevent gastric distention, nausea, and vomiting ASSESSMENT Check for history of nasal surgery or deviated septum. Assess patency of nares.

•

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• •

To remove stomach contents for laboratory analysis To lavage (wash) the stomach in case of poisoning or overdose of medications

• •

Determine presence of gag reflex. Assess mental status or ability to participate in the procedure.

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Inserting a Nasogastric Tube—continued

DELEGATION Insertion of a nasogastric tube is an invasive procedure requiring application of knowledge (e.g., anatomy and physiology, risk factors) and problem solving. In some agencies, only health care providers with advanced training are permitted to insert nasogastric tubes that require use of a stylet. Delegation of this skill to unlicensed assistive personnel (UAP) is not appropriate. The UAP, however, can assist with the oral hygiene needs of a client with a nasogastric tube.

INTERPROFESSIONAL PRACTICE Inserting a nasogastric tube may be within the scope of practice for some other health care providers such as physician assistants (PAs). Although the PA may verbally communicate their actions and plan to the health care team members, the nurse must also know where to locate their documentation in the client’s medical record.

Equipment • Large- or small-bore tube (nonlatex preferred) • Nonallergenic adhesive tape, 2.5 cm (1 in.) wide • Commercial securement device, if available • Clean gloves • Water-soluble lubricant • Facial tissues • Glass of water and drinking straw • 20- to 50-mL catheter-tip syringe • Basin • pH test strip or meter • Bilirubin dipstick • Stethoscope • Disposable pad or towel • Antireflux valve for air vent if Salem sump tube is used • Suction apparatus • Safety pin and elastic band • Clamp or plug (optional) • CO2 detector (optional)

SKILL 47–1

PLANNING Before inserting a nasogastric tube, determine the size of tube to be inserted and whether the tube is to be attached to suction.

IMPLEMENTATION Preparation • Assist the client to a high-Fowler’s position if his or her health condition permits, and support the head on a pillow. Rationale: It is often easier to swallow in this position and gravity helps the passage of the tube. • Place a towel or disposable pad across the chest. Performance 1. Prior to performing the insertion, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. The passage of a gastric tube is unpleasant because the gag reflex is activated during insertion. Establish a method for the client to indicate distress and a desire for you to pause the insertion. Raising a finger or hand is often used for this. 2. Perform hand hygiene and observe other appropriate infection prevention procedures (e.g., clean gloves). 3. Provide for client privacy. 4. Assess the client’s nares. • Apply clean gloves. • Ask the client to hyperextend the head, and, using a flashlight, observe the intactness of the tissues of the nostrils, including any irritations or abrasions. • Examine the nares for any obstructions or deformities by asking the client to breathe through one nostril while occluding the other. • Select the nostril that has the greater airflow. 5. Prepare the tube. • If a small-bore tube is being used, ensure stylet or guidewire is secured in position. Rationale: An improperly positioned stylet or guidewire can traumatize the nasopharynx, esophagus, and stomach. • If a large-bore tube is being used, place the tube in a basin of warm water while preparing the client. Rationale: This allows the tubing to become more pliable and flexible. However, if the softened tube becomes difficult to control, it may be helpful to place the distal end in a basin of ice water to help it hold its shape.

❶ Measuring the appropriate length to insert a nasogastric tube. 6. Determine how far to insert the tube. • Use the tube to mark off the distance from the tip of the client’s nose to the tip of the earlobe and then from the tip of the earlobe to the tip of the xiphoid. ❶ Rationale: This length approximates the distance from the nares to the stomach. This distance varies among individuals. • Mark this length with adhesive tape if the tube does not have markings. 7. Insert the tube. • Lubricate the tip of the tube well with water-soluble lubricant or water to ease insertion. In some agencies, topical Continued on page 1182

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SKILL 47–1

Inserting a Nasogastric Tube—continued lidocaine anesthetic is used on the tube or in the client’s nose to numb the area (Uri, Yosefov, Haim, Behrbalk, & Halpern, 2011). Rationale: A water-soluble lubricant dissolves if the tube accidentally enters the lungs. An oil-based lubricant, such as petroleum jelly, will not dissolve and could cause respiratory complications if it enters the lungs. • Insert the tube, with its natural curve downward, into the selected nostril. Ask the client to hyperextend the neck, and gently advance the tube toward the nasopharynx. Rationale: Hyperextension of the neck reduces the ­curvature of the nasopharyngeal junction. • Direct the tube along the floor of the nostril and toward the midline. Rationale: Directing the tube along the floor avoids the projections (turbinates) along the lateral wall. • Slight pressure and a twisting motion are sometimes required to pass the tube into the nasopharynx, and some client’s eyes may water at this point. Rationale: Tears are a natural body response. Provide the client with tissues as needed. • If the tube meets resistance, withdraw it, relubricate it, and insert it in the other nostril. Rationale: The tube should never be forced against resistance because of the danger of injury. • Once the tube reaches the oropharynx (throat), the client will feel the tube in the throat and may gag and retch. Ask the client to tilt the head forward, and encourage the client to drink and swallow. Rationale: Tilting the head forward facilitates passage of the tube into the posterior pharynx and esophagus rather than into the larynx; swallowing moves the epiglottis over the opening to the larynx. ❷ • If the client gags, stop passing the tube momentarily. Have the client rest, take a few breaths, and take sips of water to calm the gag reflex. • In cooperation with the client, pass the tube 5 to 10 cm (2 to 4 in.) with each swallow, until the indicated length is inserted. • If the client continues to gag and the tube does not advance with each swallow, withdraw it slightly, and inspect the throat by looking through the mouth. Rationale: The tube may be coiled in the throat. If so, withdraw it until it is straight, and try again to insert it. • If a CO2 detector is used, after the tube has been advanced approximately 30 cm (12 in.), draw air through the detector. Any change in color of the detector indicates placement of the tube in the respiratory tract. Immediately withdraw the tube and reinsert. 8. Ascertain correct placement of the tube. • Nasogastric tubes are radiopaque, and position can be ­confirmed by x-ray. If a SBFT is used, leave the stylet or guidewire in place until correct position is verified by x-ray. This is the only definitive method of verifying feeding tube tip placement. If an x-ray is not feasible, at least two of the ­following methods should be used.

SAFETY ALERT!

SAFETY

If the stylet has been removed, never reinsert it while the tube is in place. Rationale: The stylet is sharp and could pierce the tube and injure the client or cut off the tube end.

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Pharynx Epiglottis (open) Larynx Esophagus Trachea

Epiglottis (closed) Esophagus Trachea

❷ Swallowing closes the epiglottis.

Aspirate stomach contents, and check the pH, which should be acidic. Rationale: Testing pH is a reliable way to determine location of a feeding tube. Gastric contents are commonly pH 1 to 5; 6 or greater would indicate the contents are from lower in the intestinal tract or in the respiratory tract. However, pH may not discriminate between gastric and esophageal placement (Stepter, 2012). • Aspirate can also be tested for bilirubin. Bilirubin levels in the lungs should be almost zero, while levels in the stomach will be approximately 1.5 mg/dL and in the intestine more than 10 mg/dL. • Historically, nurses placed a stethoscope over the client’s epigastrium and injected 10 to 30 mL of air into the tube while listening for a whooshing sound. This method does not guarantee tube position. • If the signs indicate placement in the lungs, remove the tube and begin again. • If the signs do not indicate placement in the lungs or stomach, advance the tube 5 cm (2 in.), and repeat the tests. 9. Secure the tube by taping it to the bridge of the client’s nose. • If the client has oily skin, wipe the nose first with alcohol to defat the skin. • Apply a commercial securement device or • Cut 7.5 cm (3 in.) of tape, and split it lengthwise at one end, leaving a 2.5-cm (1-in.) tab at the end. • Place the tape over the bridge of the client’s nose, and bring the split ends either under and around the tubing, or under the tubing and back up over the nose. ❸ Ensure that the tube is centrally located prior to securing with tape to maximize airflow and prevent irritation to the side of the nares. Rationale: Taping in this manner prevents the tube from pressing against and irritating the edge of the nostril. •

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Inserting a Nasogastric Tube—continued

10. Once correct position has been determined, attach the tube to a suction source or feeding apparatus as ordered, or clamp the end of the tubing. 11. Secure the tube to the client’s gown. • Loop an elastic band around the end of the tubing, and attach the elastic band to the gown with a safety pin. or • Attach a piece of adhesive tape to the tube, and pin the tape to the gown. Rationale: The tube is attached to ­prevent it from dangling and pulling. If a Salem sump tube is used, attach the antireflux valve to the vent port (if used) and position the port above the client’s waist. Rationale: This prevents gastric contents from flowing into the vent lumen. • Remove and discard gloves. • Perform hand hygiene. 12. Document relevant information: the insertion of the tube, the means by which correct placement was determined, and client responses (e.g., discomfort or abdominal distention). EVALUATION Conduct appropriate follow-up, such as degree of client comfort, client tolerance of the nasogastric tube, correct placement of nasogastric tube in stomach, client understanding of restrictions, color

SKILL 47–1

❸ Taping a nasogastric tube to the bridge of the nose.

13. Establish a plan for providing daily nasogastric tube care. • Inspect the nostril for discharge and irritation. • Clean the nostril and tube with moistened, cotton-tipped applicators. • Apply water-soluble lubricant to the nostril if it appears dry or encrusted. • Change the adhesive as required. • Give frequent mouth care. Due to the presence of the tube, the client may breathe through the mouth. 14. If suction is applied, ensure that the patency of both the ­nasogastric and suction tubes is maintained. • Irrigation of the tube may be required at regular intervals. In some agencies, irrigations must be ordered by the ­primary care provider. Prior to each irrigation, recheck tube placement. • If a Salem sump tube is used, follow agency policies for irrigating the vent lumen with air to maintain patency of the suctioning lumen. Often, a sucking sound can be heard from the vent port if it is patent. • Keep accurate records of the client’s fluid intake and output, and record the amount and characteristics of the drainage. 15. Document the type of tube inserted, date and time of tube ­insertion, type of suction used, color and amount of gastric contents, and the client’s tolerance of the procedure.

SAMPLE DOCUMENTATION 11/5/15 1030 #8 Fr feeding tube inserted without difficulty through R nare with stylet in place. To x-ray to check placement. Radiologist reports tube tip in stomach. Stylet removed. Aspirate pH 4. Tube secured to nose. Pt. verbalizes understanding of need to not pull on tube. –––––––––––––––––––––––––––––––––––––– L. Traynor, RN

and amount of gastric contents if attached to suction, or stomach contents aspirated.

LIFESPAN CONSIDERATIONS Inserting a Nasogastric Tube INFANTS AND YOUNG CHILDREN • Restraints may be necessary during tube insertion and ­throughout therapy. Restraints will prevent accidental dislodging of the tube. • Place the infant in an infant seat or position the infant with a rolled towel or pillow under the head and shoulders. • When assessing the nares, obstruct one of the infant’s nares and feel for air passage from the other. If the nasal passageway is very small or is obstructed, an orogastric tube may be more appropriate.

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Measure appropriate nasogastric tube length from the nose to the tip of the earlobe and then to the point midway between the umbilicus and the xiphoid process. • If an orogastric tube is used, measure from the tip of the ­earlobe to the corner of the mouth to the xiphoid process. • Do not hyperextend or hyperflex an infant’s neck. Hyperextension or hyperflexion of the neck could occlude the airway. • Tape the tube to the area between the end of the nares and the upper lip as well as to the cheek. •

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Although the focus of this chapter is nutrition, nasogastric tubes may be inserted for reasons other than to provide a route for feeding the client, including these: • To prevent nausea, vomiting, and gastric distention following sur-

gery. In this case, the tube is attached to a suction source.

• To remove stomach contents for laboratory analysis. • To lavage (wash) the stomach in cases of poisoning or overdose of

medications.

A nasoenteric (nasointestinal) tube, a longer tube than the nasogastric tube (at least 40 cm [15.75 in.] for an adult), is inserted through one nostril down into the upper small intestine. See Figure 47–13A •. Some agencies require specially trained nurses or primary care providers to perform this procedure. Nasoenteric tubes are used for clients who are at risk for aspiration. Clients at risk for aspiration are those who manifest the following: • • • •

A

Decreased level of consciousness Poor cough or gag reflexes Inability to participate in the procedure Restlessness or agitation.

Gastrostomy and jejunostomy devices are used for long-term nutritional support, generally more than 6 to 8 weeks. Tubes are placed surgically or by laparoscopy through the abdominal wall into the stomach B

Figure 47–14  •  Percutaneous endoscopic gastrostomy (PEG) tube. A, Courtesy Covidien.

A

Nasogastric Nasoduodenal Nasojejunal

Figure 47–15  •  Percutaneous endoscopic jejunostomy (PEJ) tube.

B

Gastrostomy (placed surgically, endoscopically, or laparoscopically) Jejunostomy (placed surgically, endoscopically, or laparoscopically)

Figure 47–13  •  Placements for enteral access: A, for nasoenteric/ nasointestinal tubes; B, for gastrostomy and jejunostomy tubes.

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(gastrostomy) or into the jejunum (jejunostomy). See Figure 47–13B •. A percutaneous endoscopic gastrostomy (PEG) (Figure 47–14 •) or percutaneous endoscopic jejunostomy (PEJ) (Figure 47–15 •) is created by using an endoscope to visualize the inside of the stomach, making a puncture through the skin and subcutaneous tissues of the abdomen into the stomach, and inserting the PEG or PEJ catheter through the puncture. The surgical opening is sutured tightly around the tube or catheter to prevent leakage. Care of this opening before it heals requires surgical asepsis. The catheter has an external bumper and an internal inflatable retention balloon to maintain placement. When the tract is established (about 1 month), the tube or catheter can be removed and reinserted for each feeding. Alternatively, a skin-level tube can be used that remains in place (Figure 47–16 •). A feeding set is attached when needed.

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Enteral Feedings

Figure 47–16  •  Low-profile gastrostomy feeding tubes. Courtesy Covidien.

Testing Feeding Tube Placement

Before feedings are introduced, tube placement is confirmed by radiography, particularly when a small-bore tube has been inserted or when the client is at risk for aspiration. After placement is confirmed, the nurse marks the tube with indelible ink or tape at its exit point from the nose and documents the length of visible tubing for baseline data. The nurse is responsible, however, for verifying tube placement (i.e., GI placement versus respiratory placement) before each intermittent feeding and at regular intervals (e.g., at least once per shift) when continuous feedings are being administered. Methods nurses use to check tube placement include the following:

The type and frequency of feedings and amounts to be administered are ordered by the primary care provider. Liquid feeding mixtures are available commercially or may be prepared by the dietary department in accordance with the primary care provider’s orders. A standard formula provides 1 Kcal per milliliter of solution with protein, fat, carbohydrate, minerals, and vitamins in specified proportions. Enteral feedings can be given intermittently or continuously. Intermittent feedings are the administration of 300 to 500 mL of enteral formula several times per day. The stomach is the preferred site for these feedings, which are usually administered over at least 30 minutes. Initial intermittent feedings should be no more than 120 mL. If tolerated, increase by 120 mL each feeding until the goal is reached (DeBruyne & Pinna, 2014). Bolus intermittent feedings are those that use a syringe to deliver the formula into the stomach. Because the formula is delivered rapidly by this method, it is not usually recommended but may be used in long-term situations if the client tolerates it. These feedings must be given only into the stomach; the client must be monitored closely for distention and aspiration. Continuous feedings are generally administered over a 24-hour period using an infusion pump (often referred to as a kangaroo pump) that guarantees a constant flow rate (Figure 47–17 •). Initial intermittent feedings should be no more than 60 mL per hour. If tolerated,

1. Aspirate GI secretions. Because small-bore tubes offer more resistance during aspirations than large-bore tubes and are more likely to collapse when negative pressure is applied, it may not be possible to obtain an aspirate. If obtained, gastric secretions tend to be a grassy-green, off-white, or tan color; intestinal fluid is stained with bile and has a golden yellow or brownish green color. 2. Measure the pH of aspirated fluid. Testing the pH of aspirates can help distinguish gastric from respiratory and intestinal placement as follows: • Gastric aspirates tend to be acidic and have a pH of 1 to 4 but may be as high as 6 if the client is receiving medications that control gastric acid. • Small intestine aspirates generally have a pH equal to or higher than 6. • Respiratory secretions are more alkaline with values of 7 or higher. However, there is a slight possibility of respiratory placement when the pH reading is as low as 5. Therefore, when pH readings are 5 or higher, radiographic confirmation of tube location needs to be considered, especially in clients with diminished cough and gag reflexes. 3. Confirm length of tube insertion with the insertion mark. If more of the tube is now exposed, the position of the tip should be questioned. Currently, the most effective method is radiographic verification of tube placement. Repeated x-ray studies, however, are not feasible in terms of cost. More research is required to devise effective alternatives, especially for placement of small-bore tubes. In the meantime, nurses should (a) ensure initial radiographic verification of smallbore tubes, (b) aspirate contents when possible and check their acidity, (c) closely observe the client for signs of obvious distress, and (d) consider tube dislodgment after episodes of coughing, sneezing, and vomiting.

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Figure 47–17  •  An enteric feeding pump.

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increase by 20 mL each feeding until the goal is reached (DeBruyne & Pinna, 2014). Continuous feedings are essential when feedings are administered in the small bowel. Pumps are also used when smaller bore gastric tubes are in place or when gravity flow is insufficient to instill the feeding. Cyclic feedings are continuous feedings that are administered in less than 24 hours (e.g., 12 to 16 hours). These feedings, often administered at night, allow the client to attempt to eat regular meals through the day. Because nocturnal feedings may use higher nutrient densities and higher infusion rates than the standard continuous feeding, particular attention needs to be given to monitoring fluid status and circulating volume. Enteral feedings are administered to clients through open or closed systems. Open systems use an open-top container or a syringe for administration. Enteral feedings for use with open systems are provided in flip-top cans or powdered formulas that are reconstituted with sterile water. Sterile water, rather than tap water, reduces the risk of microbial contamination. Open systems should have no more than 8 to 12 hours of formula poured at one time (DeBruyne & Pinna, 2014). At the completion of this time, remaining formula should be discarded and the container rinsed before new formula is poured. The bag and tubing should be replaced every 24 hours. Closed systems consist of a prefilled container that is spiked with enteral tubing and attached to the enteral access device. Prefilled containers can hang safely for 48 hours if sterile technique is used. Closed system materials are more expensive than open system materials, but if nursing care costs are included, closed systems are less expensive (Phillips, Roman, & Glassman, 2013).

A rare but potentially fatal complication of tube feeding is

refeeding syndrome—a combination of fluid and electrolyte

shifts that can occur after a lengthy period of malnutrition or starvation. This syndrome can occur when the starving body converts from creating glucose from carbohydrates to creating it from protein stores since carbohydrate was unavailable. The body’s reaction to the sudden presence of glucose and synthesis of protein leads to the shifts. People at high risk for developing refeeding syndrome are those with chronic alcoholism, anorexia nervosa, massive weight loss, cancer clients receiving chemotherapy, or anyone who has gone 7 to 10 days without food. The nurse takes a detailed history and examines laboratory data that can indicate malnutrition, such as albumin and prealbumin levels. Serum potassium, calcium, phosphate, and magnesium levels must be checked and supplemented until within normal levels before feeding. Some experts suggest beginning feeding for at-risk clients with less than the desired amount and increasing to the full desired daily feeding slowly (DeBruyne & Pinna, 2014). Skill 47–2 provides the essential steps involved in administering a tube feeding, and Skill 47–3 indicates the steps involved in administering a gastrostomy or jejunostomy tube feeding. CLINICAL ALERT!

Enteral feedings should be started postoperatively in surgical clients without the need to wait for flatus or a bowel movement (Metheny, Mills, & Stewart, 2012).

Administering a Tube Feeding

SKILL 47–2

PURPOSES • To restore or maintain nutritional status ASSESSMENT Assess • For any clinical signs of malnutrition or dehydration. • For allergies to any food in the feeding. If the client is lactose intolerant, check the tube feeding formula. Notify the primary care provider if any incompatibilities exist. PLANNING Before commencing a tube feeding, determine the type, amount, and frequency of feedings and tolerance of previous feedings.

DELEGATION Administering a tube feeding requires application of knowledge and problem solving and it is not usually delegated to UAP. Some agencies, however, may allow a trained UAP to administer a feeding if allowed by law (for example, in California, UAPs are prohibited from performing tube feedings by the Nursing Practice Act). In any case, it is the responsibility of the nurse to assess tube placement and determine that the tube is patent, reinforce major points, such as making sure the client is sitting upright, and instruct the UAP to report any difficulty administering the feeding or any complaints voiced by the client.

INTERPROFESSIONAL PRACTICE Administering a tube feeding is generally not performed by other health care providers, although it may not be prohibited by their scope of practice.

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To administer medications

• •

For the presence of bowel sounds. For any problems that suggest lack of tolerance of previous feedings (e.g., delayed gastric emptying, abdominal distention, diarrhea, cramping, or constipation).

Equipment • Correct type and amount of feeding solution • 60-mL catheter-tip syringe • Emesis basin • Clean gloves • pH test strip or meter • Large syringe or calibrated plastic feeding bag with label and tubing that can be attached to the feeding tube or prefilled bottle with a drip chamber, tubing, and a flow-regulator clamp • Measuring container from which to pour the feeding (if using open system) • Water (60 mL unless otherwise specified) at room temperature • Feeding pump as required

SAFETY ALERT!

SAFETY

Do not add colored food dye to tube feedings. Previously, blue dye was often added to assist in recognition of aspiration. However, the FDA reports cases of many adverse reactions to the dye, including toxicity and death.

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Administering a Tube Feeding—continued

Performance 1. Prior to performing the feeding, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Inform the client that the feeding should not cause any discomfort but may cause a feeling of fullness. 2. Perform hand hygiene and observe other appropriate infection prevention procedures (e.g., clean gloves). 3. Provide privacy for this procedure if the client desires it. Tube feedings are embarrassing to some people. 4. Assess tube placement. • Apply clean gloves. • Attach the syringe to the open end of the tube and aspirate. Check the pH. • Allow 1 hour to elapse before testing the pH if the client has received a medication. • Use a pH meter rather than pH paper if the client is receiving a continuous feeding. Follow agency policy if the pH is equal to or greater than 6. 5. Assess residual feeding contents. • If the tube is placed in the stomach, aspirate all contents and measure the amount before administering the feeding. Rationale: This is done to evaluate absorption of the last feeding; that is, whether undigested formula from a previous feeding remains. If the tube is in the small intestine, residual contents cannot be aspirated. • If 100 mL (or more than half the last feeding) is withdrawn, check with the nurse in charge or refer to agency policy before proceeding. The precise amount is usually determined by the primary care provider’s order or by agency policy. Rationale: At some agencies, a feeding is delayed when the specified amount or more of formula remains in the stomach. or • Reinstill the gastric contents into the stomach if this is the agency policy or primary care provider’s order. Rationale: Removal of the contents could disturb the client’s electrolyte balance. • If the client is on a continuous feeding, check the gastric residual every 4 to 6 hours or according to agency protocol. 6. Administer the feeding. • Before administering feeding: a. Check the expiration date of the feeding. b. Warm the feeding to room temperature. Rationale: An excessively cold feeding may cause abdominal cramps. • When an open system is used, clean the top of the feeding container with alcohol before opening it. Rationale: This minimizes the risk of contaminants entering the feeding syringe or feeding bag. Feeding Bag (Open System) • Apply a label that indicates the date, time of starting the feeding, and nurse’s initials on the feeding bag. Hang the labeled bag from an infusion pole about 30 cm (12 in.)

SKILL 47–2

IMPLEMENTATION Preparation Assist the client to a Fowler’s position (at least 30° elevation) in bed or a sitting position in a chair, the normal position for eating. If a sitting position is contraindicated, a slightly elevated right side-lying position is acceptable. Rationale: These positions enhance the gravitational flow of the solution and prevent aspiration of fluid into the lungs.

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❶ Using a calibrated plastic bag to administer a tube feeding. above the tube’s point of insertion into the client. Rationale: At this height, the formula should run at a safe rate into the stomach or intestine. • Clamp the tubing and add the formula to the bag. • Open the clamp, run the formula through the tubing, and reclamp the tube. Rationale: The formula will displace the air in the tubing, thus preventing the instillation of excess air into the client’s stomach or intestine. • Attach the bag to the feeding tube ❶ and regulate the drip by adjusting the clamp to the drop factor on the bag (e.g., 20 drops/mL) if not placed on a pump. Syringe (Open System) • Remove the plunger from the syringe and connect the syringe to a pinched or clamped nasogastric tube. Rationale: Pinching or clamping the tube prevents excess air from entering the stomach and causing distention. • Add the feeding to the syringe barrel. ❷

❷ Using the barrel of a syringe to administer a tube feeding. Continued on page 1188

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Administering a Tube Feeding—continued Ask the client to remain sitting upright in Fowler’s position or in a slightly elevated right lateral position for at least 30 minutes. Rationale: These positions facilitate digestion and movement of the feeding from the stomach along the alimentary tract, and prevent the potential aspiration of the feeding into the lungs. • Check the agency’s policy on the frequency of changing the nasogastric tube and the use of smaller lumen tubes if a large-bore tube is in place. Rationale: These measures prevent irritation and erosion of the pharyngeal and esophageal mucous membranes. 10. Dispose of equipment appropriately. • If the equipment is to be reused, wash it thoroughly with soap and water so that it is ready for reuse. • Change the equipment every 24 hours or according to agency policy. • Remove and discard gloves. • Perform hand hygiene. 11. Document all relevant information. • Document the feeding, including amount and kinds of ­fluids administered (feeding plus any water used to flush the tubing), duration of the feeding, and assessments of the client. • Record the volume of the feeding and water administered on the client’s intake and output record. 12. Monitor the client for possible problems. • Carefully assess clients receiving tube feedings for ­problems. • To prevent dehydration, give the client supplemental water in

SKILL 47–2

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❸ Feeding set with spike and tubing. Note, the port on the cap can only be accessed using this special safety screw spike to prevent accidental connection using intravenous tubing. Courtesy Covidien.

Permit the feeding to flow in slowly at the prescribed rate. Raise or lower the syringe to adjust the flow as needed. Pinch or clamp the tubing to stop the flow for a minute if the client experiences discomfort. Rationale: Quickly administered feedings can cause flatus, cramps, and/or vomiting. Prefilled Bottle with Drip Chamber (Closed System) • Remove the screw-on cap from the container and attach the administration set with tubing. ❸ • Close the clamp on the tubing. • Hang the container on an intravenous (IV) pole about 30 cm (12 in.) above the tube’s insertion point into the client. Rationale: At this height, the formula should run at a safe rate into the stomach or intestine. • Squeeze the drip chamber to fill it to one third to one half of its capacity. • Open the tubing clamp, run the formula through the ­tubing, and reclamp the tube. Rationale: The formula will ­displace the air in the tubing, thus preventing the instillation of excess air. • Attach the feeding set tubing to the feeding tube and ­regulate the drip rate to deliver the feeding over the desired length of time or attach to a feeding pump. 7. If another bottle is not to be immediately hung, flush the feeding tube before all of the formula has run through the tubing. • Instill 50 to 100 mL of water through the feeding tube or medication port. Rationale: Water flushes the lumen of the tube, preventing future blockage by sticky formula. • Be sure to add the water before the feeding solution has drained from the neck of a syringe or from the tubing of an administration set. Rationale: Adding the water before the syringe or tubing is empty prevents the instillation of air into the stomach or intestine and thus prevents unnecessary distention. 8. Clamp the feeding tube. • Clamp the feeding tube before all of the water is instilled. Rationale: Clamping prevents air from entering the tube. 9. Ensure client comfort and safety. • Secure the tubing to the client’s gown. Rationale: This ­minimizes pulling of the tube, thus preventing discomfort and dislodgment. •

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addition to the prescribed tube feeding as ordered. Variation: Continuous-Drip Feeding • Clamp the tubing at least every 4 to 6 hours, or as indicated by agency protocol or the manufacturer, and aspirate and measure the gastric contents. Then flush the tubing with 30 to 50 mL of water. Rationale: This determines adequate absorption and verifies correct placement of the tube.If placement of a small-bore tube is questionable, a repeat x-ray should be done. • Determine agency protocol regarding withholding a feeding. Many agencies withhold the feeding if more than 75 to 100 mL of feeding is aspirated. • To prevent spoilage or bacterial contamination, do not allow the feeding solution to hang longer than 12 hours for an open system and 48 hours for a closed system. Check agency policy or manufacturer’s recommendations regarding time limits. • Follow agency policy regarding how frequently to change the feeding bag and tubing. Changing the feeding bag and tubing every 24 hours reduces the risk of ­contamination.

SAMPLE DOCUMENTATION 11/5/15 1330 Aspirated 20 mL pale yellow fluid from NG tube, pH 4.5. Pt. in Fowler’s position. 1 L room-temperature ordered formula begun @ 60 mL/hour on pump. No nausea reported. ––––––––––––– –––––––––––––––––––––––––––––––––––––––––––––– L. Traynor, RN

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Administering a Tube Feeding—continued Skin turgor Urine output and specific gravity Glucose and acetone in urine. Relate findings to previous assessment data if available. Report significant deviations from normal to the primary care provider. • • •

SKILL 47–2

EVALUATION Perform a follow-up examination of the following: • Tolerance of feeding (e.g., nausea, cramping) • Bowel sounds • Regurgitation and feelings of fullness after feedings • Weight gain or loss • Fecal elimination pattern (e.g., diarrhea, flatulence, constipation)

Administering a Gastrostomy or Jejunostomy Feeding PURPOSES See Skill 47–2.

Planning Before beginning a gastrostomy or jejunostomy feeding, determine the type and amount of feeding to be instilled, frequency of feedings, and any pertinent information about previous feedings (e.g., the positioning in which the client best tolerates the feeding).

DELEGATION See Skill 47–2.

INTERPROFESSIONAL PRACTICE See Skill 47–2.

IMPLEMENTATION Preparation See Skill 47–2. Performance 1. Prior to performing the feeding, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments. 2. Perform hand hygiene and observe other appropriate infection prevention procedures (e.g., clean gloves). 3. Provide for client privacy. 4. Insert a feeding tube, if one is not already in place. • Wearing gloves, remove the dressing. Then discard the dressing and gloves in the moisture-proof bag. • Perform hand hygiene • Apply new clean gloves. • Lubricate the end of the tube, and insert it into the ostomy opening 10 to 15 cm (4 to 6 in.). 5. Check the location and patency of the tube. • Determine correct placement of the tube by aspirating secretions and checking the pH. • Follow agency policy for amount of residual formula. This may include withholding the feeding, rechecking in 3 to

Equipment • Correct amount of feeding solution • Graduated container and tubing with clamp to hold the feeding • 60-mL catheter-tip syringe For a Tube That Remains in Place • Mild soap and water • Clean gloves • Petrolatum, zinc oxide ointment, or other skin protectant • Precut 4×4 gauze squares • Uncut 4×4 gauze squares • Paper tape For Tube Insertion • Clean gloves • Moisture-proof bag • Water-soluble lubricant • Feeding tube (if needed)

SKILL 47–3

ASSESSMENT See Skill 47–2.

4 hours, or notifying the primary care provider if a large residual remains. • For continuous feedings, check the residual every 4 to 6 hours and hold feedings according to agency policy. • Remove the syringe plunger. Pour 15 to 30 mL of water into the syringe, remove the tube clamp, and allow the water to flow into the tube. Rationale: This determines the patency of the tube. If water flows freely, the tube is patent. • If the water does not flow freely, notify the nurse in charge and/or primary care provider. 6. Administer the feeding. • Hold the barrel of the syringe 7 to 15 cm (3 to 6 in.) above the ostomy opening. • Slowly pour the solution into the syringe and allow it to flow through the tube by gravity. • Just before the syringe is empty, add 30 mL of water. Rationale: Water flushes the tube and preserves its patency. • If the tube is to remain in place, hold it upright, remove the syringe, and then clamp or plug the tube to prevent leakage. • If a tube was inserted for the feeding, remove it. • Remove and discard gloves. • Perform hand hygiene. Continued on page 1190

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SKILL 47–3

Administering a Gastrostomy or Jejunostomy Feeding—continued 7. Ensure client comfort and safety. • After the feeding, ask the client to remain in the sitting ­position or a slightly elevated right lateral position for at least 30 minutes. Rationale: This minimizes the risk of aspiration. • Assess status of peristomal skin. Rationale: Gastric or jejunal drainage contains digestive enzymes that can irritate the skin. Document any redness and broken skin areas. • Check orders about cleaning the peristomal skin, applying a skin protectant, and applying appropriate dressings. Generally, the peristomal skin is washed with mild soap and water at least once daily. The tube may be rotated between thumb and forefinger to release any sticking and promote tract formation. Petrolatum, zinc oxide ointment, or other skin protectant may be applied around the stoma, and precut 4×4 gauze squares may be placed around the tube. The precut squares are then covered with regular 4×4 gauze squares, and the tube is coiled over them and taped in place.

Observe for common complications of enteral feedings: aspiration, hyperglycemia, abdominal distention, diarrhea, and fecal impaction. Report findings to primary care provider. Often, a change in formula or rate of administration can correct problems. • When appropriate, teach the client how to administer feedings and when to notify the health care provider concerning problems. 8. Document all assessments and interventions. •

SAMPLE DOCUMENTATION 1/24/15 2045 No fluid aspirated from gastrostomy tube. Pt. in Fowler’s position. 30 mL water flowed freely by gravity through tube. 250 mL room-temperature Ensure formula given over 20 minutes. No complaints of discomfort. ––––––––––––––––––––– L. Traynor, RN

EVALUATION See Skill 47–2.

Evidence-Based Practice Is There a Difference in Effectiveness and Safety Between NG and PEG tubes? This article is an update to the 2010 Cochrane Review on the same subject. Gomes et al. (2012) examined controlled studies comparing nasogastric tubes to PEG tubes used for feeding clients who had swallowing disorders. Because the use of these tubes is very common, it is important to know if there are differences in the incidence or severity of complications associated with their use. The major outcomes studied were intervention failures such as displacement, feeding interruption, blockage or leakage; nutritional status, mortality, complications and adverse events (e.g., aspiration, hemorrhage, pneumonia, wound infection, sinusitis, fistula); and time on enteral nutrition, quality of life, length of hospital stay, and costs and economic issues. This review concluded that PEG tubes are associated with fewer serious complications than NG tubes. However, there were

EVIDENCE-BASED PRACTICE no differences in overall number of complications or mortality, and the use of PEG tubes is considerably more resource intensive and expensive. IMPLICATIONS One limitation of this review is the shortage of well-controlled studies. Only 686 clients were included in the combined review. Thus, more research is needed. However, the review does not conflict with the findings of previous reviews. Nurses must remember the difference between statistical differences and clinical differences in research findings. In cases where the expertise or human and financial resources do not allow for the use of PEG tubes, NG tubes are shown to be an effective alternative—especially if robust interventions are used to minimize the incidence of preventable complications.

LIFESPAN CONSIDERATIONS Administering a Tube Feeding INFANTS AND YOUNG CHILDREN • Feeding tubes may be removed after each feeding and reinserted at the next feeding to prevent irritation of the mucous membrane, nasal airway obstruction, and stomach perforation that may occur if the tube is left in place continuously. Check agency practice. • Formula should not be allowed to hang more than 4 hours (­DeBruyne & Pinna, 2014). • Position a small child or infant in your lap, provide a pacifier, and hold and cuddle the child during feedings. This promotes comfort, supports the normal sucking instinct of the infant, and facilitates digestion. OLDER ADULTS • Physiological changes associated with aging may make the older adult more vulnerable to complications associated with

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enteral feedings. Decreased gastric emptying may necessitate checking frequently for gastric residual. Diarrhea from administering the feeding too fast or at too high a concentration may cause dehydration. If the feeding has a high concentration of glucose, assess for hyperglycemia because with aging, the body has a decreased ability to handle increased glucose levels. • Conditions such as hiatal hernia and diabetes mellitus may cause the stomach to empty more slowly. This increases the risk of aspiration in a client receiving a tube feeding. Checking for gastric residual more frequently can help document this if it is an ongoing problem. Changing the formula or the rate of administration, repositioning the client, or obtaining a primary care provider’s order for a medication to increase stomach emptying may resolve this problem.

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Home Care Considerations  Administering a Tube Feeding Teach and provide the client or caregiver the rationale for how to assess for tube placement using pH measurement before administering the feeding. Instruct regarding actions to take if the pH is greater than 5. • Provide instructions and rationale for care of the tube and insertion site. • Discuss strategies for hanging formula containers if an IV pole is unavailable or inconvenient.

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Plan for optimal timing of feedings to allow for daily activities. Many clients can tolerate having the majority of their feedings run during sleep so they are free from the equipment during the day. • Teach signs and symptoms to report to the primary care ­provider or home health nurse.

•

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TABLE 47–5   Assessing Clients Receiving Tube Feedings Assessments Allergies to any food in the feeding

Rationale Common allergenic foods include milk, sugar, water, eggs, and ­vegetable oil.

Bowel sounds before each feeding or, for continuous feedings, every 4 to 8 hours

To determine intestinal activity.

Correct placement of tube before feedings

To prevent aspiration of feedings.

Presence of regurgitation and feelings of fullness after feedings

May indicate delayed gastric emptying, need to decrease quantity or rate of the feeding, or high fat content of the formula.

Dumping syndrome: nausea, vomiting, diarrhea, cramps, pallor, sweating, heart palpitations, increased pulse rate, and fainting after a feeding

Clients with a jejunostomy may experience these symptoms, which r­esult when hypertonic foods and liquids suddenly distend the ­jejunum. To make the intestinal contents isotonic, body fluids shift rapidly from the client’s vascular system.

Abdominal distention, at least daily (Measure abdominal girth at the umbilicus.)

Abdominal distention may indicate intolerance to a previous feeding.

Diarrhea, constipation, or flatulence

­ resence The lack of bulk in liquid feedings may cause constipation. The p of hypertonic or concentrated ingredients may cause diarrhea and flatulence.

Urine for sugar and acetone

Hyperglycemia may occur if the sugar content of the feeding is too high.

Hematocrit and urine specific gravity

Both hematocrit and urine specific gravity increase as a result of dehydration.

Serum BUN and sodium levels

Feeding formula may have a high protein content. If a high protein intake is combined with an inadequate fluid intake, the kidneys may not be able to excrete nitrogenous wastes adequately.

Before administering a tube feeding, the nurse must determine any food allergies of the client and assess tolerance to previous feedings. Table 47–5 lists essential assessments to conduct before administering tube feedings. The nurse must also check the expiration date on a commercially prepared formula or the preparation date and time of agency-prepared solution, discarding any formula that has passed the expiration date or that was prepared more than 24 hours previously. Feedings are usually administered at room temperature unless the order specifies otherwise. The nurse warms the specified amount of solution in a basin of warm water or leaves it to stand for a while until it reaches room temperature. Because a formula that is warmed can grow microorganisms, it should not hang longer than the manufacturer recommends. Continuous-feeding formulas should be kept

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cold; excessive heat coagulates feedings of milk and egg, and hot liquids can irritate the mucous membranes. However, excessively cold feedings can reduce the flow of digestive juices by causing vasoconstriction and may cause cramps. Guidelines for teaching clients and families regarding administration of tube feedings in the home are found in Client Teaching.

Managing Clogged Feeding Tubes Even if feeding tubes are flushed with water before and after feedings and medications, small-bore tubes still become clogged—especially SBFTs. This can occur when the feeding container runs dry, solid medication is not adequately crushed, or medications are mixed with formula. Even the important practice of aspirating to check residual volume increases the incidence of clogging. To avoid the necessity of

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CLIENT TEACHING

Tube Feedings Clients and caregivers need the following instructions to manage these feedings: • Preparation of the formula. Include name of the formula and how much and how often it is to be given; the need to inspect the formula for expiration date and leaks and cracks in bags or cans; how to mix or prepare the formula, if needed; and aseptic techniques such as cleansing the container’s top with alcohol before opening it, and changing the syringe administration set and reservoir every 24 hours. • Proper storage of the formula. Include the need to refrigerate diluted or reconstituted formula and formula that contains additives. • Administration of the feeding. Include proper hand cleansing technique, how to fill and hang the feeding bag, operation of an

removing the tube and reinserting a new tube, both prevention and intervention strategies must be used. To prevent clogged feeding tubes, flush liberally (at least 30 mL water) before, between, and after each separate medication is instilled, using a 60-mL piston syringe. Too great a pressure can rupture the tube—especially small-bore feeding tubes. Do not add medications to formula or to each other because the combination could create a precipitate that clogs the tube. Many strategies have been used to try to unclog feeding tubes. The first strategy that should be tried is to reposition the client (this may allow a kink to straighten). Alternately flush and aspirate the tube with water. Strategies that have shown inconsistent effectiveness

•

• •

•

infusion pump if indicated, the feeding rate, and client positioning during and after the feeding. Management of the enteral or parenteral access device. Include site care, aseptic precautions, dressing change, as indicated, how the site should look normally, and flushing ­protocols (e.g., type of irrigant and schedule). Daily monitoring needs. Include temperature, weight, and ­intake and output. Signs and symptoms of complications to report. Include fever, increased respiratory rate, decrease in urine output, increased stool frequency or diarrhea, and altered level of consciousness. Whom to contact about questions or problems. Include emergency telephone numbers of home care agency, nursing clinician and/or primary care provider, or other 24-hour on-call emergency service.

include instilling meat tenderizer, carbonated beverages, or cranberry juice (Stepter, 2012) or flushing with small-barrel syringes. Until 2013, only enteric-coated and extended-release pancreatic enzymes were available as unclogging agents in the United States. However, an effective uncoated enzyme product, used in combination with sodium bicarbonate, is now available (Klang, Gandhi, & Mironova, 2013). Commercial de-clogging kits containing a combination of acids, buffers, antibacterial agents, enzymes, and metal inhibitors are available. If efforts to unclog a feeding tube are unsuccessful, the tube may need to be removed. Skill 47–4 describes the steps in removing a ­nasogastric tube.

SKILL 47–4

Removing a Nasogastric Tube ASSESSMENT Assess • For the presence of bowel sounds • For the absence of nausea or vomiting when tube is clamped PLANNING

DELEGATION Due to the need for assessment of client status, the skill of removing a nasogastric tube is not delegated to UAP.

Equipment • Disposable pad or towel • Tissues • Clean gloves • 50-mL syringe (optional) • Moisture-proof trash bag

INTERPROFESSIONAL PRACTICE Removing a nasogastric tube may be within the scope of practice for other health care providers such as PAs. Although the PA may verbally communicate their actions and plan to the health care team members, the nurse must also know where to locate their documentation in the client’s health record. IMPLEMENTATION Preparation • Confirm the primary care provider’s order to remove the tube. • Assist the client to a sitting position if health permits.

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Place the disposable pad or towel across the client’s chest to collect any spillage of secretions from the tube. • Provide tissues to the client to wipe the nose and mouth after tube removal. •

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Removing a Nasogastric Tube—continued

EVALUATION • Perform a follow-up examination, such as presence of bowel sounds, absence of nausea or vomiting when tube is removed, and intactness of tissues of the nares.

Parenteral Nutrition Parenteral nutrition, also referred to as total parenteral nutrition (TPN) or intravenous hyperalimentation, is the IV infusion of dextrose, water, fat, proteins, electrolytes, vitamins, and trace elements. Because TPN solutions are hypertonic (highly concentrated in comparison to the solute concentration of blood), they are injected only into high-flow central veins, where they are diluted by the ­client’s blood. TPN is a means of achieving an anabolic state in clients who are unable to maintain a normal nitrogen balance. Such clients may include those with severe malnutrition, severe burns, bowel disease disorders (e.g., ulcerative colitis or enteric fistula), acute renal failure, hepatic failure, metastatic cancer, or major surgeries where nothing may be taken by mouth for more than 5 days. TPN is not risk free. Infection control is of utmost importance during TPN therapy. The nurse must always observe surgical aseptic technique when changing solutions, tubing, dressings, and filters. Clients are at increased risk of fluid, electrolyte, and glucose imbalances and require frequent evaluation and modification of the TPN mixture. TPN solutions are 10% to 50% dextrose in water, plus a mixture of amino acids and special additives such as vitamins (e.g., B complex,

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Place the tube in the trash bag. Rationale: Placing the tube immediately into the bag prevents the transference of microorganisms from the tube to other articles or people. • Observe the intactness of the tube. 6. Ensure client comfort. • Provide mouth care if desired. • Assist the client as required to blow the nose. Rationale: Excessive secretions may have accumulated in the nasal passages. 7. Dispose of the equipment appropriately. • Place the pad, bag with tube, and gloves in the receptacle designated by the agency. Rationale: Correct disposal prevents the transmission of microorganisms. • Remove and discard gloves. • Perform hand hygiene. 8. Document all relevant information. • Record the removal of the tube, the amount and appearance of any drainage if connected to suction, and any relevant assessments of the client. •

SKILL 47–4

Performance 1. Prior to performing the removal, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning ­further care or treatments. 2. Perform hand hygiene and observe other appropriate infection prevention procedures (e.g., clean gloves). 3. Provide for client privacy. 4. Detach the tube. • Apply clean gloves. • Disconnect the nasogastric tube from the suction apparatus, if present. • Unpin the tube from the client’s gown. • Remove the adhesive tape securing the tube to the nose. 5. Remove the nasogastric tube. • Optional: Instill 50 mL of air into the tube. Rationale: This clears the tube of any contents such as feeding or gastric drainage. • Ask the client to take a deep breath and to hold it. Rationale: This closes the glottis, thereby preventing accidental aspiration of any gastric contents. • Pinch the tube with the gloved hand. Rationale: Pinching the tube prevents any contents inside the tube from draining into the client’s throat. • Smoothly, withdraw the tube.

SAMPLE DOCUMENTATION 11/8/15 1500 NG tube removed intact without difficulty. Oral & nasal care given. No bleeding or excoriation noted. Client states is hungry & thirsty. 60 mL apple juice given. No c/o nausea. –––––– L. Traynor, RN

• •

Relate findings to previous assessment data if available. Report significant deviations from normal to the primary care provider.

C, D, K), minerals (e.g., potassium, sodium, chloride, calcium, phosphate, magnesium), and trace elements (e.g., cobalt, zinc, manganese). Additives are modified to each client’s nutritional needs. Fat emulsions may be given to provide essential fatty acids to correct and/or prevent essential fatty acid deficiency or to supplement the calories for clients who, for example, have high calorie needs or cannot tolerate glucose as the only calorie source. Note that 1,000 mL of 5% glucose or dextrose contains 50 grams of sugar. Thus, a liter of this solution provides less than 200 calories! Because TPN solutions are high in glucose, infusions are started gradually to prevent hyperglycemia. The client needs to adapt to TPN therapy by increasing insulin output from the pancreas. For example, an adult client may be given 1 liter (40 mL/h) of TPN solution the first day; if the infusion is tolerated, the amount may be increased to 2 liters (80 mL/h) for 24 to 48 hours, and then to 3 liters (120 mL/h) within 3 to 5 days. Glucose levels are monitored during the infusion. When TPN therapy is to be discontinued, the TPN infusion rates are decreased slowly to prevent hyperinsulinemia and hypoglycemia. Weaning a client from TPN may take up to 48 hours but can occur in 6 hours as long as the client receives adequate carbohydrates either orally or intravenously.

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Peripheral parenteral nutrition (PPN) is delivered into the smaller peripheral veins. PPN cannot handle as concentrated a solution as central lines, but can accommodate lipids. For example, a 20% lipid emulsion can provide nearly 2,000 Kcal/day through a peripheral vein. PPN is considered to be a safe and convenient form of therapy. One major disadvantage, however, is the frequent incidence of phlebitis (vein inflammation) associated with PPN. Substituting glycerol for dextrose may reduce vein irritation (­Julian, 2013). Peripheral parenteral nutrition is administered to clients whose needs for IV nutrition will last only a short time or in whom placement of a central IV catheter is contraindicated. It is a form of therapy used more frequently to prevent nutritional deficits than to correct them. Enteral or parenteral feedings may be continued beyond hospital care in the client’s home or may be initiated in the home.

Evaluating The goals established in the planning phase are evaluated according to specific desired outcomes, also established in that phase. If the outcomes are not achieved, the nurse should explore the reasons. The nurse might consider the following questions: • Was the cause of the problem correctly identified? • Was the family included in the teaching plan? Are family mem-

bers supportive?

• Is the client experiencing symptoms that cause loss of appetite

(e.g., pain, nausea, fatigue)?

• Were the outcomes unrealistic for this person? • Were the client’s food preferences considered? • Is anything interfering with digestion or absorption of nutrients

(e.g., diarrhea)?

NURSING CARE PLAN Nutrition Assessment Data

Nursing Diagnosis

Desired Outcomes*

Nursing Assessment Mrs. Rose Santini, a 59-year-old homemaker, attends a community hospital–sponsored health fair. She approaches the nutrition information booth, and the clinical specialist in nutritional support gathers a nutritional history. Mrs. Santini is very upset about her 9-kg (20-lb) weight gain. She relates to the nurse clinician that since the death of her husband 1 month ago she has lost interest in many of her usual physical and social activities. She no longer attends YMCA exercise and swimming sessions and has lost contact with her couple’s bridge group. Mrs. Santini states she is bored, depressed, and very unhappy about her appearance. She has a small frame and has always prided herself on her petite figure. She says her eating habits have changed considerably. She snacks while watching TV and rarely prepares a complete meal.

Overweight related to excess intake and decreased activity expenditure (as evidenced by weight gain of 9 kg (20 lb), triceps skinfold greater than normal, undesirable eating patterns)

Weight-Loss Behavior [1627] as evidenced by demonstrating: • Eats three meals each day that result in a 500-calorie reduction in intake. • Establishes a physical exercise plan that engages her in 15 to 20 minutes of exercise daily by day 5. • Identifies eating habits that contribute to weight gain by day 2.

Physical Examination Height: 162.6 cm (5′4″) Weight: 66 kg (145 lb) Temperature: 37°C (98.6°F) Pulse: 76 beats/min Respirations: 16/min Blood pressure: 144/84 mmHg Triceps skinfold: 21 mm Small frame, weight in ­excess of 10% over ideal for height and frame

Diagnostic Data CBC normal, urinalysis negative, chest x-ray negative, thyroid profile within normal limits

Nursing Interventions*/Selected Activities

Rationale

Weight Reduction Assistance [1280] Determine current eating patterns by having Mrs. Santini keep a diary of what, when, and where she eats.

Increases awareness of activities and foods that contribute to excessive intake.

Set a weekly goal for weight loss.

The desirable weight-loss rate is 1/2–1 kg (1–2 lb) per week.

Encourage use of internal reward systems when goals are accomplished.

Goal setting provides motivation, which is essential for a successful weight-loss program.

Set a realistic plan with Mrs. Santini to include reduced food intake and increased energy expenditure.

A combined plan of calorie reduction and exercise can enhance weight loss since exercise increases caloric utilization.

Assist client to identify motivation for eating and internal and external cues associated with eating.

Awareness of factors that contribute to overeating will assist the individual in planning behavior modification techniques to avoid situations that prompt excess food consumption.

Encourage attendance at support groups for weight loss and/or refer to a community weight control program.

Membership in a support group can enhance clients’ continuation of weight-loss efforts.

Develop a daily meal plan with a well-balanced diet, reduced calories, and reduced fat.

Snack foods tend to be high in calories and fat and low in nutritional values.

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NURSING CARE PLAN Nutrition—continued Nursing Interventions*/Selected Activities

Rationale

Nutritional Counseling [5246] Facilitate identification of eating behaviors to be changed.

Increases individual’s awareness of those actions that contribute to excessive intake.

Use accepted nutritional standards to assist Mrs. Santini in evaluating adequacy of dietary intake.

Comparing the individual’s dietary history with nutritional standards will facilitate identification of nutritional deficiencies and/or excesses.

Help Mrs. Santini to consider factors of age, past eating experiences, culture, and finances in planning ways to meet nutritional requirements.

Social, economic, physical, and psychological factors play a role in nutrition and/or malnutrition.

Discuss Mrs. Santini’s knowledge of the basic food groups, as well as perceptions of the needed diet modification.

Helps to determine the client’s knowledge base and identify ­misconceptions and/or gaps in understanding.

Discuss food likes and dislikes.

Incorporating Mrs. Santini’s food preferences into the dietary plan will promote adherence to the weight-loss program.

Assist Mrs. Santini in stating her feelings and concerns about goal achievement.

Fear of success, failure, or other concerns may block goal achievement.

Behavior Modification [4360] Assist Mrs. Santini to identify strengths and reinforce these.

Reinforcing strengths enhances self-esteem and encourages the ­individual to draw on these assets during the weight-loss program.

Encourage her to examine her own behavior.

Involving Mrs. Santini in self-appraisal will promote identification of ­behaviors that may be contributing to excessive caloric intake.

Identify the behavior to be changed in specific, concrete terms (e.g., stop snacking in front of the TV).

Identification of specific behaviors is essential for planning behavior modification.

Consider that it is easier to increase a behavior than to ­decrease a behavior (e.g., increase activities or hobbies that involve the hands such as sewing versus decreasing TV snacking).

Habitual behaviors are difficult to change. Breaking old habits may be easier if viewed from the standpoint of increasing an enjoyable, healthy activity.

Choose reinforcers that are meaningful to Mrs. santini.

Positive reinforcement is not likely to be an effective part of behavior modification if the reinforcer is meaningless to the individual.

Evaluation Outcome met. Mrs. Santini kept a dietary log for 5 days and has eaten balanced meals each day, resulting in a daily deficit of 400 to 500 calories. She is aware that she eats excessively because she is bored and depressed. She has reestablished her former social contacts including her church bridge club. Mrs. Santini has purchased a stationary bicycle and exercises 20 minutes daily. She enrolled in a knitting class that meets two nights per week. She has lost 2/3 kg (1 1/2 lb) in the past week. As a reward, Mrs. Santini renewed her membership to the YMCA. *The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention. Outcomes, interventions, and activities selected are only a sample of those suggested by NOC and NIC and should be further individualized for each client.

Applying Critical Thinking 1. How do Mrs. Santini’s personal characteristics influence her nutritional needs? 2. What further information do you need regarding Mrs. Santini’s present diet? 3. Offer suggestions for ways to modify Mrs. Santini’s tendency to snack. 4. Mrs. Santini asks what her weight should be. How do you respond? See Critical Thinking Possibilities on student resource website.

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CONCEPT MAP Nutrition

RS 59 y.o. female

assess

• Homemaker, 9 kg weight gain • Since death of husband 1 month ago, lost interest in many usual physical & social activities, no longer attends YMCA exercise and swimming, lost contact with couples bridge group • States is bored, depressed, & very unhappy about her appearance • Small frame & always prided herself on petite figure

• Eating habits changed: snacks, watching TV, rarely prepares complete meal • Height: 162.6 cm (5'4") • Weight: 66 kg (145 lb) • T: 37°C (98.6°F) P: 76 BPM R: 16 BP: 144/84 • Triceps skinfold: 21 mm • Weight > 10% over IBW • CBC, UA, CXR, & thyroid panel negative

generate nursing diagnosis

Overweight r/t excess intake and decreased activity expenditure (aeb weight gain of 20 lbs, triceps skin fold greater than normal, undesirable eating patterns)

outcome Weight Loss Behavior • Eats three meals each day 500-calorie reduction in intake • By day 5 establishes a physical exercise plan lasting 15 to 20 minutes of exercise daily • By day 2 identifies eating habits that contribute to weight gain nursing intervention Weight Reduction Assistance

nursing intervention

nursing intervention Nutritional Counseling

activity Encourage use of internal reward systems when goals are accomplished

activity

Set realistic plan with her to include food intake & ↑ energy expenditure

activity

activity

Set weekly goal for weight loss

activity

activity Discuss food likes & dislikes

activity

Assist in stating feelings & concerns about goal achievements

Assist to identify motivation for eating & internal & external cues associated with eating

Discuss knowledge of the basic food groups, as well as perception of needed diet modification

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Behavior Modification

Facilitate identification of eating behaviors to be changed

activity

activity

Determine current eating patterns by having her keep a diary of what, when, & where she eats

evaluation

Outcome met: • Kept dietary log for 5 days • Planned balanced meals each day daily deficit 400 to 500 cals • Is aware eats excessively because is bored & depressed • Has reestablished social contacts incl. church bridge club • Purchased stationary bicycle & exercises 20 minutes/day • Enrolled in knitting class two nights/week • Lost 1 1/2 lb last week. As a reward, renewed membership in YMCA

activity

activity

Use accepted nutritional standards to assist in evaluating adequacy of dietary intake

Help her consider factors of age, past eating experiences, culture, & finances in planning ways to meet nutritional requirements

activity Choose reinforcers that are meaningful

activity Assist her to identify strengths & reinforce these

activity

activity activity

Consider that it is easier to ↑ a behavior than to ↓ a behavior (e.g., ↑ activities or hobbies that involve the hands such as sewing and ↓ TV snacking)

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Identify behavior to be changed in specific, concrete terms (e.g., stop snacking in front of TV)

Encourage her to examine own behavior

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Chapter 47 Review CHAPTER HIGHLIGHTS • Essential nutrients are grouped into categories: carbohydrates,

• Assessment of nutritional status may involve all or some of the fol-

proteins, lipids, vitamins, and minerals. Nutrients serve three basic purposes: forming body structures (such as bones and blood), providing energy, and helping to regulate the body’s biochemical reactions. The amount of energy that nutrients or foods supply to the body is their caloric value. The basal metabolic rate (BMR) is the rate at which the body metabolizes food to maintain the energy and requirements of a person who is awake and at rest. The amount of energy required to maintain basic body functions is referred to as the resting energy expenditure (REE). A person’s state of energy balance can be determined by comparing caloric intake with caloric expenditure. Ideal body weight (IBW) is the optimal weight recommended for optimal health. Body mass index (BMI) and percent body fat are indicators of changes in body fat stores. They indicate whether a person’s weight is appropriate for height and may provide a useful estimate of nutrition. Factors influencing a person’s nutrition include development, gender, ethnicity and culture, beliefs about foods, personal preferences, religious practices, lifestyle, economics, medications and therapy, health, alcohol consumption, advertising, and psychological factors. Nutritional needs vary considerably according to age, growth, and energy requirements. Adolescents have high energy requirements due to their rapid growth; a diet plentiful in milk, meats, green and yellow vegetables, and fresh fruits is required. Middle-aged adults and older adults often need to reduce their caloric intake because of decreases in metabolic rate and activity levels. Various daily food guides have been developed to help healthy people meet the daily requirements of essential nutrients and to facilitate meal planning. These include the Dietary Guidelines for Americans and the Food Guide Pyramid/MyPlate. Both inadequate and excessive intakes of nutrients result in malnutrition. The effects of malnutrition can be general or specific, depending on which nutrients and what level of deficiency or excess are involved.

lowing: nutritional screening, nursing history data, anthropometric measurements, biochemical (laboratory) data, clinical data (physical examination), calculation of the percentage of weight loss, and a dietary history. Nursing diagnoses for clients with nutritional problems may be broadly stated as Imbalanced Nutrition: Less Than Body Requirements or Overweight. Because nutritional problems may affect many other areas of human functioning, a nutritional problem may be the etiology of other diagnoses, such as Activity Intolerance and Low Self-Esteem. Major goals for clients with or at risk for nutritional problems include the following: Maintain or restore optimal nutritional status, decrease or regain specified weight, promote healthy nutritional practices, and prevent complications associated with malnutrition. Assisting clients and support persons with therapeutic diets is a function shared by the nurse and the dietitian. The nurse reinforces the dietitian’s instructions, assists the client to make beneficial changes, and evaluates the client’s response to planned changes. Because many hospitalized clients have poor appetites, a major responsibility of the nurse is to provide nursing interventions that stimulate their appetites. Whenever possible, the nurse should help incapacitated clients to feed themselves; a number of self-feeding aids help clients who have difficulty handling regular utensils. The nurse can refer clients to various community programs that help special subgroups of the population meet their nutritional needs. Enteral feedings, administered through nasogastric, nasointestinal, gastrostomy, or jejunostomy tubes, are provided when the client is unable to ingest foods or the upper GI tract is impaired. A nasogastric or nasointestinal tube is used to provide enteral nutrition for short-term use. A gastrostomy or jejunostomy tube can be used to supply nutrients via the enteral route for long-term use. The two most accurate methods of confirming GI tube placement are radiographs and pH testing of aspirate. Parenteral nutrition, provided when oral intake is insufficient or unadvisable, is given intravenously into a large central vein (e.g., the superior vena cava).

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TEST YOUR KNOWLEDGE 1. A client receives several tube feedings each day. After documenting the client’s tolerance of the feedings and assessments in the medical record, the nurse should also document the amount of feeding provided on which of the following? 1. Graphic sheet 2. Dietary consultation notes 3. Vital signs record 4. Intake and output record 2. An adult reports usually eating the following each day: 3 cups dairy, 2 cups fruit, 2 cups vegetables, 5 ounces grains, and 5 ounces meat. The nurse would counsel the client to: 1. Maintain the diet; the servings are adequate. 2. Increase the number of servings of dairy. 3. Decrease the number of servings of vegetables. 4. Increase the number of servings of grains.

3. The nurse completes triceps skinfold measurement on a client. In order to obtain the most meaningful data, how soon should the nurse repeat this measurement? 1. Two days 2. Ten days to two weeks 3. One month 4. One year

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4. As the nasogastric tube is passed into the oropharynx, the client begins to gag and cough. What is the correct nursing action? 1. Remove the tube and attempt reinsertion. 2. Give the client a few sips of water. 3. Use firm pressure to pass the tube through the glottis. 4. Have the client tilt the head back to open the passage. 5. What is the proper technique with gravity tube feeding? 1. Hang the feeding bag 1 foot higher than the tube’s insertion point into the client. 2. Administer the next feeding only if there is less than 25 mL of residual volume from the previous feeding. 3. Place client in the left lateral position. 4. Administer feeding directly from the refrigerator. 6. A 55-year-old female is about 9 kg (20 lb) over her desired weight. She has been on a “low-calorie” diet with no improvement. Which statement reflects a healthy approach to the desired weight loss? “I need to: 1. Increase my exercise to at least 30 minutes every day.” 2. Switch to a low-carbohydrate diet.” 3. Keep a list of my forbidden foods on hand at all times.” 4. Buy more organic and less processed foods.” 7. An older Asian client has mild dysphagia from a recent stroke. The nurse plans the client’s meals based on the need to: 1. Have at least one serving of thick dairy (e.g., pudding, ice cream) per meal. 2. Eliminate the beer usually ingested every evening. 3. Include as many of the client’s favorite foods as possible. 4. Increase the calories from lipids to 40%. 8. Two months ago a client weighed 195 pounds. The current weight is 182 pounds. Calculate the client’s percentage of weight loss and determine its significance. 1. % weight loss 2. Not significant 3. Significant weight loss 4. Severe weight loss

9. Which of the sites on the diagram below indicates the correct location for the tip of a small-bore nasally placed feeding tube? 1

2

3

4

Gastrointestinal tract

10. Which of the following meals would the nurse recommend to the client as highest in calcium, iron, and fiber? 1. 3 ounces cottage cheese with 1/3 cup raisins and 1 banana 2. 1/2 cup broccoli with 3 ounces chicken and 1/2 cup peanuts 3. 1/2 cup spaghetti with 2 ounces ground beef and 1/2 cup lima beans plus 1/2 cup ice cream 4. 3 ounces tuna plus 1 ounce cheese sandwich on ­whole-wheat bread plus a pear See Answers to Test Your Knowledge in Appendix A.

READINGS AND REFERENCES Suggested Readings Iannotti, R. J., & Wang, J. (2013). Trends in physical activity, sedentary behavior, diet, and BMI among US adolescents, 2001–2009. Pediatrics, 132, 606–614. doi:10.1542/ peds.2013-1488 More than 35,000 U.S. high school students were studied for their activity and eating habits. Although activity, eating habits, and amount of television viewing improved, BMI did not. Peate, I., & Gault, C. (2013). Clinical skills series/4: Nasogastric tube insertion. British Journal of Healthcare Assistants, 6, 272–277. This article provides a concise review of NG tube insertion and care.

Related Research Chan, E., Ng, I., Tan, S., Jabin, K., Lee, L., & Ang, C. (2012). Nasogastric feeding practices: A survey using clinical scenarios. International Journal of Nursing Studies, 49, 310–319. doi:10.1016/j.ijnurstu.2011.09.014 Massey, R. L. (2012). Return of bowel sounds indicating an end of postoperative ileus: Is it time to cease this long-standing nursing tradition? MedSurg Nursing, 21, 146–150.

References American Academy of Pediatrics, Section on Breastfeeding. (2012). Policy statement: Breastfeeding and the use of human milk. Pediatrics, 129, e827–e841. doi:10.1542/ peds.2011-3552

American Dietetic Association. (2002). National dysphagia diet: Standardization for optimal care. Chicago, IL: Author. Bulechek, G. M., Butcher, H. K., Dochterman, J. M., & ­Wagner, C. M. (Eds.). (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Mosby Elsevier. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases. (2011). Botulism. Retrieved from http://www.cdc.gov/nczved/ divisions/dfbmd/diseases/botulism/#prevent DeBruyne, L. K., & Pinna, K. (2014). Nutrition for health and healthcare (5th ed.). Belmont, CA: Wadsworth/Cengage. Gomes, Jr., C., Lustosa, S., Matos, D., Andriolo, R., Waisberg, D., & Waisberg, J. (2012). Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances. Cochrane Database of Systematic Reviews, Issue 3, Art. No.: CD008096. doi:10.1002/14651858.CD008096.pub3 Herdman, T. H., & Kamitsuru, S. (Eds.). (2014). NANDA International nursing ­diagnoses: Definitions and classification, 2015–2017. ­Oxford, United Kingdom: Wiley-Blackwell. Julian, M. K. (2013). Caring for your patient receiving TPN. Nursing Made Incredibly Easy, 11(1), 8–11. doi:10.1097/01.NME.0000423373.68269.52 Klang, M. G., Gandhi, U. D., & Mironova, O. (2013). Dissolving a nutrition clog with a new pancreatic enzyme formulation. Nutrition in Clinical Practice, 28, 410–412. doi:10.1177/0884533613481477 Lichtenstein, A. H., Rasmussen, H., Yu, W. W., Epstein, S. R., & Russell, R. M. (2008). Modified MyPyramid for older adults. Journal of Nutrition, 138, 5–11.

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Metheny, N. A., Mills, A. C., & Stewart, B. H. (2012). Monitoring for intolerance to gastric tube feedings: A national survey. American Journal of Critical Care, 21, e33–e40. doi:10.4037/ajcc2012647 Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Mosby Elsevier. National Academy of Science. (2005). Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC: National Academies Press. Retrieved from http://www.nal.usda.gov/fnic/ DRI//DRI_Energy/energy_full_report.pdf National Heart, Lung, and Blood Institute. (n.d.). Aim for a healthy weight: Classification of overweight and obesity by BMI, waist circumference, and associated disease risks. Washington, DC: U.S. Department of Health & Human Services. Retrieved from http://www.nhlbi.nih.gov/health/ public/heart/obesity/lose_wt/bmi_dis.htm Nutrition Screening Initiative. (2008). Determine your nutritional health. Washington, DC: National Council on Aging. Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2012). Prevalence of obesity and trends in body mass index among US children and adolescents, 1999–2010. Journal of the American Medical Association, 307, 483–490. doi:10.1001/jama.2012.40 Phillips, W., Roman, B., & Glassman, K. (2013). Economic ­impact of switching from an open to a closed enteral nutrition feeding system in an acute care setting. Nutrition in Clinical Practice, 28, 510–514. doi:10.1177/0884533613489712

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Chapter 47  •  Nutrition Porter, R. S., & Kaplan, J. L. (Eds.). (2012). Overview of undernutrition. The Merck manual online. Whitehouse Station, NJ: Merck Sharp & Dohme Corp. Retrieved from http:// www.merckmanuals.com/professional/nutritional_ disorders/undernutrition/overview_of_undernutrition.html Roth, R. A. (2014). Nutrition and diet therapy (11th ed.). Clifton Park, NY: Delmar/Cengage. Stepter, C. R. (2012). Maintaining placement of temporary enteral feeding tubes in adults: A critical appraisal of the evidence. Medsurg Nursing, 21(2), 61–68, 102. Uri, O., Yosefov, L., Haim, A., Behrbalk, E., & Halpern, P. (2011). Lidocaine gel as an anesthetic protocol for nasogastric tube insertion in the ED. American Journal of Emergency Medicine, 29, 386–390. doi:10.1016/j .ajem.2009.10.011 U.S. Department of Agriculture. (2005). MyPyramid—Getting started. Retrieved from http://www.choosemyplate.gov/ food-groups/downloads/MyPyramid_Getting_Started.pdf U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2010). Dietary guidelines for Americans, 2010 (7th ed.), Washington, DC: U.S. Government Printing Office. Retrieved from http://www.health.gov/ dietaryguidelines/dga2010/DietaryGuidelines2010.pdf U.S. Department of Health and Human Services. (2013). Healthy people 2020 nutrition and weight status: Objectives. Retrieved from http://www.healthypeople .gov/hp2020/topicsobjectives2020/objectiveslist .aspx?topicId=29 U.S. Food and Drug Administration, Center for Food Safety and Applied Nutrition. (2004). How to understand and use the nutrition facts label. Retrieved from http://www.fda .gov/food/ingredientspackaginglabeling/labelingnutrition/ ucm274593.htm

Selected Bibliography Akhtar, S. R. (2011). TPN? And when? Critical Care Alert, 19(8), 57–58.

Chasen, M., & Bhargava, R. (2012). Gastrointestinal symptoms, electrogastrography, inflammatory markers, and PG-SGA in patients with advanced cancer. Supportive Care in Cancer, 20, 1283–1290. doi:10.1007/ s00520-011-1215-8 Dandeles, L. M, & Lodolce, A. E. (2011). Efficacy of agents to prevent and treat enteral feeding tube clogs. Annals of Pharmacotherapy, 45, 676–680. doi:10.1345/aph.1P487 Di Sabatino, A., & Corazza, G. (2012). Nonceliac gluten sensitivity: Sense or sensibility? Annals of Internal Medicine, 156, 309–311. doi:10.7326/0003-4819-156-4-201202210-00010 Fletcher, J. (2013). Parenteral nutrition: Indications, risks and nursing care. Nursing Standard, 27(46), 50–57. doi:10.7748/ns2013.07.27.46.50.e7508 Gabrielson, D. K., Scaffidi, D., Leung, E., Stoyanoff, L., Robinson, J., Nisenbaum, R., . . . Darling, P. B. (2013). Use of an abridged scored Patient-Generated Subjective Global Assessment (abPG-SGA) as a nutritional screening tool for cancer patients in an outpatient setting. Nutrition & Cancer, 65, 234–239. doi:10.1080/01635581.2013.755554 Hanson, L. C., Carey, T. S., Caprio, A. J., Lee, T., Ersek, M., Garrett, J., & Mitchell, S. L. (2011). Improving decision-making for feeding options in advanced dementia: A randomized, controlled trial. Journal of the American Geriatrics Society, 59, 2009–2016. doi:10.1111/j.1532-5415.2011.03629.x Karon, B. S. (2011). Tips from the clinical experts. Blood specimens from patients receiving TPN. Medical Laboratory Observer, 43(10), 38–39. Kirkland, L., Kashiwagi, D., Brantley, S., Scheurer, D., & Varkey, P. (2013). Nutrition in the hospitalized patient. Journal of Hospital Medicine, 8(1), 52–58. doi:10.1002/jhm.1969 Longo, M. (2011). Best evidence: Nasogastric tube placement verification. Journal of Pediatric Nursing, 26, 373–376. doi:10.1016/j.pedn.2011.04.030 Lundin, K., & Alaedini, A. (2012). Non-celiac gluten sensitivity. Gastrointestinal Endoscopy Clinics of North America, 22, 723–734. doi:10.1016/j.giec.2012.07.006

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Pan, H., Cai, S., Ji, J., Jiang, Z., Liang, H., Lin, F., & Liu, X. (2013). The impact of nutritional status, nutritional risk, and nutritional treatment on clinical outcome of 2248 hospitalized cancer patients: A multi-center, prospective cohort study in Chinese teaching hospitals. Nutrition and Cancer, 65(1), 62–70. doi:10.1080/01635581.2013.741752 Payne, C., Methven, L., Fairfield, C., & Bell, A. (2011). Consistently inconsistent: Commercially available starchbased dysphagia products. Dysphagia, 26(1), 27–33. doi:10.1007/s00455-009-9263-7 Pietzak, M. (2012). Celiac disease, wheat allergy, and gluten sensitivity: When gluten free is not a fad. Journal of Parenteral & Enteral Nutrition, 36(1 Suppl.), 68S–75S. doi:10.1177/0148607111426276 Sekino, M., Yoshitomi, O., Nakamura, T., Makita, T., & Sumikawa, K. (2012). A new technique for post-pyloric feeding tube placement by palpation in lean critically ill patients. Anaesthesia & Intensive Care, 40(1), 154–158. Shah, Z. M., Suraiya, H. S., Poi, P. J., Tan, K. S., Lai, P. S., Ramakrishnan, K., & Mahadeva, S. (2012). Long-term nasogastric tube feeding in elderly stroke patients: An assessment of nutritional adequacy and attitudes to gastrostomy feeding in Asians. Journal of Nutrition, Health & Aging, 16, 701–706. doi:10.1007/s12603-012-0027-y Son, Y., & Song, E. (2013). High nutritional risk is associated with worse health-related quality of life in patients with heart failure beyond sodium intake. European Journal of Cardiovascular Nursing, 12, 184–192. doi:10.1177/1474515112443439 Tucker, S. B., & Duffenbach, V. (2011). Nutrition and diet therapy for nurses. Upper Saddle River, NJ: Prentice Hall. Upile, T., Stimpson, P., Christie, M., Mahil, J., Tailor, H., & Jerjes, W. (2011). Use of gel caps to aid endoscopic insertion of nasogastric feeding tubes: A comparative audit. Head & Neck Oncology, 3. doi:10.1186/1758-3284-3-24

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48

Urinary Elimination

LEARNING OUTCOMES After completing this chapter, you will be able to: 1. Describe the process of urination, from urine formation through micturition. 2. Identify factors that influence urinary elimination. 3. Identify common causes of selected urinary problems. 4. Describe nursing assessment of urinary function, including subjective and objective data. 5. Identify normal and abnormal characteristics and constituents of urine. 6. Develop nursing diagnoses and desired outcomes related to urinary elimination. 7. Describe nursing interventions to maintain normal urinary elimination, prevent urinary tract infection, and manage urinary incontinence.

8. Delineate ways to prevent urinary infection. 9. Explain the care of clients with retention catheters or urinary diversions. 10. Verbalize the steps used in: a. Applying an external urinary device. b. Performing urinary catheterization. c. Performing bladder irrigation. 11. Recognize when it is appropriate to delegate aspects of ­urinary elimination to unlicensed assistive personnel. 12. Demonstrate appropriate documentation and reporting of applying an external catheter, performing urethral urinary catheterization, and performing bladder irrigation.

KEY TERMS anuria, 1206 bladder retraining, 1214 blood urea nitrogen (BUN), 1210 CAUTI, 1217 creatinine clearance, 1210 Credé’s maneuver, 1217 detrusor muscle, 1201 dialysis, 1206 diuresis, 1205 diuretics, 1205

dysuria, 1207 enuresis, 1202 flaccid, 1217 glomerulus, 1200 habit training, 1214 ileal conduit, 1228 irrigation, 1225 meatus, 1202 micturition, 1202 nephrostomy, 1228

INTRODUCTION

Elimination from the urinary tract is usually taken for granted. Only when a problem arises do most people become aware of their urinary habits and any associated symptoms. A person’s urinary habits depend on social culture, personal habits, and physical abilities. In North America, most people are accustomed to privacy and clean (even decorative) surroundings while they urinate. Personal habits regarding urination are affected by the social politeness of leaving to urinate, the availability of a private clean facility, and initial bladder training. Urinary elimination is essential to health, and voiding can be postponed for only so long before the urge normally becomes too great to control.

PHYSIOLOGY OF URINARY ELIMINATION

Urinary elimination depends on the effective functioning of the upper urinary tract’s kidneys and ureters and the lower urinary tract’s urinary bladder, urethra, and pelvic floor (Figure 48–1 •).

neurogenic bladder, 1207 nocturia, 1206 nocturnal enuresis, 1203 nocturnal frequency, 1203 oliguria, 1205 polydipsia, 1205 polyuria, 1205 postvoid residual (PVR), 1209 reflux, 1201 suprapubic catheter, 1228

trigone, 1201 ureterostomy, 1228 urgency, 1206 urinary frequency, 1206 urinary hesitancy, 1207 urinary incontinence (UI), 1207 urinary retention, 1207 urination, 1202 vesicostomy, 1228 voiding, 1202

Kidneys

The paired kidneys are situated on either side of the spinal column, behind the peritoneal cavity. The right kidney is slightly lower than the left due to the position of the liver. They are the primary regulators of fluid and acid–base balance in the body. The functional units of the kidneys, the nephrons, filter the blood and remove metabolic wastes. In the average adult 1,200 mL of blood, or about 21% of the cardiac output, passes through the kidneys every minute. Each kidney contains approximately 1 million nephrons. Each nephron has a glomerulus, a tuft of capillaries surrounded by Bowman’s capsule (Figure 48–2 •). The endothelium of glomerular capillaries is porous, allowing fluid and solutes to readily move across this membrane into the capsule. Plasma proteins and blood cells, however, are too large to cross the membrane normally. Glomerular filtrate is similar in composition to plasma, made up of water, electrolytes, glucose, amino acids, and metabolic wastes. From Bowman’s capsule the filtrate moves into the tubule of the nephron. In the proximal convoluted tubule, most of the water and electrolytes are reabsorbed. Solutes such as glucose are reabsorbed in

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Abdominal aorta Vena cava Ureter

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the loop of Henle. Other substances are secreted into the filtrate in the same area, resulting in concentrated urine. In the distal convoluted tubule, additional water and sodium are reabsorbed under the control of hormones such as antidiuretic hormone (ADH) and aldosterone. This controlled reabsorption allows regulation of fluid and electrolyte balance in the body. When fluid intake is low or the concentration of solutes in the blood is high, ADH is released from the posterior pituitary, more water is reabsorbed in the distal tubule, and less urine is excreted. By contrast, when fluid intake is high or the blood solute concentration is low, ADH is suppressed. Without ADH, the distal tubule becomes impermeable to water, and more urine is excreted. When aldosterone is released from the adrenal cortex, sodium and water are reabsorbed in greater quantities, increasing the blood volume and decreasing urinary output.

Ureters Orifice of ureter Trigone Internal urethral orifice Urethra

Bladder

Figure 48–1 • Anatomic structures of the urinary tract.

Proximal convoluted tubule Glomerular (Bowman's) capsule

Efferent arteriole

Glomerulus Afferent arteriole Arcuate artery Distal convoluted tubule

Arcuate vein Collecting duct

Once the urine is formed in the kidneys, it moves through the collecting ducts into the calyces of the renal pelvis and from there into the ureters. In adults the ureters are from 25 to 30 cm (10 to 12 in.) long and about 1.25 cm (0.5 in.) in diameter. The upper end of each ureter is funnel shaped as it enters the kidney. The lower ends of the ureters enter the bladder at the posterior corners of the floor of the bladder (see Figure 48–1). At the junction between the ureter and the bladder, a flaplike fold of mucous membrane acts as a valve to prevent reflux (backflow) of urine up the ureters.

Bladder

The urinary bladder (vesicle) is a hollow, muscular organ that serves as a reservoir for urine and as the organ of excretion. When empty, it lies behind the symphysis pubis. In men, the bladder lies in front of the rectum and above the prostate gland (Figure 48–3 •); in women it lies in front of the uterus and vagina (Figure 48–4 •). The wall of the bladder is made up of four layers: (1) an inner mucous layer; (2) a connective tissue layer; (3) three layers of smooth muscle fibers, some of which extend lengthwise, some obliquely, and some more or less circularly; and (4) an outer serous layer. The smooth muscle layers are collectively called the detrusor muscle. The detrusor muscle allows the bladder to expand as it fills with urine, and to contract to release urine to the outside of the body during voiding The trigone at the base of the bladder is a triangular area Cavernous (penile) urethra

Descending and ascending loop of Henle Peritubular capillaries

Bladder

Rectum

Spermatic cord

Prostate

Scrotum

Pelvic muscles

Testis

Prostatic urethra

Glans

Figure 48–2 • The nephrons of the kidney are composed of six parts: the glomerulus, Bowman’s capsule, proximal convoluted tubule, loop of Henle, distal convoluted tubule, and collecting duct.

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Urethral orifice

Epididymis

Membranous urethra

Figure 48–3 • The male urogenital system.

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Urination

Rectum

Micturition, voiding, and urination all refer to the process of emp-

Uterus Urinary bladder

Symphysis pubis Urethra

Pelvic muscles

Vagina

Figure 48–4 • The female urogenital system.

marked by the ureter openings at the posterior corners and the opening of the urethra at the anterior inferior corner (see Figure 48–1). The bladder is capable of considerable distention because of rugae (folds) in the mucous membrane lining and because of the elasticity of its walls. When full, the dome of the bladder may extend above the symphysis pubis; in extreme situations, it may extend as high as the umbilicus. Normal bladder capacity is between 300 and 600 mL of urine.

Urethra

The urethra extends from the bladder to the urinary meatus (opening). In the adult woman, the urethra lies directly behind the symphysis pubis, anterior to the vagina, and is between 3 and 4 cm (1.5 in.) long (see Figure 48–4). The urethra serves only as a passageway for the elimination of urine. The urinary meatus is located between the labia minora, in front of the vagina and below the clitoris. The male urethra is approximately 20 cm (8 in.) long and serves as a passageway for semen as well as urine (see Figure 48–3). The meatus is l­ ocated at the distal end of the penis. In both men and women, the urethra has a mucous membrane lining that is continuous with the bladder and the ureters. Thus, an infection of the urethra can extend through the urinary tract to the kidneys. Women are particularly prone to urinary tract infections (UTIs) because of their short urethra and the proximity of the urinary meatus to the vagina and anus.

Pelvic Floor

The vagina, urethra, and rectum pass through the pelvic floor, which consists of sheets of muscles and ligaments that provide support to the viscera of the pelvis (see Figures 48–3 and 48–4). These muscles and ligaments extend from the symphysis pubis to the coccyx forming a sling. Specific sphincter muscles contribute to the continence mechanism (see the Anatomy & Physiology Review). The internal sphincter muscle situated in the proximal urethra and the bladder neck is composed of smooth muscle under involuntary control. It provides active tension designed to close the urethral lumen. The external sphincter muscle is composed of skeletal muscle under voluntary control, allowing the individual to choose when urine is eliminated.

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tying the urinary bladder. Urine collects in the bladder until pressure stimulates special sensory nerve endings in the bladder wall called stretch receptors. This occurs when the adult bladder contains between 250 and 450 mL of urine. In children, a considerably smaller volume, 50 to 200 mL, stimulates these nerves. The stretch receptors transmit impulses to the spinal cord, specifically to the voiding reflex center located at the level of the second to fourth sacral vertebrae, causing the internal sphincter to relax and stimulating the urge to void. If the time and place are appropriate for urination, the conscious portion of the brain relaxes the external urethral sphincter muscle and urination takes place. If the time and place are inappropriate, the micturition reflex usually subsides until the bladder becomes more filled and the reflex is stimulated again. Voluntary control of urination is possible only if the nerves supplying the bladder and urethra, the neural tracts of the cord and brain, and the motor area of the cerebrum are all intact. The individual must be able to sense that the bladder is full. Injury to any of these parts of the nervous system—for example, by a cerebral hemorrhage or spinal cord injury above the level of the sacral region—results in intermittent involuntary emptying of the bladder. Older adults whose cognition is impaired may not be aware of the need to urinate or able to respond to this urge by seeking toilet facilities.

FACTORS AFFECTING VOIDING

Numerous factors affect the volume and characteristics of the urine produced and the manner in which it is excreted.

Developmental Factors INFANTS Urine output varies according to fluid intake but gradually increases to 250 to 500 mL a day during the first year. An infant may urinate as often as 20 times a day. The urine of the neonate is colorless and odorless and has a specific gravity of 1.008. Because newborns and infants have immature kidneys, they are unable to concentrate urine very effectively. Infants are born without urinary control. Most will develop this between the ages of 2 and 5 years. Control during the daytime normally precedes night-time control. PRESCHOOLERS The preschooler is able to take responsibility for independent toileting. Parents need to realize that accidents do occur and the child should never be punished or disciplined for this. Children often forget to wash their hands or flush the toilet and need instruction in wiping themselves. Girls should be taught to wipe from front to back to prevent contamination of the urinary tract by feces. SCHOOL-AGE CHILDREN The school-age child’s elimination system reaches maturity during this period. The kidneys double in size between ages 5 and 10 years. During this period, the child urinates six to eight times a day. ­Enuresis, which is defined as the involuntary passing of urine

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ANATOMY & PHYSIOLOGY REVIEW Female and Male Urinary Bladders and Urethras The pelvic floor muscles are under voluntary control and are important in controlling urination (continence). These muscles can become weakened by pregnancy and childbirth, chronic constipation, a

decrease in estrogen (menopause), being overweight, aging, and lack of general fitness. Review the figures and find the pelvic floor muscles.

Kidney Ureter Detrusor muscle Opening of ureters Trigone Internal urethral sphincter Prostate gland Urethra External urethral sphincter Pelvic oor muscle

QUESTIONS 1. Do you think pelvic floor muscles can be strengthened? Provide your rationale.

when control should be established (about 5 years of age), can be a problem for some school-age children. About 10% of all 6-year-olds experience difficulty controlling the bladder. Nocturnal enuresis, or bed-wetting, is the involuntary passing of urine during sleep. It has many causes but basically it occurs because the client fails to awaken when the bladder empties. Bed-wetting should not be considered a problem until after the age of 6. Nocturnal enuresis may be referred to as primary when the child has never achieved nighttime urinary control. The incidence of nocturnal enuresis declines as the child matures. Secondary enuresis is that which appears after the child has achieved dryness for a period of 6 consecutive months. It is often related to another problem such as constipation, stress, or illness and may resolve when the cause is eliminated. Recent research indicates that primary and secondary nocturnal enuresis may both be related to poor daytime voiding habits, and children should be taught to be aware of the sensation to void (Norfolk & Wootton, 2012).

OLDER ADULTS The excretory function of the kidney diminishes with age, but usually not significantly below normal levels unless a disease process

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2. Explain how exercising the pelvic floor muscles helps to control urination. See student resource website for answers.

intervenes. Blood flow can be reduced by arteriosclerosis, impairing renal function. With age, the number of functioning nephrons decreases to some degree, impairing the kidney’s filtering abilities. Conditions that alter normal fluid intake and output, such as having influenza or having surgery, can compromise the kidney’s ability to filter, maintain acid–base balance, and maintain electrolyte balance in older adults. It also takes a much longer time for these processes to return to normal functioning. The decrease in kidney function also places the older adult at higher risk for toxicity from medications if excretion rates are longer. The more noticeable changes with age are those related to the bladder. Complaints of urinary urgency and urinary frequency are common. In men these changes are often due to an enlarged prostate gland, and in women they may be due to weakened muscles supporting the bladder or weakness of the urethral sphincter. The capacity of the bladder and its ability to completely empty diminish with age. This explains the need for older adults to arise during the night to void (nocturnal frequency) and the retention of residual urine, predisposing the older adult to bladder infections. See Table 48–1 for a summary of the developmental changes ­affecting urinary output and the Lifespan Considerations feature.

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Psychosocial Factors

For many people, a set of conditions helps stimulate the micturition reflex. These conditions include privacy, normal position, sufficient time, and, occasionally, running water. Circumstances that do not allow for the client’s accustomed conditions may produce anxiety and muscle tension. As a result, the person is unable to relax abdominal and perineal muscles and the external urethral sphincter; thus, voiding is inhibited. People also may voluntarily suppress urination

because of perceived time pressures; for example, nurses often ignore the urge to void until they are able to take a break. This behavior can increase the risk of UTIs.

Fluid and Food Intake

The healthy body maintains a balance between the amount of fluid ingested and the amount of fluid eliminated. When the amount of fluid intake increases, therefore, the output normally increases.

TABLE 48–1   Changes in Urinary Elimination Throughout the Life Span Stage Fetuses Infants Children

Adults

Older Adults

Variations The fetal kidney begins to excrete urine between the 11th and 12th week of development. Ability to concentrate urine is minimal; therefore, urine appears light yellow. Because of neuromuscular immaturity, voluntary urinary control is absent. Kidney function reaches maturity between the first and second year of life; urine is concentrated effectively and ­appears a normal amber color. Between 18 and 24 months of age, the child starts to recognize bladder fullness and is able to hold urine beyond the urge to void. At approximately 2 1/2 to 3 years of age, the child can perceive bladder fullness, hold urine after the urge to void, and communicate the need to urinate. Full urinary control usually occurs at age 4 or 5 years; daytime control is usually achieved by age 3 years. The kidneys reach maximum size between 35 and 40 years of age. After 50 years, the kidneys begin to diminish in size and function. Most shrinkage occurs in the cortex of the kidney as individual nephrons are lost. An estimated 30% of nephrons are lost by age 80. Renal blood flow decreases because of vascular changes and a decrease in cardiac output. The ability to concentrate urine declines. Bladder muscle tone diminishes, causing increased frequency of urination and nocturia (awakening to urinate at night). Diminished bladder muscle tone and contractibility may lead to residual urine in the bladder after voiding, increasing the risk of bacterial growth and infection. Urinary incontinence may occur due to mobility problems or neurologic impairments.

LIFESPAN CONSIDERATIONS Factors Affecting Voiding INFANTS AND CHILDREN • Urinary tract infections (UTIs) are the second most common infection in children, after respiratory infections. They are seen more frequently in newborn and young infant boys than girls and are most often due to obstructions or malformations of the urinary system in these children (Ball, Bindler, & Cowen, 2012). In older infants and children, girls have more UTIs than boys, usually due to contamination of the urethra with stool. • Teaching proper perineal hygiene can reduce infection. Girls should learn to wipe from front to back and wear cotton underwear. • Teach children and parents that they should go to the bathroom as soon as the sensation to void is felt and not try to hold the urine in. OLDER ADULTS Many changes of aging cause specific problems in urinary elimination. Many conditions can be treated to lessen symptoms. Some of the following conditions are etiologic factors in problems with urinary elimination: • Many older men have enlarged prostate glands, which can inhibit complete emptying of the bladder, resulting in urinary retention and urgency that can cause incontinence.

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After menopause women have decreased estrogen levels, which results in a decrease in perineal tone and support of bladder, vagina, and supporting tissues. This often results in urgency and stress incontinence and can even increase the incidence of UTIs. • Increased stiffness and joint pain, previous joint surgery, and neuromuscular problems can impair mobility, making it difficult to get to the bathroom. • Cognitive impairment, such as in dementia, often prevents the person from understanding the need to urinate and the actions needed to perform the activity. Interventions that may improve these conditions include: • Medications or surgery to relieve obstructions in men and strengthen support in the urogenital area in women. • Behavioral training for better bladder control. • Providing safe, easy access to the bathroom or bedside commode, whether at home or in an institution. Make sure the room is well lit, the environment is safe, and the proper assistive devices are within reach (such as walkers, canes). • Habit training, such as taking the person to the bathroom at a regular, scheduled time. This can often work very well with people who have cognitive impairments. •

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Certain fluids, such as alcohol, increase fluid output by inhibiting the production of antidiuretic hormone. Fluids that contain caffeine (e.g., coffee, tea, and cola drinks) also increase urine production. By contrast, food and fluids high in sodium can cause fluid retention because water is retained to maintain the normal concentration of electrolytes. Some foods and fluids can change the color of urine. For example, beets can cause urine to appear red; foods containing carotene can cause the urine to appear yellower than usual.

Medications

Many medications, particularly those affecting the autonomic nervous system, interfere with the normal urination process and may cause retention (Box 48–1). Diuretics (e.g., chlorothiazide and furosemide) increase urine formation by preventing the reabsorption of water and electrolytes from the tubules of the kidney into the bloodstream. Some medications may alter the color of the urine.

Muscle Tone

Good muscle tone is important to maintain the stretch and contractility of the detrusor muscle so the bladder can fill adequately and empty completely. Clients who require a retention catheter for a long period may have poor bladder muscle tone because continuous drainage of urine prevents the bladder from filling and emptying normally. Pelvic muscle tone also contributes to the ability to store and empty urine.

Pathologic Conditions

Some diseases and pathologies can affect the formation and excretion of urine. Diseases of the kidneys may affect the ability of the nephrons to produce urine. Abnormal amounts of protein or blood cells may be present in the urine, or the kidneys may virtually stop producing urine altogether, a condition known as renal failure. Heart and circulatory disorders such as heart failure, shock, or hypertension can affect blood flow to the kidneys, interfering with urine production. If abnormal amounts of fluid are lost through another route (e.g., vomiting or high fever), the kidneys retain water and urinary output falls. Processes that interfere with the flow of urine from the kidneys to the urethra affect urinary excretion. A urinary stone (calculus)

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may obstruct a ureter, blocking urine flow from the kidney to the bladder. Hypertrophy of the prostate gland, a common condition affecting older men, may obstruct the urethra, impairing urination and bladder emptying.

Surgical and Diagnostic Procedures

Some surgical and diagnostic procedures affect the passage of urine and the urine itself. The urethra may swell following a cystoscopy, and surgical procedures on any part of the urinary tract may result in some postoperative bleeding; as a result, the urine may be red or pink tinged for a time. Spinal anesthetics can affect the passage of urine because they decrease the client’s awareness of the need to void. Surgery on structures adjacent to the urinary tract (e.g., the uterus) can also affect voiding because of swelling in the lower abdomen.

ALTERED URINE PRODUCTION

Although people’s patterns of urination are highly individual, most people void about five to six times a day. People usually void when they first awaken in the morning, before they go to bed, and around mealtimes. Table 48–2 shows the average urinary output per day at different ages.

Polyuria

Polyuria (or diuresis) refers to the production of abnormally large

amounts of urine by the kidneys, often several liters more than the client’s usual daily output. Polyuria can follow excessive fluid intake, a condition known as polydipsia, or may be associated with diseases such as diabetes mellitus, diabetes insipidus, and chronic nephritis. Polyuria can cause excessive fluid loss, leading to intense thirst, dehydration, and weight loss.

Oliguria and Anuria

The terms oliguria and anuria are used to describe decreased urinary output. Oliguria is low urine output, usually less than 500 mL a day or 30 mL an hour for an adult. Although oliguria may occur because of abnormal fluid losses or a lack of fluid intake, it often indicates impaired blood flow to the kidneys or impending renal failure and should be promptly reported to the primary care provider. TABLE 48–2   Average Daily Urine Output by Age

BOX 48–1 • • • • • • •

Medications That May Cause Urinary Retention

Anticholinergic medications, such as Atropine, Robinul, and Pro-Banthine Antidepressant and antipsychotic agents, such as tricyclic ­antidepressants and MAO inhibitors Antihistamine preparations, such as pseudoephedrine (Actifed and Sudafed) Antihypertensives, such as hydralazine (Apresoline) and ­methyldopa (Aldomet) Antiparkinsonism drugs, such as levodopa, trihexyphenidyl (­Artane), and benztropine mesylate (Cogentin) Beta-adrenergic blockers, such as propranolol (Inderal) Opioids, such as hydrocodone (Vicodin)

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Age

Amount (ml)

1–2 days

15–60

3–10 days

100–300

10 days–2 months

250–450

2 months–1 year

400–500

1–3 years

500–600

3–5 years

600–700

5–8 years

700–1,000

8–14 years

800–1,400

14 years through adulthood

1,500

Older adulthood

1,500 or less

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Restoring renal blood flow and urinary output promptly can prevent renal failure and its complications. Anuria refers to a lack of urine production. Should the kidneys become unable to adequately function, some mechanism of filtering the blood is necessary to prevent illness and death. This filtering is done through the use of renal dialysis, a technique by which fluids and molecules pass through a semipermeable membrane according to the rules of osmosis. The two most common methods of dialysis are hemodialysis and peritoneal dialysis. In hemodialysis, the client’s blood flows through vascular catheters, passes by the dialysis solution in an external machine, and then returns to the client. In peritoneal dialysis, the dialysis solution is instilled into the abdominal cavity through a catheter, allowed to rest there while the fluid and molecules exchange, and then removed through the catheter. Both hemodialysis and peritoneal dialysis must be performed at frequent intervals until the client’s kidneys can resume the filtering function.

ALTERED URINARY ELIMINATION

Despite normal urine production, a number of factors or conditions can affect urinary elimination. Frequency, nocturia, urgency, and dysuria often are manifestations of underlying conditions such as a

UTI. Enuresis, incontinence, retention, and neurogenic bladder may be either a manifestation or the primary problem affecting urinary elimination. Selected factors associated with altered patterns of urine elimination are identified in Table 48–3.

Frequency and Nocturia

Urinary frequency is voiding at frequent intervals, that is, more than four to six times per day. An increased intake of fluid causes some increase in the frequency of voiding. Conditions such as UTI, stress, and pregnancy can cause frequent voiding of small quantities (50 to 100 mL) of urine. Total fluid intake and output may be normal. Nocturia is voiding two or more times at night. Like frequency, it is usually expressed in terms of the number of times the person gets out of bed to void, for example, “nocturia × 4.”

Urgency

Urgency is the sudden, strong desire to void. There may or may not be a great deal of urine in the bladder, but the person feels a need to void immediately. Urgency accompanies psychological stress and irritation of the trigone and urethra. It is also common in people who have poor external sphincter control and unstable bladder contractions. It is not a normal finding.

TABLE 48–3   Selected Factors Associated with Altered Urinary Elimination Pattern

Selected Associated Factors

Polyuria

Ingestion of fluids containing caffeine or alcohol Prescribed diuretic Presence of thirst, dehydration, and weight loss History of diabetes mellitus, diabetes insipidus, or kidney disease

Oliguria, anuria

Decrease in fluid intake Signs of dehydration Presence of hypotension, shock, or heart failure History of kidney disease Signs of renal failure such as elevated blood urea nitrogen (BUN) and serum creatinine, edema, hypertension

Frequency or nocturia

Pregnancy Increase in fluid intake UTI

Urgency

Presence of psychological stress UTI

Dysuria

Urinary tract inflammation, infection, or injury Hesitancy, hematuria, pyuria (pus in the urine), and frequency

Enuresis

Family history of enuresis Difficult access to toilet facilities Home stresses

Incontinence

Bladder inflammation, cerebrovascular accident (CVA; stroke), spinal cord injury, or other disease Difficulties in independent toileting (mobility impairment) Leakage when coughing, laughing, sneezing Cognitive impairment Retention Distended bladder on palpation and percussion Associated signs, such as pubic discomfort, restlessness, frequency, and small urine volume Recent anesthesia Recent perineal surgery Presence of perineal swelling Medications prescribed Lack of privacy or other factors inhibiting micturition

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Dysuria

Dysuria means voiding that is either painful or difficult. It can ac-

company a stricture (decrease in caliber) of the urethra, urinary infections, and injury to the bladder and urethra. Often clients will say they have to push to void or that burning accompanies or follows voiding. The burning may be described as severe, like a hot poker, or more subdued, like a sunburn. Often, urinary hesitancy (a delay and difficulty in initiating voiding) is associated with dysuria.

Enuresis

Enuresis is involuntary urination in children beyond the age when voluntary bladder control is normally acquired, usually 4 or 5 years of age. Nocturnal enuresis often is irregular in occurrence and affects boys more often than girls. Diurnal (daytime) enuresis may be persistent and pathologic in origin. It affects women and girls more frequently.

Urinary Incontinence

Urinary incontinence (UI), or involuntary leakage of urine or loss of bladder control, is a health symptom, not a disease. It is only normal in infants. It has been estimated that 20 million women and 6 million men experience some type of UI in their lifetime (Scemons, 2013, p. 53). Shultz (2012) found that 30% of homebound older adults are incontinent, and UI contributed significantly to their being homebound. More than half of all residents in long-term care (LTC) facilities are incontinent and UI is the second leading cause of institutionalization (p. 32). In spite of the high numbers of adults with UI, it is underreported and undertreated, and can lead to a decreased qualify of life (Keyock & Newman, 2011). Direct and indirect costs are associated with UI. The annual cost of around $20 billion for incontinence is higher than for chronic diseases such as arthritis (Scemons, 2013). The majority of direct cost is spent on routine care including pads, diapers, and laundry related to frequent clothing changes. Other costs include medications and surgical treatment. Indirect costs relate to quality-of-life issues and psychosocial consequences. Studies have shown that incontinent women have an increased incidence of social isolation, social withdrawal, less positive relationships with others, poorer perceived health, negative effect on sexual function and intimacy, increased incidence of depression, and a barrier to social interest, physical activity, and other everyday activities (Schultz, 2012). The four main types of UI are stress urinary incontinence, urge urinary incontinence, mixed urinary incontinence, and overflow incontinence.

STRESS URINARY INCONTINENCE Stress urinary incontinence (SUI) occurs because of weak pelvic floor muscles and/or urethral hypermobility, causing urine leakage with such activities as laughing, coughing, sneezing, or any body movement that puts pressure on the bladder. Facts that make women more likely to experience SUI include shorter urethras, the trauma to the pelvic floor associated with childbirth, and changes related to menopause. For men, SUI may result after a prostatectomy. Keyock and Newman (2011) stress the importance of clients understanding that SUI is not related to emotional stress

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but is “caused by increased pressure or ‘stress’ on the bladder as well as anatomical changes to the urethra, and pelvic floor muscle weakness” (p. 26).

URGE URINARY INCONTINENCE This type of incontinence is described as an urgent need to void and the inability to stop micturition (passage of urine). The urine leakage can range from a few drops to soaking of undergarments. Urge incontinence is a major symptom of an overactive bladder (National Association for Continence [NAFC], 2014). MIXED URINARY INCONTINENCE Mixed incontinence is diagnosed when symptoms of both stress UI and urgency UI are present. It is very common among middle-age and older women (Scemons, 2013). Treatment is usually based on which type of UI is the most bothersome to the client. OVERFLOW INCONTINENCE This is “continuous involuntary leakage or dribbling of urine that occurs with incomplete bladder emptying” (Scemons, 2013, p. 55). It can be seen in men with an enlarged prostate and clients with a neurologic disorder (e.g., multiple sclerosis, Parkinson’s disease, spinal cord injury). An impaired neurologic function can interfere with the normal mechanisms of urine elimination, resulting in a neurogenic bladder. The client with a neurogenic bladder does not perceive bladder fullness and is therefore unable to control the urinary sphincters. The bladder may become flaccid and distended or spastic, with frequent involuntary urination.

Urinary Retention

When emptying of the bladder is impaired, urine accumulates and the bladder becomes overdistended, a condition known as urinary retention. Overdistention of the bladder causes poor contractility of the detrusor muscle, further impairing urination. Common causes of urinary retention include prostatic hypertrophy (enlargement), surgery, and some medications (see Box 48–1). Acute urinary retention is the most common complication in the first 2 to 4 hours postoperatively (Palese, Buchini, Deroma, & Barbone, 2010). Causes of chronic urinary retention can include paraplegia, quadriplegia, multiple sclerosis, and urethral or perineal trauma (Bullman, 2011, p. 259). Clients with urinary retention may experience overflow incontinence, eliminating 25 to 50 mL of urine at frequent intervals. The bladder is firm and distended on palpation and may be displaced to one side of the midline. ●◯●

NURSING MANAGEMENT

Assessing A complete assessment of a client’s urinary function includes the following: • Nursing history • Physical assessment of the genitourinary system, hydration status,

and examination of the urine

• Relating the data obtained to the results of any diagnostic tests and

procedures.

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Nursing History The nurse determines the client’s normal voiding pattern and frequency, appearance of the urine and any recent changes, any past or current problems with urination, the presence of an ostomy, and factors influencing the elimination pattern. Examples of interview questions to elicit this information are shown in the Assessment Interview. The number of questions asked depends on the individual and the responses to the first three categories. Physical Assessment Complete physical assessment of the urinary tract usually includes percussion of the kidneys to detect areas of tenderness. Palpation and percussion of the bladder are also performed. If the client’s history or current problems indicate a need for it, the urethral meatus of both male and female clients is inspected for swelling, discharge, and inflammation. Because problems with urination can affect the elimination of wastes from the body, it is important for the nurse to assess the skin for color, texture, and tissue turgor as well as the presence of edema. If incontinence, dribbling, or dysuria is noted in the history, the skin of the perineum should be inspected for irritation because contact with urine can excoriate the skin. Assessing Urine Normal urine consists of 96% water and 4% solutes. Organic solutes include urea, ammonia, creatinine, and uric acid. Urea is the chief organic solute. Inorganic solutes include sodium, chloride, potassium, sulfate, magnesium, and phosphorus. Sodium chloride is the most abundant inorganic salt. Variations in color can occur. Characteristics of normal and abnormal urine are shown in Table 48–4. Measuring Urinary Output

Normally, the kidneys produce urine at a rate of approximately 60 mL/h or about 1,500 mL/day. Urine output is affected by many factors, including fluid intake, body fluid losses through other routes

such as perspiration and breathing or diarrhea, and the cardiovascular and renal status of the individual. Urine outputs below 30 mL/h may indicate low blood volume or kidney malfunction and must be reported. To measure fluid output the nurse follows these steps: • Wear clean gloves to prevent contact with microorganisms or

blood in urine.

• Ask the client to void in a clean urinal, bedpan, commode, or toilet

collection device (“hat”) (Figure 48–5 •).

• Instruct the client to keep urine separate from feces and to avoid

putting toilet paper in the urine collection container.

• Pour the voided urine into a calibrated container. • Hold the container at eye level, read the amount in the container.

Containers usually have a measuring scale on the inside.

• Record the amount on the fluid intake and output sheet, which

may be at the bedside or in the bathroom.

• Rinse the urine collection and measuring containers with cool

water and store appropriately.

• Remove gloves and perform hand hygiene. • Calculate and document the total output at the end of each shift

and at the end of 24 h on the client’s chart.

Many clients can measure and record their own urine output when the procedure is explained to them. When measuring urine from a client who has a urinary catheter, the nurse follows these steps: • Apply clean gloves. • Take the calibrated container to the bedside. • Place the container under the urine collection bag so that the

spout of the bag is above the container but not touching it. The calibrated container is not sterile, but the inside of the collection bag is sterile (Figure 48–6 •). • Open the spout and permit the urine to flow into the container. • Close the spout, then proceed as described in the previous list.

ASSESSMENT INTERVIEW  Urinary Elimination VOIDING PATTERN • How many times do you urinate during a 24-hour period? • Has this pattern changed recently? • Do you need to get out of bed to void at night? How often? DESCRIPTION OF URINE AND ANY CHANGES • How would you describe your urine in terms of color, clarity (clear, transparent, or cloudy), and odor (faint or strong)? URINARY ELIMINATION PROBLEMS • What problems have you had or do you now have with passing your urine? • Passage of small amounts of urine? • Voiding at more frequent intervals? • Trouble getting to the bathroom in time, or feeling an urgent need to void? • Painful voiding? • Difficulty starting urine stream? • Frequent dribbling of urine or feeling of bladder fullness associated with voiding small amounts of urine? • Reduced force of stream? • Accidental leakage of urine? If so, when does this occur (e.g., when coughing, laughing, or sneezing; at night; during the day)?

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Past urinary tract illness such as infection of the kidney, bladder, or urethra? History of renal, ureteral, or bladder surgery?

FACTORS INFLUENCING URINARY ELIMINATION • Medications. What medications are you taking? Do you know if any of your medications increase urinary output or cause retention of urine? Note specific medication and dosage. • Fluid intake. How much and what kind of fluid do you drink each day (e.g., six glasses of water, two cups of coffee, three cola drinks with or without caffeine)? • Environmental factors. Do you have any problems with toileting (mobility, removing clothing, toilet seat too low, facility without grab bar)? • Stress. Are you experiencing any major stress? If so, what are the stressors? Do you think these affect your urinary pattern? • Disease. Have you had or do you have any illnesses that may affect urinary function, such as hypertension, heart disease, neurologic disease, cancer, prostatic enlargement, or diabetes? • Diagnostic procedures and surgery. Have you recently had a cystoscopy or anesthetic?

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TABLE 48–4   Characteristics of Normal and Abnormal Urine Characteristic Amount in 24 hours (adult)

Normal 1,200–1,500 mL

Abnormal Under 1,200 mL A large amount over intake

Nursing Considerations Urinary output normally is approximately equal to fluid intake. Output of less than 30 mL/h may indicate decreased blood flow to the kidneys and should be immediately reported.

Color, clarity

Straw, amber Transparent

Dark amber Cloudy Dark orange Red or dark brown Mucous plugs, viscid, thick

Concentrated urine is darker in color. Dilute urine may appear almost clear, or very pale yellow. Some foods and drugs may color urine. Red blood cells in the urine (hematuria) may be evident as pink, bright red, or rusty brown urine. Menstrual bleeding can also color urine but should not be confused with hematuria. White blood cells, bacteria, pus, or contaminants such as prostatic fluid, sperm, or vaginal drainage may cause cloudy urine.

Odor

Faint aromatic

Offensive

Some foods (e.g., asparagus) cause a musty odor; infected urine can have a fetid odor; urine high in glucose has a sweet odor.

Sterility

No microorganisms present

Microorganisms present

Urine in the bladder is sterile. Urine specimens, however, may be contaminated by bacteria from the perineum during collection.

pH

4.5–8

Over 8 Under 4.5

Freshly voided urine is normally somewhat acidic. Alkaline urine may indicate a state of alkalosis, UTI, or a diet high in fruits and vegetables. More acidic urine (low pH) is found in starvation, with diarrhea, or with a diet high in protein foods or cranberries.

Specific gravity

1.010–1.025

Over 1.025 Under 1.010

Concentrated urine has a higher specific gravity; diluted urine has a lower specific gravity.

Glucose

Not present

Present

Glucose in the urine indicates high blood glucose levels (greater than 180 mg/dL) and may be indicative of undiagnosed or ­uncontrolled diabetes mellitus.

Ketone bodies (acetone)

Not present

Present

Ketones, the end product of the breakdown of fatty acids, are not normally present in urine. They may be present in the urine of clients who have uncontrolled diabetes mellitus, who are in a state of starvation, or who have ingested excessive amounts of aspirin.

Blood

Not present

Occult (microscopic) Bright red

Blood may be present in the urine of clients who have UTI, k­ idney disease, or bleeding from the urinary tract.

Figure 48–5 • A urine “hat”—a urine collection device for the toilet. Measuring Residual Urine

Postvoid residual (PVR) (urine remaining in the bladder follow-

ing voiding) is normally 50 to 100 mL. However, a bladder outlet obstruction (e.g., enlargement of the prostate gland) or loss of bladder muscle tone may interfere with complete emptying of the bladder

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Figure 48–6 • Urine being measured from a urine collection bag.

during urination. Manifestations of urine retention may include frequent voiding of small amounts (e.g., less than 100 mL in an adult), urinary stasis, and UTI. PVR is measured to assess the amount of retained urine after voiding and determine the need for interventions (e.g., medications to promote detrusor muscle contraction).

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To measure PVR, the nurse catheterizes or bladder scans the client after voiding (Figure 48–7 •). The amount of urine voided and the amount obtained by catheterization or bladder scan are measured and recorded. An indwelling catheter may be inserted if the PVR exceeds a specified amount.

Diagnostic Tests Blood levels of two metabolically produced substances, urea and creatinine, are routinely used to evaluate renal function. The kidneys through filtration and tubular secretion normally eliminate both urea and creatinine. Urea, the end product of protein metabolism, is measured as blood urea nitrogen (BUN). Creatinine is produced in relatively constant quantities by the muscles. The creatinine clearance test uses 24-hour urine and serum creatinine levels to determine the glomerular filtration rate, a sensitive indicator of renal function. Other tests related to urinary functions such as collecting urine specimens, measuring specific gravity, and visualization procedures are described in Chapter 34 .

Diagnosing NANDA International (Herdman & Kamitsuru, 2014) includes two general diagnostic labels for urinary elimination: • Impaired Urinary Elimination: dysfunction in urine elimination • Readiness for Enhanced Urinary Elimination: a pattern of

u­ rinary functions for meeting eliminatory needs, which can be strengthened.

It is suggested that a more specific diagnostic label be used when possible. The more specific NANDA International nursing diagnoses related to urinary elimination include the following: • Functional Urinary Incontinence • Overflow Urinary Incontinence • Reflex Urinary Incontinence

Figure 48–7 • A handheld, portable ultrasound device can measure bladder urine volume noninvasively.

• • • •

Stress Urinary Incontinence Urge Urinary Incontinence Risk for Urge Urinary Incontinence Urinary Retention

See Box 48–2 for definitions of NANDA diagnoses related to incontinence. Clinical examples of assessment data clusters and related nursing diagnoses, outcomes, and interventions are shown in the Nursing Care Plan and Concept Map at the end of this chapter.

Evidence-Based Practice What Is the Effectiveness of the Ultrasound Bladder Scanner in Reducing Urinary Tract Infections? Urinary retention, a common complication postoperatively, can lead to complications, client discomfort, and a longer hospitalization stay. Two ways to detect and monitor urinary retention are with an ultrasound bladder scanner or with intermittent catheterization. Catheterization is an invasive procedure and increases the risk of UTI. On the other hand, the bladder scanner is noninvasive and permits evaluation of the bladder volume so that catheterization is only performed when the volume is over a designated amount. Palese and colleagues (2010) believed that there was a need to analyze the available research comparing the use of the bladder scanner followed by the decision to catheterize or not catheterize versus the clinical judgment of the nurse who decides whether to catheterize or not catheterize the client and the effect of these procedures in reducing catheter-associated UTIs (CAUTIs). A meta-analysis study was conducted to synthesize the evidence available in the literature on the effectiveness of the ultrasound bladder scanner in reducing the risk of UTI. The criteria for studies to be included in the research included the following: type of subject (hospitalized male and female subjects age 18 or over whose treatment required a need to evaluate bladder urinary volume); type of intervention (use of bladder scanner versus the clinical judgment of the nurses in evaluation

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EVIDENCE-BASED PRACTICE 

of acute urinary retention followed by a decision whether or not to catheterize the client); and type of outcome (occurrence of at least one CAUTI before release from the hospital). A total of 61 articles were found and 58 were excluded based on the criteria. The three studies that remained had some variation; for example, subjects in one study were neurosurgical and those in the other two studies were orthopedic; each study used a different type of scanner; evaluations were performed at 8 hours or 4 to 6 hours after surgery or the period was not indicated in one study; and the cutoff amount of when to catheterize varied from less than 499 mL to less than 800 mL. In spite of these variations, based on the statistical analyses, the studies were considered homogeneous. The researchers stated that the “use of bladder ultrasound reduced the risk of CAUTI by some 73%” (p. 2976). IMPLICATIONS A limitation of this study was the small number of appropriate studies included in the meta-analysis. Nevertheless, the use of the bladder scanner as a noninvasive assessment tool should become a common practice of nurses who provide care to surgical clients who develop acute urinary retention.

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BOX 48–2 • • •

• • •

Definitions of NANDA International Incontinence Diagnoses

Functional Urinary Incontinence—inability of usually continent person to reach toilet in time to avoid unintentional loss of urine Overflow Urinary Incontinence—involuntary loss of urine associated with overdistention of the bladder Reflex Urinary Incontinence—involuntary loss of urine at ­somewhat predictable intervals when a specific bladder ­volume is reached Stress Urinary Incontinence—sudden leakage of urine with ­activities that increase intra-abdominal pressure Urge Urinary Incontinence—involuntary passage of urine ­occurring soon after a strong sense of urgency to void Risk for Urge Urinary Incontinence—vulnerable to involuntary passage of urine occurring soon after a strong sensation or urgency to void, which may compromise health

From NANDA International Nursing Diagnoses: Definitions and Classification, 2015–2017, by T. H. Herdman and S. Kamitsuru (Eds.), 2014, Oxford, United Kingdom: Wiley-Blackwell.

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• Disturbed Body Image if the client has a urinary diversion ostomy. • Deficient Knowledge if the client requires self-care skills to man-

age (e.g., a new urinary diversion ostomy).

• Risk for Caregiver Role Strain if the client is incontinent and be-

ing cared for by a family member for extended periods.

• Risk for Social Isolation if the client is incontinent.

Planning The goals established will vary according to the diagnosis and defining characteristics. Examples of overall goals for clients with urinary elimination problems may include the following: • Maintain or restore a normal voiding pattern. • Regain normal urine output. • Prevent associated risks such as infection, skin breakdown, fluid

and electrolyte imbalance, and lowered self-esteem.

• Perform toileting activities independently with or without assis-

Problems of urinary elimination also may become the etiology for other problems experienced by the client. Examples include the following: • Risk for Infection if the client has urinary retention or under-

•

•

• •

goes an invasive procedure such as catheterization or cystoscopic examination. Situational Low Self-Esteem or Social Isolation if the client is incontinent. Incontinence can be physically and emotionally distressing to clients because it is considered socially unacceptable. Often the client is embarrassed about dribbling or having an accident and may restrict normal activities for this reason. Risk for Impaired Skin Integrity if the client is incontinent. Bed linens and clothes saturated with urine irritate and macerate the skin. Prolonged skin dampness leads to dermatitis (inflammation of the skin) and subsequent formation of dermal ulcers. Toileting Self-Care Deficit if the client has functional incontinence. Risk for Deficient Fluid Volume or Excess Fluid Volume if the client has impaired urinary function associated with a disease process.

tive devices.

• Contain urine with the appropriate device, catheter, ostomy appli-

ance, or absorbent product.

Appropriate preventive and corrective nursing interventions that relate to these must be identified. Specific nursing activities associated with each of these interventions can be selected to meet the client’s individual needs. Examples of clinical applications of these using NANDA, NIC, and NOC designations are shown in the Nursing Care Plan and Concept Map at the end of the chapter.

Planning for Home Care To provide for continuity of care, the nurse needs to consider the client’s needs for teaching and assistance with care in the home. Discharge planning includes assessment of the client and family’s resources and abilities for self-care, available financial resources, and the need for referrals and home health services. Home Care Assessment outlines an assessment of home care capabilities related to urinary elimination problems and needs. Client Teaching addresses the learning needs of the client and family.

DRUG CAPSULE

Anticholinergic Agent  oxybutynin ER (Ditropan XL) THE CLIENT WITH MEDICATIONS FOR URGE URINARY INCONTINENCE Anticholinergic agents reduce urgency and frequency by blocking muscarinic receptors in the detrusor muscle of the bladder, thereby inhibiting contractions and increasing storage capacity. They are useful in relieving symptoms associated with voiding problems in clients with neurogenic bladder and reflex neurogenic bladder, and urge UI. NURSING RESPONSIBILITIES • Monitor for constipation, dry mouth, urinary retention, blurred vision, and mental confusion in older adults; symptoms may be dose related. • Keep primary care provider informed of expected responses to therapy (e.g., effect on urinary frequency, urge incontinence, nocturia, and bladder emptying). • Start with small doses in clients over the age of 75.

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Try using intermittently. Oxybutynin is contraindicated in clients with urinary retention, gastrointestinal motility problems (partial or complete GI obstruction, paralytic ileus), or uncontrolled narrow-angle glaucoma.

CLIENT AND FAMILY TEACHING • Explain the reason for taking oxybutynin. • Explain the side effects and the importance of reporting them to the health care provider. • Exercise caution in hot environments. By suppressing sweating, oxybutynin can cause fever and heat stroke. • Provide strategies for managing dry mouth. • Instruct and advise regarding behavioral therapies for urge suppression. Note: Prior to administering any medication, review all aspects with a current drug handbook or other reliable source.

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Home Care Assessment  Urinary Elimination CLIENT AND ENVIRONMENT • Self-care abilities: ability to consume adequate fluids, to perceive bladder fullness, to ambulate and get to the toilet, to manipulate clothing for toileting, and to perform hygiene measures after toileting • Current level of knowledge: fluid and dietary intake modifications to promote normal patterns of urinary elimination, bladder training methods, and specific techniques to promote voiding care for indwelling catheter or ostomy (if appropriate) • Assistive devices required: ambulatory aids such as walker, cane, or wheelchair; safety devices such as grab bars; toileting aids such as raised toilet seat, urinal, commode, or bedpan; presence of a urinary catheter • Physical layout of the toileting facilities: presence of mobility aids; toilet at correct height to enable older clients to get up after voiding • Home environment factors that interfere with toileting: distance to the bathroom from living areas or bedrooms; barriers such as stairways, scatter rugs, clutter, or narrow doorways that interfere with bathroom access; lighting (including night lighting) • Urinary elimination problems: type of incontinence and precipitating factors; manifestations of UTI such as dysuria, frequency,

Implementing Maintaining Normal Urinary Elimination Most interventions to maintain normal urinary elimination are independent nursing functions. These include promoting adequate fluid intake, maintaining normal voiding habits, and assisting with toileting. Promoting Fluid Intake

Increasing fluid intake increases urine production, which in turn stimulates the micturition reflex. A normal daily intake averaging 1,500 mL of measurable fluids is adequate for most adult clients. Many clients have increased fluid requirements, necessitating a higher daily fluid intake. For example, clients who are perspiring excessively (have diaphoresis) or who are experiencing abnormal fluid losses through vomiting, gastric suction, diarrhea, or wound drainage require fluid to replace these losses in addition to their normal daily intake requirements. Clients who are at risk for UTI or urinary calculi (stones) should consume 2,000 to 3,000 mL of fluid daily. Dilute urine and frequent urination reduce the risk of UTI as well as stone formation. Increased fluid intake may be contraindicated for some clients such as people with kidney failure or heart failure. For these clients, a fluid restriction may be necessary to prevent fluid overload and edema. Maintaining Normal Voiding Habits

Prescribed medical therapies often interfere with a client’s normal voiding habits. When a client’s urinary elimination pattern is adequate, the nurse helps the client adhere to normal voiding habits as much as possible (see Practice Guidelines).

PATIENT-CENTERED CARE urgency; evidence of prostatic hypertrophy and effect on urination; ability to perform self-catheterization and care for other urinary elimination devices such as indwelling catheter, urinary diversion ostomy, or condom drainage FAMILY • Caregiver availability, skills, and responses: ability and willingness to assume responsibilities for care, including assisting with toileting, intermittent catheterization, indwelling catheter care, urinary drainage devices or ostomy care; ready access to laundry facilities; access to and willingness to use respite or relief caregivers • Family role changes and coping: effect on spousal and family roles, sleep/rest patterns, sexuality, and social interactions • Financial resources: ability to purchase protective pads and garments, supplies for catheterization or ostomy care COMMUNITY • Environment: access to public restrooms and sanitary facilities • Current knowledge of and experience with community resources: medical and assistive equipment and supply companies, home health agencies, local pharmacies, available financial assistance, support and educational organizations

falling. The bathroom should contain an easily accessible call signal to summon help if needed. Clients also need to be encouraged to use handrails placed near the toilet. For clients unable to use bathroom facilities, the nurse provides urinary equipment close to the bedside (e.g., urinal, bedpan, commode) and provides the necessary assistance to use them.

Preventing Urinary Tract Infections The rate of UTI is greater in women than men because of the short urethra and its proximity to the anal and vaginal areas. Most UTIs are caused by bacteria common to the intestinal environment (e.g., Escherichia coli). These gastrointestinal bacteria can colonize the perineal area and move into the urethra, especially when there is urethral trauma, irritation, or manipulation. For women who have experienced a UTI, nurses need to provide instructions about ways to prevent a recurrence. The following guidelines are useful for anyone: • Drink eight 8-ounce glasses of water per day to flush bacteria out

of the urinary system.

• Practice frequent voiding (every 2 to 4 hours) to flush bacteria

•

• •

•

Assisting with Toileting

Clients who are weakened by a disease process or impaired physically may require assistance with toileting. The nurse should assist these clients to the bathroom and remain with them if they are at risk for

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out of the urethra and prevent organisms from ascending into the bladder. Void immediately after intercourse. Avoid use of harsh soaps, bubble bath, powder, or sprays in the perineal area. These substances can be irritating to the urethra and encourage inflammation and bacterial infection. Avoid tight-fitting pants or other clothing that creates irritation to the urethra and prevents ventilation of the perineal area. Wear cotton rather than nylon underclothes. Accumulation of perineal moisture facilitates bacterial growth. Cotton enhances ventilation of the perineal area. Girls and women should always wipe the perineal area from front to back following urination or defecation in order to prevent introduction of gastrointestinal bacteria into the urethra. If recurrent urinary infections are a problem, take showers rather than baths. Bacteria present in bath water can readily enter the urethra.

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CLIENT TEACHING

Urinary Elimination in the Home Setting FACILITATING URINARY ELIMINATION SELF-CARE • Teach the client and family to maintain easy access to toilet facilities, including removing scatter rugs and ensuring that halls and doorways are free of clutter. • Suggest graduated lighting for night-time voiding: a dim nightlight in the bedroom and low-wattage hallway lighting. • Advise the client and family to install grab bars and elevated toilet seats as needed. • Provide for instruction in safe transfer techniques. Contact physical therapy to provide training as needed. • Suggest clothing that is easily removed for toileting, such as elastic waist pants or Velcro closures. PROMOTING URINARY ELIMINATION • Instruct the client to respond to the urge to void as soon as possible; avoid voluntary urinary retention. • Teach the client to empty the bladder completely at each voiding. • Emphasize the importance of drinking eight to ten 8-ounce glasses of water daily. • Teach female clients about pelvic muscle exercises to strengthen perineal muscles. • Inform the client about the relationship between tobacco use and bladder cancer and provide information about smoking cessation programs as indicated. • Teach the client to promptly report any of the following to the primary care provider: pain or burning on urination, changes in urine color or clarity, malodorous urine, or changes in voiding patterns (e.g., nocturia, frequency, dribbling). ASEPSIS • Teach the client to maintain perineal-genital cleanliness, ­washing with soap and water daily and cleansing the anal and perineal area after defecating. • Instruct female clients to wipe from front to back (from the ­urinary meatus toward the anus) after voiding, and to discard toilet paper after each swipe. • Provide information about products to protect the skin, clothing, and furniture for clients who are incontinent. Emphasize the importance of cleaning and drying the perineal area after incontinence episodes. Instruct in the use of protective skin barrier products as needed. • Teach clients with an indwelling catheter and their family about care measures such as cleaning the urinary meatus, managing and emptying the collection device, maintaining a closed system, and bladder irrigation or flushing if ordered. • For clients with a urinary diversion, teach about care of the stoma, drainage devices, and surrounding skin. For continent diversions, teach the client how to catheterize the stoma to drain urine. • For clients with an indwelling catheter or urinary diversion, ­emphasize the importance of maintaining a generous fluid intake (2.5 to 3 quarts daily) and of promptly reporting changes in urinary output, signs of urinary retention such as abdominal

Managing Urinary Incontinence It is important to remember that UI is not a normal part of aging and often is treatable. The preliminary assessment and identification of the symptoms of UI are truly within the scope of nursing practice. All clients should be asked about their voiding patterns. Older adults who are incontinent while in their home or who manage to contain or conceal their incontinence from others do not consider themselves

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pain, and manifestations of UTI such as malodorous urine, ­abdominal discomfort, fever, or confusion. MEDICATIONS • Emphasize the importance of taking medications as prescribed. Instruct the client to take the full course of antibiotics ordered to treat a UTI, even though symptoms are relieved. • Inform the client and family about any expected changes in urine color or odor associated with prescribed medications. • For clients with urinary retention, emphasize the need to contact the primary care provider before taking any medication (even over-the-counter medications such as antihistamines) that may exacerbate symptoms. • For clients taking medications that may damage the kidneys (e.g., aminoglycoside antibiotics), stress the importance of maintaining a generous fluid intake while taking the medication. • Suggest measures to reduce anticipated side effects of prescribed medications, such as increasing intake of potassiumrich foods when taking a potassium-depleting diuretic such as furosemide. DIETARY ALTERATIONS • Teach the client about dietary changes to promote urinary ­function, such as consuming cranberry juice and foods that acidify the urine to reduce the risk of repeated UTIs or forming calcium-based urinary stones. See the Dietary Measures ­section on page 1198. • Instruct clients with stress or urge incontinence to limit their intake of caffeine, alcohol, citrus juices, and artificial sweeteners because these are bladder irritants that may increase incontinence. Also, teach clients to limit their evening fluid intake to reduce the risk of night-time incontinence episodes. MEASURES SPECIFIC TO URINARY PROBLEMS • Provide instructions for clients with specific urinary problems or treatments such as these: a. Timed urine specimens (see Chapter 34 ) b. Urinary incontinence c. Urinary retention d. Retention catheters. REFERRALS • Make appropriate referrals to home health agencies, community agencies, or social services for assistance with resources such as installing grab bars and raised toilet seats; providing wheelchair access to bathrooms; obtaining toileting aids such as commodes, urinals, or bedpans; and services such as home health aides for assistance with activities of daily living. COMMUNITY AGENCIES AND OTHER RESOURCES • Provide information about resources for durable medical equipment such as commodes or raised toilet seats, possible financial assistance, and medical supplies such as drainage bags, incontinence briefs, or protective pads. • Suggest additional sources of information and help such as the National Council of Independent Living, United Ostomy Association, National Association for Continence, and Simon Foundation for Continence.

incontinent. Therefore, if asked if they are incontinent, they may deny it. However, asking if they lose urine when they cough, sneeze, or laugh or if they need to use some type of incontinence product may provide more accurate information (Keyock & Newman, 2011). Independent nursing interventions for clients with UI include (a) a behavior-oriented continence training program that may consist of bladder retraining, habit training, and pelvic floor muscle exercises;

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PRACTICE GUIDELINES

Maintaining Normal Voiding Habits POSITIONING • Assist the client to a normal position for voiding: standing for male clients; for female clients, squatting or leaning slightly forward when sitting. These positions enhance movement of urine through the tract by gravity. • If the client is unable to ambulate to the lavatory, use a bedside commode for females and a urinal for males standing at the bedside. • If necessary, encourage the client to push over the pubic area with the hands or to lean forward to increase intra-abdominal pressure and external pressure on the bladder. RELAXATION • Provide privacy for the client. Many people cannot void in the presence of another person. • Allow the client sufficient time to void. • Suggest the client read or listen to music. • Provide sensory stimuli that may help the client relax. Pour warm water over the perineum of a female or have the client sit in a warm bath to promote muscle relaxation. Applying a hot water bottle to the lower abdomen of both men and women may also foster muscle relaxation.

(b) meticulous skin care; and (c) for males, application of an external drainage device (condom-type catheter device). CLINICAL ALERT!

Turn on running water within hearing distance of the client to stimulate the voiding reflex and to mask the sound of voiding for people who find this embarrassing. • Provide ordered analgesics and emotional support to relieve physical and emotional discomfort to decrease muscle tension. •

TIMING • Assist clients who have the urge to void immediately. Delays only increase the difficulty in starting to void, and the desire to void may pass. • Offer toileting assistance to the client at usual times of voiding, for example, on awakening, before or after meals, and at bedtime. FOR CLIENTS WHO ARE CONFINED TO BED • Warm the bedpan. A cold bedpan may prompt contraction of the perineal muscles and inhibit voiding. • Elevate the head of the client’s bed to Fowler’s position, place a small pillow or rolled towel at the small of the back to increase physical support and comfort, and have the client flex the hips and knees. This position simulates the normal voiding position as closely as possible.

PRACTICE GUIDELINES

Bladder Retraining •

If the client has any type of incontinence, recommend the use of incontinence pads because they are designed to absorb urine as opposed to feminine hygiene pads. Continence (Bladder) Retraining

A continence retraining program requires the involvement of the nurse, the client, and support people. Clients must be alert and physically able to participate in the training protocol. A bladder retraining program may include the following:

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• Education of the client and support people. • Bladder retraining, which requires that the client postpone void-

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ing, resist or inhibit the sensation of urgency, and void according to a timetable rather than according to the urge to void. The goals are to gradually lengthen the intervals between urination to correct the client’s frequent urination, to stabilize the bladder, and to diminish urgency. This form of training may be used for clients who have bladder instability and urge incontinence. Delayed voiding provides larger voided volumes and longer intervals between voiding. Initially, voiding may be encouraged every 2 to 3 hours except during sleep and then every 4 to 6 hours. A vital component of ­bladder training is inhibiting the urge-to-void sensation. To do this, the nurse instructs the client to practice deep, slow breathing until the urge diminishes or disappears. This is performed every time the client has a premature urge to void. See Practice Guidelines. • Habit training, also referred to as scheduled toileting, attempts to keep clients dry by having them void at regular intervals, such as every 2 to 4 hours. The goal is to keep the client dry and is a common therapy for frail older clients and those who are bedridden or have Alzheimer’s disease (NAFC, 2013).

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• •

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Determine the client’s voiding pattern and encourage voiding at those times, or establish a regular voiding schedule and help the client to maintain it, whether the client feels the urge or not (e.g., on awakening, every 1 or 2 hours during the day and evening, before retiring at night, every 4 hours at night). The stretching-relaxing sequence of such a schedule tends to increase bladder muscle tone and promote more voluntary control. Encourage the client to inhibit the urge-to-void sensation when a premature urge to void is experienced. Instruct the client to practice slow, deep breathing until the urge diminishes or disappears. When the client finds that voiding can be controlled, the intervals between voiding can be lengthened slightly without loss of continence. Regulate fluid intake, particularly during evening hours, to help reduce the need to void during the night. Encourage fluids between the hours of 0600 and 1800. Avoid excessive consumption of citrus juices, carbonated beverages (especially those containing artificial sweeteners), alcohol, and drinks containing caffeine because these irritate the bladder, increasing the risk of incontinence. Schedule diuretics early in the morning. Explain to clients that adequate fluid intake is required to ­ensure adequate urine production that stimulates the ­micturition reflex. Apply protector pads to keep the bed linen dry and provide specially made waterproof underwear to contain the urine and decrease the client’s embarrassment. Avoid using diapers, which are demeaning and also suggest that incontinence is permissible. Assist the client with an exercise program to increase the general muscle tone and a pelvic muscle exercise program aimed at strengthening the pelvic floor muscles. Provide positive reinforcements to encourage continence. Praise clients for attempting to toilet and for maintaining continence.

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Chapter 48  •  Urinary Elimination Pelvic Floor Muscle Exercises

CLIENT TEACHING

Pelvic floor muscle (PFM), or Kegel, exercises help to strengthen pelvic floor muscles (see Figures 48–3 and 48–4) and can reduce or eliminate episodes of incontinence. The client can identify the perineal muscles by tightening the anal sphincter as if to control the passing of gas or to hold a bowel movement. Keyock and Newman (2011) describe two types of muscle contractions to practice PFM. One is a quick 2-second contraction where the client squeezes the pelvic muscle quickly and hard and then relaxes immediately. The other is a slow 3- , 5-, or 10-second long contraction. The pelvic muscle is relaxed after the sustained contraction. The client gradually builds up to the 10-second sustained contraction. When the exercise is properly performed, contraction of the muscles of the buttocks and thighs is avoided. PFM can be performed anytime, anywhere, sitting or standing. Specific client instructions for performing PFM are summarized in Client Teaching.

Pelvic Floor Muscle Exercises (Kegels) •

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•

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Maintaining Skin Integrity

Skin that is continually moist becomes macerated (softened). Urine that accumulates on the skin is converted to ammonia, which is very irritating to the skin. Because both skin irritation and maceration predispose the client to skin breakdown and ulceration, the incontinent person requires meticulous skin care. To maintain skin integrity, the nurse washes the client’s perineal area with mild soap and water or a commercially prepared no-rinse cleanser after episodes of incontinence. The nurse then rinses the area thoroughly if soap and water were used, and dries it gently and thoroughly. Clean, dry clothing or bed linen should be provided. The nurse applies barrier ointments or creams to protect the skin from contact with urine. If it is necessary to pad the client’s clothes for protection, the nurse should use products that absorb wetness and leave a dry surface in contact with the skin. Specially designed incontinence drawsheets provide significant advantages over standard drawsheets for incontinent clients confined to bed. These sheets are like a drawsheet but are double layered, with a quilted upper nylon or polyester surface and an absorbent viscose rayon layer below. The rayon soaker layer generally has a waterproof backing on its underside. Fluid (i.e., urine) passes through the upper

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Complete two sets of exercises: a quick contraction followed by immediate relaxation and a long contraction followed by relaxation. Contract your pelvic floor muscle (PFM) whereby you pull your rectum, urethra, and vagina up inside, and contract the PFM, followed by relaxation. Do not hold your breath or tighten your thighs, buttocks, or abdomen while doing PFM exercises. Complete 45 of the quick and 45 of the long contraction exercises each day (Keyock & Newman, 2011, p. 32). Gradually increase the long contractions up to a full 10 seconds. Make the exercises part of your daily life, for example, before getting out of bed in the morning, when working at the kitchen sink, or on your way to the bathroom. The exercises can be done anywhere, anytime, and in any position. To control episodes of stress incontinence, perform a pelvic muscle contraction when initiating any activity that increases intra-abdominal pressure, such as coughing, laughing, ­sneezing, or lifting.

quilted layer and is absorbed and dispersed by the viscose rayon, leaving the quilted surface dry to the touch. This absorbent sheet helps maintain skin integrity; it does not stick to the skin when wet, decreases the risk of bedsores, and reduces odor. Applying External Urinary Draining Devices

The application of a condom or external catheter connected to a urinary drainage system can be used for incontinent males. Use of a condom appliance is preferable to insertion of a retention catheter because the risk of UTI is minimal. Methods of applying condoms vary. The nurse needs to follow the manufacturer’s instructions when applying a condom. First the nurse determines when the client experiences incontinence. Some clients may require a condom appliance at night only, others continuously. Skill 48–1 describes how to apply and remove an external catheter.

Applying an External Urinary Device

ASSESSMENT • Review the client record to determine a voiding pattern and other pertinent data, such as latex sensitivity/allergy. PLANNING • Discuss the use of external urinary devices with the client and/ or family. Research has shown that condom catheters may be more comfortable than an indwelling catheter and cause fewer urinary tract infections (Kyle, 2011). • Determine if the client has had an external catheter previously and any difficulties with it. • Perform any procedures that are best completed without the catheter in place; for example, weighing the client would be easier without the tubing and bag.

•

Apply clean gloves to examine the client’s penis for swelling or excoriation that would contraindicate use of the condom catheter.

SKILL 48–1

PURPOSES • To collect urine and control urinary incontinence • To permit the client physical activity while controlling UI • To prevent skin irritation as a result of UI

DELEGATION Applying a condom catheter may be delegated to unlicensed assistive personnel (UAP). However, the nurse must determine if the specific client has unique needs such as impaired circulation or latex allergy that would require special training of the UAP in the use of the condom catheter. Abnormal findings must be validated and interpreted by the nurse.

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Promoting Physiological Health

SKILL 48–1

Applying an External Urinary Device—continued Equipment • Condom sheath of appropriate size: small, medium, large, extra large. Use the manufacturer’s size guide as indicated. Use latexfree silicone for clients with latex allergies. Use self-adhering condoms, or those with Velcro, tape, or other external securing device. ❶ • Leg drainage bag if ambulatory or urinary drainage bag with ­tubing • Clean gloves • Basin of warm water and soap • Washcloth and towel

❶ An external or condom catheter. IMPLEMENTATION Preparation • Assemble the leg drainage bag or urinary drainage bag for attachment to the condom sheath. • If the condom supplied is not rolled onto itself, roll the condom outward onto itself to facilitate easier application. Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he can participate. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Position the client in either a supine or a sitting position. Provide for client privacy. • Drape the client appropriately with the bath blanket, exposing only the penis. 4. Apply clean gloves. 5. Inspect and clean the penis. • Clean the genital area and dry it thoroughly. Rationale: This minimizes skin irritation and excoriation after the condom is applied. 6. Apply and secure the condom. • Roll the condom smoothly over the penis, leaving 2.5 cm. (1 in.) between the end of the penis and the rubber or plastic connecting tube. ❷ Rationale: This space prevents irritation of the tip of the penis and provides for full drainage of urine. • Secure the condom firmly, but not too tightly, to the penis. Some condoms have an adhesive inside the proximal end that adheres to the skin of the base of the penis. Many condoms are packaged with special tape. If neither is present, use a strip of elastic tape or Velcro around the base of the penis over the condom. Ordinary tape is contraindicated because it is not flexible and can stop blood flow. 7. Securely attach the urinary drainage system. • Make sure that the tip of the penis is not touching the condom and that the condom is not twisted. Rationale: A twisted condom could obstruct the flow of urine. • Attach the urinary drainage system to the condom. • Remove and discard gloves. • Perform hand hygiene. • If the client is to remain in bed, attach the urinary drainage bag to the bed frame. • If the client is ambulatory, attach the bag to the client’s leg. ❸ Rationale: Attaching the drainage bag to the leg helps ­control

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❷ A self-adhering condom rolled over the penis.

❸ Urinary drainage leg bag. the movement of the tubing and prevents twisting of the thin material of the condom appliance at the tip of the penis. 8. Teach the client about the drainage system. • Instruct the client to keep the drainage bag below the level of the condom and to avoid loops or kinks in the tubing. Instruct the client to report pain, irritation, swelling, or ­wetness/leaking around the penis to health care personnel.

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Chapter 48  •  Urinary Elimination

Applying an External Urinary Device—continued

EVALUATION • Perform a detailed follow-up based on findings that deviated from expected or normal for the client. Relate findings to previous assessment data if available.

Managing Urinary Retention Interventions that assist the client to maintain a normal voiding pattern, discussed earlier, also apply when dealing with urinary retention. If these actions are unsuccessful, the primary care provider may order a cholinergic drug such as bethanechol chloride (Urecholine) to stimulate bladder contraction and facilitate voiding. Clients who have a flaccid bladder (weak, soft, and lax bladder muscles) may use manual pressure on the bladder to promote bladder emptying. This is known as Credé’s maneuver or Credé’s method. It is not advised without a primary care provider or nurse practitioner’s order and is used only for clients who have lost and are not expected to regain voluntary bladder control. When all measures fail to initiate voiding, urinary catheterization may be necessary to empty the bladder completely. An indwelling Foley catheter may be inserted until the underlying cause is treated. Alternatively, intermittent straight catheterization (every 3 to 4 hours) may be performed because the risk of UTI may be less than with an indwelling catheter. Urinary Catheterization Urinary catheterization is the introduction of a catheter into the urinary bladder. This is usually performed only when absolutely necessary, because the danger exists of introducing microorganisms into the bladder. The most frequent health care–associated infection is a UTI, and indwelling urethral catheters cause 80% of these UTIs (Institute for Healthcare Improvement [IHI], 2011). A catheter-­associated urinary tract infection (CAUTI) is a “urinary tract infection that occurs while an indwelling catheter is in place or within 48 hours of its removal” (Seckel, 2013, p. 63). Clients with a CAUTI remain in the hospital longer and need to be placed on antibiotic therapy, which increases health care costs. The high incidence and high costs related to CAUTI, in addition to the fact that most are preventable, resulted in the Centers for Medicare and Medicaid Services (CMS) not reimbursing hospitals unless the CAUTI was documented as present on

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Reapply a new condom. Remove and discard gloves. Perform hand hygiene. 11. Document in the client record using forms or checklists supplemented by narrative notes when appropriate. Record the application of the condom, the time, and pertinent observations, such as irritated areas on the penis. • • •

SKILL 48–1

9. Inspect the penis 30 minutes following condom application and at least every 4 hours. Check urine flow. Document these findings. • Assess the penis for swelling and discoloration. Rationale: This indicates that the condom is too tight. • Assess urine flow if the client has voided. Normally, some urine is present in the tube if the flow is not obstructed. • Assess for redness and/or skin blistering the first few days. Rationale: This could indicate a latex allergy. 10. Change the condom as indicated and provide skin care. In most settings, the condom is changed daily. • Remove the elastic or Velcro strip, apply clean gloves, and roll off the condom. • Wash the penis with soapy water, rinse, and dry it ­thoroughly. • Assess the foreskin for signs of irritation, swelling, and ­discoloration.

SAMPLE DOCUMENTATION 4/22/2015 2145 Condom catheter applied for the night per client request. Glans clean, skin intact. Catheter attached to bedside collection bag, Instructed to notify staff if pain, irritation, swelling, or wetness/ leaking occurs. Verbalized that he would –––––––––––– L. Chan, RN

•

Report significant deviations from normal to the primary care provider.

admission (Magers, 2013). It is well documented that the risk to the client of developing a CAUTI correlates to the duration of the catheter being in place. According to the Centers for Disease Control and Prevention, the risk of infection increases by 5% for each day that a catheter remains in place (Lee & Carter, 2013, p. 53). Oman et al. (2012) reported that urinary catheters are often “retained for days because of convenience, misunderstanding of their necessity/­appropriateness, or lack of clear orders for removal” (p. 548). Best practice is to remove a urinary catheter that is not necessary. Box 48–3 provides evidencebased guidelines for preventing CAUTIs. SAFETY ALERT!

SAFETY

2014 National Patient Safety Goals (The Joint Commission, 2013) Goal 7: Reduce the Risk of Health Care–Associated Infections • Implement evidence-based practices to prevent indwelling ­catheter-associated urinary tract infections (CAUTI). • Insert indwelling urinary catheters according to established evidence-based guidelines. • Manage indwelling urinary catheters according to established evidence-based guidelines. • Measure and monitor catheter-associated urinary tract infection prevention processes and outcomes in high-volume areas.

Another hazard is trauma with urethral catheterization, particularly in the male client, whose urethra is longer and more tortuous. It is important to insert a catheter along the normal contour of the urethra. Damage to the urethra can occur if the catheter is forced through strictures or at an incorrect angle. In males, the urethra is normally curved, but it can be straightened by elevating the penis to a position perpendicular to the body.

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BOX 48–3   Preventing or Reducing the Risk of CAUTIs AVOID UNNECESSARY USE OF URINARY CATHETERS • Develop criteria for appropriate catheter insertion. • Consider alternatives to an indwelling catheter such as external condom catheter. • Use a bladder scanner to assess for urinary retention. INSERT URINARY CATHETERS USING ASEPTIC TECHNIQUE • Catheters should only be inserted by trained individuals. • Use aseptic technique and sterile equipment. • Catheter kit should include a catheter and all necessary items in one place. • Use the smallest catheter possible that allows for proper drainage and decreases urethral trauma. MAINTAIN THE URINARY CATHETER • Use hand hygiene and standard precautions during any manipulation of the catheter or collecting system. • Maintain a sterile, closed drainage system. • Maintain unobstructed urine flow; keep catheter and tubing from kinking. • Keep the collection bag below the level of the bladder at all times, but do not rest the bag on the floor. • Empty the collection bag regularly with a separate, clean collecting container for each client; and prevent contact of the drainage spigot with the nonsterile collecting container.

BOX 48–4 

Selecting a Urinary Catheter

Determine the appropriate catheter length by the client’s gender. For adult female clients use a 22-cm catheter; for adult male clients, a 40-cm catheter. • Determine appropriate catheter size by the size of the urethral canal. Use sizes such as #8 or #10 for children, #14 or #16 for adults. Men frequently require a larger size than women, for example, #18. The lumen of a silicone catheter is slightly larger than that of a same-sized latex catheter. • Select the appropriate balloon size. For adults, use a 5-mL balloon to facilitate optimal urine drainage. The smaller balloons allow more complete bladder emptying because the catheter tip is closer to the urethral opening in the bladder. However, a 30-mL balloon is commonly used to achieve ­hemostasis of the prostatic area following a prostatectomy. Use 3-mL balloons for children. •

Catheters are commonly made of rubber or plastics although they may be made from latex, silicone, or polyvinyl chloride (PVC). They are sized by the diameter of the lumen using the French (Fr) scale: the larger the number, the larger the lumen. Either straight catheters, inserted to drain the bladder and then immediately removed, or retention catheters, which remain in the bladder to drain urine, may be used. Box 48–4 provides guidelines for catheter selection. The straight catheter is a single-lumen tube with a small eye or opening about 1.25 cm (0.5 in.) from the insertion tip (Figure 48–8 •). The retention, or Foley, catheter is a double-lumen catheter. The outside end of this two-way retention catheter is bifurcated; that is, it has two openings, one to drain the urine, the other to inflate the balloon (Figure 48–9 •). The larger lumen drains urine from the bladder and the second smaller lumen is used to inflate the balloon near

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PRACTICES TO AVOID • Irrigation of catheters, except in cases of catheter obstruction • Disconnecting the catheter from the drainage tubing • Replacing catheters routinely • Cleaning the periurethral area with antiseptics. Routine hygiene (cleaning the meatus during daily bathing) is appropriate REVIEW URINARY CATHETER NECESSITY DAILY AND REMOVE PROMPTLY • Assess the need for catheter in daily nursing assessments; contact the primary care provider if criteria not met. • Develop nursing protocols that allow nurses to remove urinary catheters if criteria for necessity are not met and there are no contraindications for removal. • Implement automatic stop orders for 48 to 72 hours after catheter insertion. Continue catheter use only with a documented order from the primary care provider. • Use alerts in chart or computerized charting system to inform the primary care provider of the presence of a catheter and require an order for continued use. From How-to-Guide: Prevent Catheter-Associated Urinary Tract Infections,by IHI, 2011,Cambridge, MA: Author; “Using Evidence-Based Practice to Reduce Catheter-Associated Urinary Tract Infections, by T. L. Magers, 2013, American Journal of Nursing, 113(6), pp. 34–42; and “Maintaining Urinary Catheters: What Does the Evidence Say?” by M. A. Seckel, 2013, ­Nursing, 43(2), pp. 63–65.

the tip of the catheter to hold the catheter in place within the bladder. Some catheter manufacturers apply an antimicrobial coating to their catheters to reduce CAUTIs. A variation of the indwelling catheter is the coudé (elbowed) catheter, which has a curved tip (Figure 48–10 •). This is sometimes used for men who have a hypertrophied prostate, because its tip is somewhat stiffer than a regular catheter and thus it can be better controlled during insertion, and passage is often less traumatic. Clients who require continuous or intermittent bladder irrigation may have a three-way Foley catheter (Figure 48–11 •). The three-way catheter has a third lumen through which sterile irrigating fluid can flow into the bladder. The fluid then exits the bladder through the drainage lumen, along with the urine. The size of the retention catheter balloon is indicated on the catheter along with the diameter, for example, “#16 Fr—5 mL balloon.” The purpose of the catheter balloon is to secure the catheter in the bladder. Historically, nurses pretested the catheter balloon to prevent insertion of a defective catheter. Some catheter manufacturers (e.g., Bard) test the balloon as part of their quality assurance process and do not recommend pretesting of the balloon by the nurse. Pretesting of silicone balloons in particular is not recommended because the silicone can form a cuff or crease at the balloon area that can cause trauma to the urethra during catheter insertion. It is important to follow the manufacturer’s instructions for the proper volume to use for balloon inflation. Improperly inflated catheter balloons may cause drainage and deflation difficulties. Retention catheters are usually connected to a closed gravity drainage system. This system consists of the catheter, drainage tubing, and a collecting bag for the urine. A closed system cannot be opened anywhere along the system, from catheter to collecting bag. Some health facilities, however, may use an open system, which consists of

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Figure 48–8 • Red-rubber or plastic Robinson straight catheters. Courtesy Covidien.

Figure 48–9 • An indwelling/retention (Foley) catheter with the balloon inflated.

Figure 48–11 • A three-way Foley catheter often used for continuous bladder irrigation. Courtesy Covidien.

Figure 48–10 • A coudé catheter.

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separate packages for the catheter and the drainage tubing and collecting bag. The open system requires the nurse to be especially vigilant to ensure sterile technique is maintained when connecting the catheter and drainage tubing. The closed system is preferred because it reduces the risk of microorganisms entering the system and infecting the urinary tract. Urinary drainage systems typically depend on the force of gravity to drain urine from the bladder to the collecting bag. Skill 48–2 describes catheterization of females and males, using straight and retention catheters.

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SKILL 48–2

Performing Urinary Catheterization PURPOSES • To relieve discomfort due to bladder distention or to provide gradual decompression of a distended bladder • To assess the amount of residual urine if the bladder empties incompletely • To obtain a sterile urine specimen • To empty the bladder completely prior to surgery ASSESSMENT • Determine the most appropriate method of catheterization based on the purpose and any criteria specified in the order such as total amount of urine to be removed or size of catheter to be used. • Use a straight catheter if only a one-time urine specimen is needed, if amount of residual urine is being measured, or if temporary decompression/emptying of the bladder is required. • Use an indwelling/retention catheter if the bladder must remain empty, intermittent catheterization is contraindicated, or continuous urine measurement/collection is needed. • Assess the client’s overall condition. Determine if the client is able to participate and hold still during the procedure and if

To facilitate accurate measurement of urinary output for critically ill clients whose output needs to be monitored hourly • To provide for intermittent or continuous bladder drainage and/ or irrigation • To prevent urine from contacting an incision after perineal ­surgery •

the client can be positioned supine with head relatively flat. For female clients, determine if she can have knees bent and hips externally rotated. • Determine when the client last voided or was last catheterized. • If catheterization is being performed because the client has been unable to void, when possible, complete a bladder scan to assess the amount of urine present in the bladder. Rationale: This prevents catheterizing the bladder when insufficient urine is present. Often, a minimum of 500 to 800 mL of urine indicates urinary retention and the client should be reassessed until that amount is present.

PLANNING • Allow adequate time to perform the catheterization. Although the entire procedure can require as little as 15 minutes, several sources of difficulty could result in a much longer period of time. If possible, it should not be performed just prior to or after a meal. • Some clients may feel uncomfortable being catheterized by nurses of the opposite gender. If this is the case, obtain the client’s permission. Also consider whether agency policy requires or encourages having a person of the client’s same gender present for the procedure.

DELEGATION Due to the need for sterile technique and detailed knowledge of anatomy, insertion of a urinary catheter is not delegated to UAP. Equipment • Sterile catheter of appropriate size (An extra catheter should also be at hand.) • Catheterization kit ❶ or individual sterile items: • Sterile gloves • Waterproof drape(s) • Antiseptic solution • Cleansing balls • Forceps • Water-soluble lubricant • Urine receptacle • Specimen container IMPLEMENTATION Preparation • If using a catheterization kit, read the label carefully to ensure that all necessary items are included. • Apply clean gloves and perform routine perineal care to cleanse gross contamination. For women, use this time to locate the ­urinary meatus relative to surrounding structures. ❷ • Remove and discard gloves. • Perform hand hygiene.

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❶ A closed indwelling catheter insertion kit. •

• • • • •

For an indwelling catheter: • Syringe prefilled with sterile water in amount specified by catheter manufacturer • Collection bag and tubing 5–10 mL 2% Xylocaine gel or water-soluble lubricant for male urethral injection (if agency permits) Clean gloves Supplies for performing perineal cleansing Bath blanket or sheet for draping the client Adequate lighting (Obtain a flashlight or lamp if necessary.)

Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Provide for client privacy.

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Performing Urinary Catheterization—continued

SKILL 48–2

Labia majora Clitoris Urinary meatus (urethral orifice) Vagina Labia minora Anus

❷ To expose the urinary meatus, separate the labia minora and retract the tissue upward.

❸ When cleaning the urinary meatus, move the swab downward. 4. Place the client in the appropriate position and drape all areas except the perineum. • Female: supine with knees flexed, feet about 2 feet apart, and hips slightly externally rotated, if possible • Male: supine, thighs slightly abducted or apart 5. Establish adequate lighting. Stand on the client’s right if you are right-handed, on the client’s left if you are left-handed. 6. If using a collecting bag and it is not contained within the ­catheterization kit, open the drainage package and place the end of the tubing within reach. Rationale: Because one hand is needed to hold the catheter once it is in place, open the package while two hands are still available. 7. If agency policy permits, apply clean gloves and inject 10 to 15 mL Xylocaine gel into the urethra of the male client. Wipe the underside of the penile shaft to distribute the gel up the urethra. Wait at least 5 minutes for the gel to take effect before inserting the catheter. 8. Remove and discard gloves. • Perform hand hygiene. 9. Open the catheterization kit. Place a waterproof drape under the buttocks (female) or penis (male) without contaminating the center of the drape with your hands. 10. Apply sterile gloves. 11. Organize the remaining supplies: • Saturate the cleansing balls with the antiseptic solution. • Open the lubricant package. • Remove the specimen container and place it nearby with the lid loosely on top. 12. Attach the prefilled syringe to the indwelling catheter inflation hub. Apply agency policy and/or manufacturer recommendation regarding pretesting of the balloon. Rationale: There is little ­research regarding pretesting of the balloon; however, some balloons (e.g., silicone) may form a cuff on deflation that can ­irritate the urethra on insertion. 13. Lubricate the catheter 2.5 to 5 cm (1 to 2 in.) for females, 15 to 17.5 cm (6 to 7 in.) for males, and place it with the drainage end inside the collection container. 14. If desired, place the fenestrated drape over the perineum, ­exposing the urinary meatus.

15. Cleanse the meatus. Note: The nondominant hand is considered contaminated once it touches the client’s skin. • Females: Use your nondominant hand to spread the labia so that the meatus is visible. Establish firm but gentle pressure on the labia. The antiseptic may make the tissues slippery but the labia must not be allowed to return over the cleaned meatus. Note: Location of the urethral meatus is best identified during the cleansing process. Pick up a cleansing ball with the forceps in your dominant hand and wipe one side of the labia majora in an anteroposterior direction.❸ Use great care that wiping the client does not contaminate this sterile hand. Use a new ball for the opposite side. Repeat for the labia minora. Use the last ball to cleanse directly over the meatus. • Males: Use your nondominant hand to grasp the penis just below the glans. If necessary, retract the foreskin. Hold the penis firmly upright, with slight tension. Rationale: Lifting the penis in this manner helps straighten the urethra. Pick up a cleansing ball with the forceps in your dominant hand and wipe from the center of the meatus in a circular motion around the glans. Use great care that wiping the client does not contaminate the sterile hand. Use a new ball and repeat three more times. The antiseptic may make the tissues slippery but the foreskin must not be allowed to return over the cleaned meatus nor the penis be dropped. 16. Insert the catheter. • Grasp the catheter firmly 5 to 7.5 cm (2 to 3 in.) from the tip. Ask the client to take a slow deep breath and insert the catheter as the client exhales. Slight resistance is expected as the catheter passes through the sphincter. If necessary, twist the catheter or hold pressure on the catheter until the sphincter relaxes. • Advance the catheter 5 cm (2 in.) farther after the urine begins to flow through it. Rationale: This is to be sure it is fully in the bladder, will not easily fall out, and the balloon is in the bladder completely. For male clients, some experts recommend advancing the catheter to the “Y” bifurcation of the catheter. Check your agency’s policy. Continued on page 1222

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Performing Urinary Catheterization—continued If the catheter accidentally contacts the labia or slips into the vagina, it is considered contaminated and a new, sterile catheter must be used. The contaminated catheter may be left in the vagina until the new catheter is inserted to help avoid mistaking the vaginal opening for the urethral meatus. 17. Hold the catheter with the nondominant hand. 18. For an indwelling catheter, inflate the retention balloon with the designated volume. • Without releasing the catheter (and, for females, without releasing the labia), hold the inflation valve between two fingers of your nondominant hand while you attach the syringe (if not left attached earlier) and inflate with your dominant hand. If the client complains of discomfort, immediately withdraw the instilled fluid, advance the catheter farther, and attempt to inflate the balloon again. • Pull gently on the catheter until resistance is felt to ensure that the balloon has inflated and to place it in the trigone of the bladder. ❹ 19. Collect a urine specimen if needed. For a straight catheter, allow 20 to 30 mL to flow into the bottle without touching the catheter to the bottle. For an indwelling catheter preattached

SKILL 48–2

•

to a drainage bag, a specimen may be taken from the bag this initial time only. 20. Allow the straight catheter to continue draining into the urine receptacle. If necessary (e.g., open system), attach the drainage end of an indwelling catheter to the collecting tubing and bag. 21. Examine and measure the urine. In some cases, only 750 to 1,000 mL of urine are to be drained from the bladder at one time. Check agency policy for further instructions if this should occur. 22. Remove the straight catheter when urine flow stops. For an indwelling catheter, secure the catheter tubing to the thigh for female clients or the upper thigh or lower abdomen for male clients to prevent movement on the urethra or excessive tension or pulling on the retention balloon (Fisher, 2010; Herter & Kazer, 2010). Adhesive and nonadhesive catheter-securing devices are available and should be used to secure the catheter tubing to the client. ❺ Rationale: This prevents unnecessary trauma to the urethra.

A

A

B B

❺ Catheter securement devices: A, nonadhesive device (Velcro strap); B, adhesive device.

❹ Placement of indwelling catheter and inflated balloon of a closed ­system in A, female client and B, male client.

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SKILL 48–2

23. Next, hang the bag below the level of the bladder. No tubing should fall below the top of the bag. ❻ 24. Wipe any remaining antiseptic or lubricant from the perineal area. Replace the foreskin if retracted earlier. Return the client to a comfortable position. Instruct the client on positioning and moving with the catheter in place. 25. Discard all used supplies in appropriate receptacles. 26. Remove and discard gloves. • Perform hand hygiene. 27. Document the catheterization procedure including catheter size and results in the client record using forms or checklists supplemented by narrative notes when appropriate.

SAMPLE DOCUMENTATION 2/24/2015 0530 Client agreed to insertion of pre-op catheter as per order. #16 Fr Foley with 5-mL balloon inserted without difficulty, secured to thigh, connected to straight drainage. Immediate return of 300 mL pale, clear, yellow urine ––––––––––––– G. Hampton, RN

❻ Correct position for urine drainage bag and tubing. EVALUATION • Notify the primary care provider of the catheterization results. • Perform a detailed follow-up based on findings that deviated from expected or normal for the client. Relate findings to ­previous assessment data if available.

LIFESPAN CONSIDERATIONS

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Teach the client how to care for the indwelling catheter, to drink more fluids, and provide other appropriate instructions.

CATHETERIZATION

Infants and Children

• Adapt the size of the catheter for pediatric clients. • Ask a family member to assist in holding the child during ­catheterization, if appropriate. OLDER ADULTS When catheterizing older clients, be very attentive to problems of limited movement, especially in the hips. Arthritis, or previous hip

or knee surgery, may limit their movement and cause discomfort. Modify the position (e.g., side-lying) as needed to perform the procedure safely and comfortably. For women, obtain the assistance of another nurse to flex and hold the client’s knees and hips as necessary or place her in a modified Sims’ position.

Home Care Considerations Catheterization For intermittent catheterization, instruct the client to: • Follow instructions for clean technique. • Wash hands well with warm water and soap prior to handling equipment or performing catheterization. • Monitor for signs and symptoms of UTI including burning, ­urgency, abdominal pain, and cloudy urine; in older adults, ­confusion may be an early sign. • Ensure adequate oral intake of fluids. • After each catheterization, assess the urine for color, odor, ­clarity, and the presence of blood. • Wash rubber catheters thoroughly with soap and water after use, dry, and store in a clean place. For indwelling catheters, instruct the client to: • Never pull on the catheter. • Secure the catheter tubing to your leg using a catheter-securing device.

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PATIENT-CENTERED CARE Ensure that there are no kinks or twists in the tubing. Keep the urine drainage bag below the level of the bladder. A leg bag may substitute for a hanging bag for those who are upright. • Empty the drainage bag regularly. • Take a shower rather than a tub bath. Sitting in a tub allows bacteria easier access to the urinary tract. • Monitor for signs and symptoms of UTI including ­burning, ­urgency, abdominal pain, cloudy urine; in older adults, ­confusion may be an early sign. • Ensure adequate oral intake of fluids. Clients who have indwelling catheters for lengthy periods of time need to have the catheter and bag changed at regular intervals. Changing equipment once a month is often the standard, although agency policy may differ. • •

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Nursing Interventions for Clients with Indwelling Catheters Nursing care of the client with an indwelling catheter and continuous drainage is largely directed toward preventing infection of the urinary tract and encouraging urinary flow through the drainage system. It includes encouraging large amounts of fluid intake, accurately recording the fluid intake and output, changing the retention catheter and tubing, maintaining the patency of the drainage system, preventing contamination of the drainage system, and teaching these measures to the client.

an indwelling catheter in place, the bladder muscle does not stretch and contract regularly as it does when the bladder fills and empties by voiding. A few days before removal, the catheter may be clamped for specified periods of time (e.g., 2 to 4 hours), then released to allow the bladder to empty. This allows the bladder to distend and stimulates its musculature. Check agency policy regarding bladder training procedures. To remove a retention catheter the nurse follows these steps: • Obtain a receptacle for the catheter (e.g., a disposable basin); a

Fluids

The client with a retention catheter should drink up to 3,000 mL/day if permitted. Large amounts of fluid ensure a large urine output, which keeps the bladder flushed out and decreases the likelihood of urinary stasis and subsequent infection. Large volumes of urine also minimize the risk of sediment or other particles obstructing the drainage tubing. Dietary Measures

Acidifying the urine of clients with a retention catheter may reduce the risk of UTI and calculus formation. Foods such as eggs, cheese, meat and poultry, whole grains, cranberries, plums and prunes, and tomatoes tend to increase the acidity of urine. Conversely, most fruits and vegetables, legumes, and milk and milk products result in alkaline urine.

• • •

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Perineal Care

No special cleaning other than routine hygienic care is necessary for clients with retention catheters, nor is special meatal care recommended. The nurse should check agency practice in this regard. Changing the Catheter and Tubing

Routine changing of catheter and tubing is not recommended. Collection of sediment in the catheter or tubing and impaired urine drainage are indicators for changing the catheter and drainage system. When this occurs the catheter and drainage system are removed and discarded, and a new sterile catheter with a closed drainage system is inserted using aseptic technique. Removing Indwelling Catheters

Indwelling catheters are removed after their purpose has been achieved, usually on the order of the primary care provider. Unfortunately, not all primary care providers know which of their clients has an indwelling catheter. As a result, some facilities have incorporated an alert system that requires the provider to take an action after a specified time frame. Also, some health care facilities allow the nurse to remove an indwelling catheter through the use of a protocol with specific criteria (Wenger, 2010). If the catheter has been in place for a short time (e.g., 48 to 72  hours), the client usually has little difficulty regaining normal urinary elimination patterns. Swelling of the urethra, however, may initially interfere with voiding, so the nurse should regularly assess the client for urinary retention until voiding is reestablished. Clients who have had a retention catheter for a prolonged period may require bladder retraining to regain bladder muscle tone. With

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• • • • •

•

•

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clean, disposable towel; clean gloves; and a sterile syringe to deflate the balloon. The syringe should be large enough to withdraw all the solution in the catheter balloon. The size of the balloon is indicated on the label at the end of the catheter. Ask the client to assume a supine position as for a catheterization. Optional: Obtain a sterile specimen before removing the catheter. Check agency protocol. Remove the catheter-securing device attaching the catheter to the client, apply gloves, and then place the towel between the legs of the female client or over the thighs of the male. Insert the syringe into the injection port of the catheter, and withdraw the fluid from the balloon. After the fluid has been aspirated, the walls of the balloon do not deflate to their original shape but collapse into uneven ridges, forming a “cuff ” around the catheter. This cuff is more pronounced with a silicone catheter (Wilson, 2012). This cuff can cause discomfort to the client as the catheter is removed. Little research exists about the balloon cuffing that occurs following deflation of a catheter balloon. One recent research study by Chung and So (2012) specifically tested four balloon deflation methods. They found that active deflation (rapid deflation of balloon within 5 seconds) caused the greatest degree of catheter balloon cuffing, followed by passive deflation (very slow active deflation over 30 seconds). Passive autodeflation (attaching an empty syringe to the balloon inflow channel to allow for gentle autodeflation) and excision of the balloon inflow channel caused the least cuffing (p. 176). Do not pull the catheter while the balloon is inflated; doing so will injure the urethra. After all of the fluid is removed from the balloon, gently withdraw the catheter and place it in the waste receptacle. Dry the perineal area with a towel. • Measure the urine in the drainage bag. Remove and discard gloves. • Perform hand hygiene. Record the removal of the catheter. Include in the recording (a) the time the catheter was removed; (b) the amount, color, and clarity of the urine; (c) the intactness of the catheter; and (d) instructions given to the client. Provide the client with either a urinal (men), bedpan, commode, or toilet collection device (“hat”) to be used with each, subsequent unassisted void. Following removal of the catheter, determine the time of the first voiding and the amount voided during the first 8 hours. Compare this output to the client’s intake. Observe for dysfunctional voiding behaviors (i.e., < 100 mL per void), which might indicate urinary retention. If this occurs, perform an assessment of PVR using a bladder scanner if available.

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CLIENT TEACHING

Clean Intermittent Self-Catheterization • •

• • •

•

• •

Catheterize as often as needed to maintain. At first, catheterization may be necessary every 2 to 3 hours, increasing to 4 to 6 hours. Attempt to void before catheterization; insert the catheter to remove residual urine if unable to void or if amount voided is insufficient (e.g., less than 100 mL). Assemble all needed supplies ahead of time. Good lighting is essential, especially for women. Wash your hands. Clean the urinary meatus with either a towelette or soapy washcloth, then rinse with a wet washcloth. Women should clean the area from front to back. Assume a position that is comfortable and that facilitates passage of the catheter, such as a semireclining position in bed or sitting on a chair or the toilet. Men may prefer to stand over the toilet; women may prefer to stand with one foot on the side of the bathtub. Apply lubricant to the catheter tip (1 in. [2.5 cm] for women; 2 to 6 in. [5 to 15 cm] for men). Insert the catheter until urine flows through. a. If a woman, locate the meatus using a mirror or other aid, or use the “touch” technique as follows: • Place the index finger of your nondominant hand on your clitoris.

Place the third and fourth fingers at the vagina. Locate the meatus between the index and third fingers. • Direct the catheter through the meatus and then upward and forward. b. If a man, hold the penis with a slight upward tension at a 60- to 90-degree angle to insert the catheter. Return the penis to its natural position when urine starts to flow. Hold the catheter in place until all urine is drained. Withdraw the catheter slowly to ensure complete drainage of urine. Wash the catheter with soap and water; store in a clean container. Replace the catheter when it becomes difficult to clean, or too soft or hard to insert easily. Contact your care provider if your urine becomes cloudy or contains sediment; if you have bleeding, difficulty, or pain when passing the catheter; or if you have a fever. Drink at least 2,000 to 2,500 mL of fluid a day to ensure ­adequate bladder filling and flushing. To keep your urine acidic and reduce the risk of bladder infections, drink cranberry and prune juices. • •

• • •

•

•

Generally a PVR greater than 200 mL will require straight catheterization as needed.

mirror but eventually should perform the procedure by using only the sense of touch (as described in Client Teaching).

Clean Intermittent Self-Catheterization Clean intermittent self-catheterization (CISC) is performed by many clients who have some form of neurogenic bladder dysfunction such as that caused by spinal cord injury and multiple sclerosis. Clean or medical aseptic technique is used. Intermittent self-catheterization has these benefits:

Urinary Irrigations An irrigation is a flushing or washing-out with a specified solution. Bladder irrigation is carried out on a primary care provider’s order, usually to wash out the bladder and sometimes to apply a medication to the bladder lining. Catheter irrigations may also be performed to maintain or restore the patency of a catheter, for example, to remove pus or blood clots blocking the catheter. Sterile technique is used. The closed method is the preferred technique for catheter or bladder irrigation because it is associated with a lower risk of UTI. Closed catheter irrigations may be either continuous or intermittent. This method is most often used for clients who have had genitourinary surgery. The continuous irrigation helps prevent blood clots from occluding the catheter. A three-way, or triple lumen, catheter (see Figure 48–11) is generally used for closed irrigations. The irrigating solution flows into the bladder through the irrigation port of the catheter and out through the urinary drainage lumen of the catheter. Occasionally an open irrigation may be necessary to restore catheter patency. The risk of injecting microorganisms into the urinary tract is greater with open irrigations, because the connection between the indwelling catheter and the drainage tubing is broken. Strict precautions must be taken to maintain the sterility of both the drainage tubing connector and the interior of the indwelling catheter. The open method of catheter or bladder irrigation is performed with double-lumen indwelling catheters. It may be necessary for clients who develop blood clots and mucous fragments that occlude the catheter or when it is undesirable to change the catheter. Techniques for bladder irrigation are outlined in Skill 48–3.

• Enables the client to retain independence and gain control of the • • • • •

bladder. Reduces incidence of UTI. Protects the upper urinary tract from reflux. Allows normal sexual relations without incontinence. Reduces the use of aids and appliances. Frees the client from embarrassing dribbling.

The procedure for self-catheterization is similar to that used by the nurse to catheterize a client. Essential steps are outlined in the accompanying Client Teaching. Because the procedure requires physical and mental preparation, client assessment is important. The client should have: • • • • •

Sufficient manual dexterity to manipulate a catheter Sufficient mental ability Motivation and acceptance of the procedure For women, reasonable agility to access the urethra Bladder capacity greater than 100 mL.

Before teaching CISC, the nurse should establish the client’s voiding patterns, the volume voided, fluid intake, and residual amounts. CISC is easier for males to learn because of the visibility of the urinary meatus. Females need to learn initially with the aid of a

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SKILL 48–3

Performing Bladder Irrigation PURPOSES • To maintain the patency of a urinary catheter and tubing (closed continuous irrigation) ASSESSMENT • Determine the client’s current urinary drainage system. Review the client record for recent intake and output and any difficulties the client has been experiencing with the system. Review the results of previous irrigations. PLANNING Before irrigating a catheter or bladder, check (a) the reason for the irrigation; (b) the order authorizing the continuous or intermittent irrigation (in most agencies, a primary care provider’s order is required); (c) the type of sterile solution, the amount and strength to be used, and the rate (if continuous); and (d) the type of catheter in place. If these are not specified on the client’s chart, check agency protocol.

DELEGATION Due to the need for sterile technique, urinary irrigation is generally not delegated to UAP. If the client has continuous irrigation, the UAP may care for the client and note abnormal findings. These must be validated and interpreted by the nurse.

IMPLEMENTATION Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. The irrigation should not be painful or uncomfortable. Discuss how the results will be used in planning further care or treatments. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Provide for client privacy. 4. Apply clean gloves. 5. Empty, measure, and record the amount and appearance of urine present in the drainage bag. Rationale: Emptying the drainage bag allows more accurate measurement of urinary output after the irrigation is in place or completed. Assessing the character of the urine provides baseline data for later comparison. 6. Discard urine and gloves. 7. Prepare the equipment. • Perform hand hygiene. • Connect the irrigation infusion tubing to the irrigating solution and flush the tubing with solution, keeping the tip sterile. Rationale: Flushing the tubing removes air and prevents it from being instilled into the bladder. • Apply clean gloves and cleanse the port with antiseptic swabs. • Connect the irrigation tubing to the input port of the threeway catheter. • Connect the drainage bag and tubing to the urinary drainage port if not already in place. • Remove and discard gloves. • Perform hand hygiene. 8. Irrigate the bladder. • For closed continuous irrigation using a three-way catheter, open the clamp on the urinary drainage tubing (if present). ❶ Rationale: This allows the irrigating solution to flow out of the bladder continuously. a. Apply clean gloves.

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To free a blockage in a urinary catheter or tubing (open intermittent irrigation)

•

Assess the client for any discomfort, bladder spasms, or distended bladder.

Equipment Clean gloves (two pairs) Retention catheter in place Drainage tubing and bag (if not in place) Drainage tubing clamp Antiseptic swabs Sterile receptacle Sterile irrigating solution warmed or at room temperature (Label the irrigant clearly with the words Bladder Irrigation, including the information about any medications that have been added to the original solution, and the date, time, and nurse’s initials.) • Infusion tubing • IV pole • • • • • • •

Irrigation bag

Drip chamber Clamp Bladder

Tubing to irrigation port

Port for inflation of catheter balloon

Tubing from bladder

Drainage bag

❶ A continuous bladder irrigation (CBI) setup. b. Open the regulating clamp on the irrigating fluid infusion tubing and adjust the flow rate as prescribed by the primary care provider or to 40 to 60 drops per minute if not specified. c. Assess the drainage for amount, color, and clarity. The amount of drainage should equal the amount of irrigant entering the bladder plus expected urine output. Empty the bag frequently so that it does not exceed half full. • For closed intermittent irrigation, determine whether the solution is to remain in the bladder for a specified time. a. If the solution is to remain in the bladder (a bladder irrigation or instillation), close the clamp to the urinary drainage

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SKILL 48–3

tubing. Rationale: Closing the flow clamp allows the solution to be retained in the bladder and in contact with bladder walls. b. If the solution is being instilled to irrigate the catheter, open the flow clamp on the urinary drainage tubing. Rationale: Irrigating solution will flow through the urinary drainage port and tubing, removing mucous shreds or clots. c. If a three-way catheter is used, open the flow clamp to the irrigating fluid infusion tubing, allowing the specified amount of solution to infuse. Then close the clamp on the infusion tubing. or d. If a two-way catheter is used, connect an irrigating syringe with a needleless adapter to the injection port on the drainage tubing and instill the solution. e. After the specified period the solution is to be retained has passed, open the drainage tubing flow clamp and allow the bladder to empty. f. Assess the drainage for amount, color, and clarity. The amount of drainage should equal the amount of irrigant entering the bladder plus expected urine output. g. Remove and discard gloves. • Perform hand hygiene. 9. Assess the client and the urinary output. • Assess the client’s comfort. • Apply clean gloves. • Empty the drainage bag and measure the contents. Subtract the amount of irrigant instilled from the total volume of drainage to obtain the volume of urine output. • Remove and discard gloves. • Perform hand hygiene. 10. Document findings in the client record using forms or checklists supplemented by narrative notes when appropriate. • Note any abnormal constituents such as blood clots, pus, or mucous shreds. Variation: Open Irrigation Using a Two-Way Indwelling Catheter 1. Assemble the equipment. Use an irrigation tray ❷ or assemble individual items, including: • Clean gloves • Disposable water-resistant towel • Sterile irrigating solution • Sterile irrigation set • Sterile basin • Sterile 30- to 50-mL irrigating syringe • Antiseptic swabs • Sterile protective cap for catheter drainage tubing 2. Prepare the client (see steps 1–5 of main procedure for catheter irrigation). 3. Prepare the equipment. • Perform hand hygiene. • Using aseptic technique, open supplies and pour the irrigating solution into the sterile basin or receptacle. Rationale: Aseptic technique is vital to reduce the risk of instilling microorganisms into the urinary tract during the irrigation. EVALUATION • Perform detailed follow-up based on findings that deviated from expected or normal for the client. Relate findings to previous assessment data if available.

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❷ An irrigation set.

Place the disposable water-resistant towel under the ­catheter. • Apply clean gloves. • Disconnect catheter from drainage tubing and place the catheter end in the sterile basin. Place sterile protective cap over end of drainage tubing. Rationale: The end of the drainage tubing will be considered contaminated if it touches bed linens or skin surfaces. • Draw the prescribed amount of irrigating solution into the syringe, maintaining the sterility of the syringe and solution. 4. Irrigate the bladder. • Insert the tip of the syringe into the catheter opening. • Gently and slowly inject the solution into the catheter at approximately 3 mL per second. In adults, about 30 to 40 mL generally is instilled for catheter irrigations; 100 to 200 mL may be instilled for bladder irrigation or instillation. Rationale: Gentle instillation reduces the risks of injury to bladder mucosa and of bladder spasms. • Remove the syringe and allow the solution to drain back into the basin. • Continue to irrigate the client’s bladder until the total amount to be instilled has been injected or when fluid returns are clear and/or clots are removed. • Remove the protective cap from the drainage tube and wipe with antiseptic swab. • Reconnect the catheter to drainage tubing. • Remove and discard gloves. • Perform hand hygiene. • Assess the drainage for amount, color, and clarity. The amount of drainage should equal the amount of irrigant entering the bladder plus any urine that may have been dwelling in the bladder. Determine the amount of fluid used for the irrigation and subtract from total output on the client’s I&O record. 5. Assess the client and the urinary output and document the ­procedure as in steps 8 and 9 above. •

•

Report significant deviations from normal to the primary care provider.

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Suprapubic Catheter Care A suprapubic catheter is inserted surgically through the abdominal wall above the symphysis pubis into the urinary bladder. The suprapubic catheter may have a balloon or pigtail that holds it in the bladder depending on the manufacturer (Figure 48–12 •). The health care provider inserts the catheter using local anesthesia or during bladder or vaginal surgery. The catheter may be secured in place with sutures to reinforce the security of the catheter and is then attached to a closed drainage system. The suprapubic catheter may be placed for temporary bladder drainage until the client is able to resume normal voiding (e.g., after urethral, bladder, or vaginal surgery) or it may become a permanent device (e.g., urethral or pelvic trauma). Care of clients with a suprapubic catheter includes regular assessments of the client’s urine, fluid intake, and comfort; maintenance of a patent drainage system; skin care around the insertion site; and periodic clamping of the catheter preparatory to removing it if it is not a permanent appliance. If the catheter is temporary, orders generally include leaving the catheter open to drainage for 48 to 72 hours, then clamping the catheter for 3- to 4-hour periods during the day until the client can void satisfactory amounts. Satisfactory voiding is determined by measuring the client’s residual urine after voiding. Care of the catheter insertion site involves sterile technique. Dressings around the newly placed suprapubic catheter are changed whenever they are soiled with drainage to prevent bacterial growth around the insertion site and reduce the potential for infection. Cleanse with 4×4s with chlorhexidine gluconate and warm water. The area is dressed with a 4×4 and taped in an occlusive fashion (Bullman, 2011). Securing the catheter tube to the abdomen helps to reduce tension at the insertion site. For catheters that have been in place for an extended period, no dressing may be needed and the healed insertion tract enables removal and replacement of the catheter as needed. Formation, however, of a healed insertion tract takes approximately 6 weeks to 6 months to develop. Before that time, the catheter needs to be replaced within 30 minutes if it falls out to prevent the opening from closing over (Bullman, 2011; Winder, 2012). The nurse assesses the insertion area at regular intervals. If pubic hair invades the

insertion site, it may be carefully trimmed with scissors. Any redness or discharge at the skin around the insertion site must be reported.

Urinary Diversions A urinary diversion is the surgical rerouting of urine from the kidneys to a site other than the bladder. Clients with bladder cancer often need a urinary diversion when the bladder must be removed or bypassed. There are two categories of diversions: incontinent and continent. Incontinent

With incontinent diversions clients have no control over the passage of urine and require the use of an external ostomy appliance to contain the urine. Urinary diversions may or may not involve the removal of the bladder (cystectomy). Examples of incontinent diversions include ureterostomy, nephrostomy, vesicostomy, and ileal conduits. A ureterostomy is when one or both of the ureters may be brought directly to the side of the abdomen to form small stomas. This procedure, however, has some disadvantages in that the stomas provide direct access for microorganisms from the skin to the kidneys, the small stomas are difficult to fit with an appliance to collect the urine, and they may narrow, impairing urine drainage. A nephrostomy diverts urine from the kidney via a catheter inserted into the renal pelvis to a nephrostomy tube and bag (Figure 48–13 •). A vesicostomy may be formed when the bladder is left intact but voiding through the urethra is not possible (e.g., due to an obstruction or a neurogenic bladder). The ureters remain connected to the bladder, and the bladder wall is surgically attached to an opening in the skin below the navel, forming an opening (stoma) for urinary drainage. The most common incontinent urinary diversion is the ileal conduit or ileal loop (Figure 48–14 •). In this procedure, a segment of the ileum is removed and the intestinal ends are reattached. One end of the portion removed is closed with sutures to create a pouch, and the other end is brought out through the abdominal wall to create a stoma. The ureters are implanted into the ileal pouch. The ileal stoma is more readily fitted with an appliance than ureterostomies because of its larger size. The mucous membrane lining of the ­ileum also provides some protection from ascending infection. Urine drains continuously from the ileal pouch.

To collection bag Symphysis pubis

Bladder

Removable trocar cannula

Inflated balloon Prostate

Catheter Suprapubic catheter

Urinary bladder

Pubic bone Urethra

A

B

Figure 48–12 • A suprapubic catheter in place: A, using a pigtail loop; B, using a balloon to keep catheter in place.

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Rib cage Kidney

Kidney Nephrostomy catheter

Nephrostomy catheter Ureter

Nephrostomy tube and bag Ureter

Bladder Urethra

Pigtail loop locks nephrostomy tube in place

Figure 48–13 • A nephrostomy.

Kidney

Ileal conduit

Bladder removed

Stoma

Ureter

Stoma

Reattachment or Anastomosis of ileum

Kock pouch

Figure 48–14 • An incontinent urinary diversion (ileal conduit). Continent

Continent urinary diversion involves creation of a mechanism that allows the client to control the passage of urine, either by intermittent catheterization of the internal reservoir (e.g., Kock pouch) or by creating a neobladder or internal pouch. The Kock (pronounced “coke”) pouch, or continent ileal bladder conduit, also uses a portion of the ileum to form a reservoir for urine (Figure 48–15 •). In this procedure, nipple valves are formed by doubling the tissue backward into the reservoir where the pouch connects to the skin and the ureters connect to the pouch. These valves close as the pouch fills with urine, preventing leakage and reflux of urine back toward the kidneys. The client empties the pouch by inserting a clean catheter approximately every 2 to 3 hours at first and increases to every 5 to 6 hours as the pouch expands. Over time, the pouch can expand to between 600 and 1,000 mL (Avent, 2012, p. 51). Between catheterizations, a small dressing is worn to protect the stoma and clothing. A continent diversion with a neobladder involves replacing a diseased or damaged bladder with a piece of ileum and colon that is located in the same location as the bladder that was removed (Avent, 2012). A pouch or new bladder is created. The ureters are sutured to one end of the new pouch/bladder and this new bladder is then sutured to the functional urethra to facilitate client voiding control (Figure 48–16 •). The client will need to relearn how to void. Voiding occurs when the urethral sphincter muscle relaxes and abdominal straining occurs to put pressure on the pouch.

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Figure 48–15 • The Kock pouch—a continent urinary diversion.

When caring for clients with a urinary diversion, the nurse must accurately assess intake and output; note any changes in urine color, odor, or clarity (mucous shreds are commonly seen in the urine of clients with an ileal diversion); and frequently assess the condition of the stoma and surrounding skin. Clients who must wear a urine collection appliance are at risk for impaired skin integrity because of irritation by urine. Well-fitting appliances are vital. The nurse should consult with the wound ostomy continence nurse (WOCN) to identify strategies for management of stoma and peristomal problems when selecting the most appropriate appliance for the client’s needs. The steps of changing a urostomy appliance are similar to those described in the procedure for changing a bowel diversion appliance (see Chapter 49 ). However, there are some differences, including the following: Incontinent urinary diversions drain continually. As a result, some type of wicking material (e.g., rolled dry gauze pad or tampon) can be placed over the stoma to absorb the urine and keep the skin dry throughout the measurement and change of the ostomy appliance (Avent, 2012). Immediately following surgery, ureteral stents may be present and protruding from the stoma. These remain in place for 10 to 14 days postop

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Evaluating Using the overall goals and desired outcomes identified in the planning stage, the nurse collects data to evaluate the effectiveness of nursing activities. If the desired outcomes are not achieved, explore the reasons before modifying the care plan. For example, if the outcome “Remains dry between voidings and at night” is not met, examples of questions that need to be considered include:

Kidney

Ureters

• What is the client’s perception of the problem? • Does the client understand and comply with the health care in-

New bladder joined to urethra

structions provided?

Urethra carrying urine from new bladder down the penis

• Is access to toilet facilities a problem? • Can the client manipulate clothing for toileting? Can adjustments

be made to allow easier disrobing?

• Are scheduled toileting times appropriate? • Is there adequate transition lighting for night-time toileting? • Are mobility aids such as a walker, elevated toilet seat, or grab bar

needed? If currently used, are they appropriate or adequate?

• Is the client performing pelvic floor muscle exercises appropri-

ately as scheduled?

Figure 48–16 • A neobladder.

• Is the client’s fluid intake adequate? Does the timing of fluid intake

need to be adjusted (e.g., restricted after dinner)?

and are removed by either the surgeon or the WOCN, depending on institutional protocol. Ureteral stents are used to maintain the patency of ureters at the anastomotic sites. Clients with urinary diversions may experience body image and sexuality problems and may require assistance in coping with these changes and managing the stoma. Most clients are able to resume their normal activities and lifestyle.

• Is the client restricting caffeine, citrus juice, carbonated beverages,

and artificial sweetener intake?

• Is the client taking a diuretic? If so, when is the medication taken?

Do the times need to be adjusted (e.g., taking second dose no later than 4 pm)? • Should continence aids such as a condom catheter or absorbent pads be used?

NURSING CARE PLAN Urinary Elimination Assessment Data

Nursing Diagnosis

Desired Outcomes*

Nursing Assessment Mr. John Baker is a 68-year-old shopkeeper who was admitted to the hospital with urinary retention, hematuria, and fever. The admitting nurse gathers the following information when taking a nursing history. Mr. Baker states he has noticed urinary frequency during the day for the past 2 weeks, and that he doesn’t feel he has emptied his bladder after urinating. He also has to get up two or three times during the night to urinate. During the past few days, he has had difficulty starting urination and dribbles afterward. He verbalizes the embarrassment his urinary problems cause in his dealings with the public. Mr. Baker is concerned about the cause of this urinary problem. He is diagnosed with benign prostatic hypertrophy (BPH) and referred to a urologist who suggests a transurethral resection of the prostate (TURP) in several months. He is placed on antibiotic therapy.

Impaired Urinary Elimination (dysfunction in urine elimination) related to bladder neck obstruction by enlarged prostate gland (as evidenced by dysuria, frequency, nocturia, dribbling, hesitancy, and bladder distention)

Urinary Continence [0502] sometimes demonstrated as ­evidenced by: • Able to start and stop stream • Empties bladder completely Knowledge: Treatment ­Regimen [1813] as evidenced by substantial knowledge of: • Self-care responsibilities for ­ongoing treatment • Self-monitoring techniques

Physical Examination

Diagnostic Data

Height: 185.4 cm (6′2″) Weight: 85.7 kg (189 lb) Temperature: 38.1°C (100.6°F) Pulse: 88 beats/min Respirations: 20/min Blood pressure: 146/86 mmHg Catheterization for urinary retention yielded 300 mL amber urine, Foley left in place for 2 days

CBC normal; urinalysis: amber, clear, pH 6.5, specific gravity 1.025, negative for glucose, protein, ketone, RBCs, and bacteria; IVP: evidence of enlarged prostate gland

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NURSING CARE PLAN Urinary Elimination—continued Nursing Interventions*/Selected Activities

Rationale

URINARY INCONTINENCE CARE [0610] Monitor urinary elimination, including consistency, odor, volume, and color.

These parameters help determine adequacy of urinary tract function.

Help the client select appropriate incontinence garment or pad for short-term management while more definitive ­treatment is designed.

Appropriate undergarments can help diminish the embarrassing aspects of urinary incontinence.

Instruct Mr. Baker to limit fluids for 2 to 3 hours before bedtime.

Decreased fluid intake several hours before bedtime will decrease the incidence of urinary retention and overflow incontinence, and promote rest.

Instruct him to drink a minimum of 1,500 mL (six 8-ounce glasses) fluids per day.

Increased fluids during the day will increase urinary output and ­discourage bacterial growth.

Limit ingestion of bladder irritants (e.g., colas, coffee, tea, and chocolate).

Alcohol, coffee, and tea have a natural diuretic effect and are bladder irritants.

URINARY RETENTION CARE [0620] Instruct Mr. Baker or a family member to record urinary output.

Serves as an indicator of urinary tract and renal function and of fluid balance.

Monitor degree of bladder distention by palpation and ­percussion and/or bladder scanner.

An enlarged prostate compresses the urethra so that urine is retained. Checking for bladder distention provides information about bladder emptying and potential residual urine.

Implement intermittent catheterization, as appropriate.

Helps maintain tonicity of the bladder muscle by preventing overdistention and providing for complete emptying.

Provide enough time for bladder emptying (10 minutes).

In addition to the effect of an enlarged prostate on the bladder, stress or anxiety can inhibit relaxation of the urinary sphincter. Sufficient time should be allowed for micturition.

Instruct the client in ways to avoid constipation or stool impaction.

Impacted stool may place pressure on the bladder outlet, causing ­urinary retention.

TEACHING: DISEASE PROCESS [5602] Appraise Mr. Baker’s current level of knowledge about ­benign prostatic hypertrophy.

Assessing the client’s knowledge will provide a foundation for building a teaching plan based on his present understanding of his condition.

Explain the pathophysiology of the disease and how it ­relates to urinary anatomy and function.

In this case, urinary retention and overflow incontinence are caused by obstruction of the bladder neck by an enlarged prostate gland.

Describe the rationale behind management, therapy, and treatment recommendations.

Adequate information about treatment options is important to diminish anxiety, promote compliance, and enhance decision making.

Instruct Mr. Baker on which signs and symptoms to report to the health care provider (e.g., burning on urination, ­hematuria, oliguria).

In the individual with prostatic hypertrophy, urinary retention and an overdistended bladder reduce blood flow to the bladder wall, making it more susceptible to infection from bacterial growth. Monitoring for these manifestations of UTI is essential to prevent urosepsis.

EVALUATION Outcomes partially met. Following removal of the Foley catheter, Mr. Baker reported continued difficulty initiating a urinary stream but experienced less dribbling and nocturia. He and his wife selected an undergarment that was acceptable to Mr. Baker and he reports that he feels more confident. Intermittent catheterization not indicated. Intake is approximately 200 mL in excess of output. He is able to discuss the correlation between his enlarged prostate and urinary difficulties. A transurethral resection of the prostate is scheduled in 2 weeks. *The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention. Outcomes, interventions, and activities ­selected are only a sample of those suggested by NOC and NIC and should be further individualized for each client.

APPLYING CRITICAL THINKING 1. Considering Mr. Baker’s history and assessment data, what other physical conditions could explain his symptoms? 2. The primary care provider has recommended surgery. What assumptions will the nurse need to validate in helping prepare Mr. and Mrs. Baker for this surgery? 3. It does not appear that other alternatives have been considered. Why might this be so? 4. Incontinence can lead to client decisions to limit social interactions. What would be an appropriate response if Mr. Baker states that he will just stay home until he has his surgery? See Critical Thinking Possibilities on student resource website.

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CONCEPT MAP Urinary Elimination

JB 68 y.o. male BPH

• Shopkeeper, c/o urinary frequency 2 weeks, nocturia 2–3 X/night, difficulty starting stream, dribbles, c/o not feeling like bladder is emptied

assess

• • • • • •

Height: 185.4 cm (6' 2") Weight: 85.7 kg (189 lb) Temperature: 38.1°C (100.6°F) Pulse: 88 Respirations: 20/min BP: 146/86

• Catheterization for residual: 300 mL amber urine • Foley left in place for 2 days • CBC normal; UA: amber, clear, pH 6.5, SpGr 1.025, negative for glucose, protein, ketones, RBCs, and bacteria; IVP: enlarged prostate gland

generate nursing diagnosis Outcomes partially met: • Following removal of the Foley catheter, reported continued difficulty initiating a urinary stream but less dribbling and nocturia • Intermittent catheterization not indicated • Intake is about 200 mL > output • Selected an acceptable undergarment and he reports more confidence

Impaired Urinary Elimination (Dysfunction in Urine Elimination) r/t bladder neck obstruction by enlarged prostate gland (aeb dysuria, frequency, nocturia, dribbling, hesitancy, and bladder distention)

evaluation

nursing intervention

outcome

outcome

Urinary Continence “Sometimes demonstrated” aeb • Able to start and stop stream • Empties bladder completely

Knowledge: Treatment Regimen aeb substantial knowledge of: • Self-care responsibilities for ongoing “treatment” • Self-monitoring techniques

nursing intervention

Outcomes met: • Able to discuss the correlation between enlarged prostate and urinary difficulties • TURP scheduled in 2 weeks

evaluation

nursing intervention

Urinary Incontinence Care Urinary Retention Care

Teaching: Disease process

activity activity activity

Monitor urinary elimination, including odor, volume, and color

Instruct client to limit fluids for 2 to 3 hours before bedtime

activity

activity Help client select appropriate incontinence garment or pad for short-term management while more definitive treatment is designed

activity

Limit ingestion of bladder irritants (e.g., colas, coffee, tea, and chocolate)

Instruct to drink a minimum of 1,500 mL (six 8-ounce glasses fluids) per day

Instruct client or family member to record urinary output

activity

activity

Provide enough time for bladder emptying (10 min)

Implement intermittent catheterization; as appropriate

Instruct in ways to avoid constipation or stool impaction

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activity

activity

activity activity

Monitor degree of bladder distention by palpation and percussion and/or bladder scanner

Appraise current level of knowledge about benign prostatic hypertrophy

activity Instruct on which signs and symptoms to report to the primary care provider (e.g., burning on urination, hematuria, oliguria)

Explain the pathophysiology of the disease and how it relates to urinary anatomy and function

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Describe the rationale behind management, therapy, and treatment recommendations

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•

•

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nary tract’s kidneys and ureters and the lower urinary tract’s urinary bladder, urethra, and pelvic floor. Urine is formed in the nephron, the functional unit of the kidney, through a process of filtration, reabsorption, and secretion. Hormones such as antidiuretic hormone (ADH) and aldosterone affect the reabsorption of sodium and water, thus affecting the amount of urine formed. The normal process of urination is stimulated when sufficient urine collects in the bladder to stimulate stretch receptors. Impulses from stretch receptors are transmitted to the spinal cord and the brain, causing relaxation of the internal sphincter (unconscious control) and, if appropriate, relaxation of the external sphincter (conscious control). In the adult, urination generally occurs after 250 to 450 mL of urine has collected in the bladder. Many factors influence a person’s urinary elimination, including growth and development, psychosocial factors, fluid intake, medications, muscle tone, various diseases and conditions, and surgical and diagnostic procedures. Alterations in urine production and elimination include polyuria, oliguria, anuria, frequency, nocturia, urgency, dysuria, enuresis, incontinence, and retention. Each may have various influencing and associated factors that need to be identified. Millions of Americans, mostly women, suffer from urinary incontinence (UI). UI can have a significant impact on the client’s quality of life, creating physical problems, such as skin breakdown and also psychosocial problems, such as social isolation and withdrawal, less positive relationships with others, poorer perceived health, negative effect on sexual function and intimacy, depression, and a barrier to physical and everyday activities. The four main types of UI are stress urinary incontinence, urge urinary incontinence, mixed urinary incontinence, and overflow incontinence. Nurses, as part of their clinical practice, should assess all clients for UI. Assessment of a client’s urinary function includes (a) a nursing

•

•

• • • •

• •

•

• •

history that identifies voiding patterns, recent changes, past and current problems with urination, and factors influencing the elimination pattern; (b) a physical assessment of the genitourinary system; (c) inspection of the urine for amount, color, clarity, and odor; and, if indicated, (d) testing of urine for specific gravity, pH, and the presence of glucose, ketone bodies, protein, and occult blood. Many NANDA-approved nursing diagnoses may apply to clients with altered urinary elimination patterns, for example, Functional Urinary Incontinence, Urinary Retention, and related diagnoses such as Risk for Infection. Goals for the client with problems with urinary elimination include maintaining or restoring normal voiding patterns and preventing associated risks such as skin breakdown. In planning for home care, the nurse considers the client’s needs for teaching and assistance in the home. Interventions include assisting the client to maintain adequate fluid intake and normal voiding patterns, and assisting with toileting. The most common cause of UTI is bacteria. Women in particular are prone to UTIs because of their short urethras. Urinary catheterization is frequently required for clients with urinary retention but is only performed when all other measures to facilitate voiding fail. Sterile technique is essential to prevent urinary infections. It is well documented that the risk to the client of developing a CAUTI correlates to the duration of the catheter being in place. Care of clients with indwelling catheters is directed toward assessing the necessity for the catheter, preventing infection of the urinary tract, and encouraging urinary flow through the drainage system. Clients with urinary retention may be taught to perform clean intermittent self-catheterization to enhance their independence, reduce the risk of infection, and eliminate incontinence. Bladder or catheter irrigations may be used to apply medication to bladder walls or maintain catheter patency. A urinary diversion is the surgical rerouting of urine from the kidneys to a site other than the bladder. There are two categories of diversions: incontinent and continent.

TEST YOUR KNOWLEDGE 1. A client is diagnosed with an elevated aldosterone level. The nurse realizes that this finding will affect what aspect of urinary elimination? 1. Increased urine output 2. Urinary incontinence 3. Decreased urine output 4. Urinary retention 2. A client needs a test to determine the amount of residual urine. The nurse realizes that this assessment is used to do which of the following? (Select all that apply.) 1. Evaluate glomerular filtration rate. 2. Determine the extent of renal failure. 3. Determine the amount of retained urine after voiding. 4. Determine the need for medications. 5. Evaluate fluid volume status.

3. The nurse is applying an external urinary device to a client. Before attaching the device to the drainage bag, what should the nurse do? 1. Wash her hands. 2. Document the client’s tolerance of the procedure. 3. Instruct the client about the drainage system. 4. Ensure that the condom is not twisted. 4. The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action? 1. Leaves the catheter in place and gets a new sterile catheter. 2. Leaves the catheter in place and asks another nurse to ­attempt the procedure. 3. Removes the catheter and redirects it to the urinary meatus. 4. Removes the catheter, wipes it with a sterile gauze, and ­redirects it to the urinary meatus.

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5. Which statement indicates a need for further teaching of the home care client with a long-term indwelling catheter? 1. “I will keep the collecting bag below the level of the bladder at all times.” 2. “Intake of cranberry juice may help decrease the risk of infection.” 3. “Soaking in a warm tub bath may ease the irritation ­associated with the catheter.” 4. “I should use clean technique when emptying the collecting bag.” 6. During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate? 1. Stress Urinary Incontinence 2. Reflex Urinary Incontinence 3. Functional Urinary Incontinence 4. Urge Urinary Incontinence 7. A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to the client? Select all that apply. 1. Limit fluids to avoid the burning sensation on urination. 2. Review symptoms of UTI with the client. 3. Wipe the perineal area from back to front. 4. Wear cotton underclothes. 5. Take baths rather than showers.

8. The nurse will need to assess the client’s performance of clean intermittent self-catheterization (CISC) for a client with which urinary diversion? 1. Ileal conduit 2. Kock pouch 3. Neobladder 4. Vesicostomy 9. Which focus is the nurse most likely to teach for a client with a flaccid bladder? 1. Habit training: Attempt voiding at specific time periods. 2. Bladder training: Delay voiding according to a preschedule timetable. 3. Credé’s maneuver: Apply gentle manual pressure to the lower abdomen. 4. Kegel exercises: Contract the pelvic muscles. 10. Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes? Select all that apply. 1. Voids each time there is an urge. 2. Practices slow, deep breathing until the urge decreases. 3. Uses adult diapers, for “just in case.” 4. Drinks citrus juices and carbonated beverages. 5. Performs pelvic muscle exercises. See Answers to Test Your Knowledge in Appendix A.

READINGS AND REFERENCES Suggested Readings

References

Magers, T. L. (2013). Using evidence-based practice to reduce catheter-associated urinary tract infections. ­American Journal of Nursing, 113(6), 34–21. doi:10.1097/01 .NAJ.0000430923.07539.a7 This article reports on an evidence-based project (EBP) in which a seven-step approach to EBP was used to reduce the incidence of catheter-associated urinary tract infection among adult clients in a long-term acute care hospital by reducing the duration of catheterization. Scemons, D. (2013). Urinary incontinence in adults. Nursing, 43(11), 52–60. doi:10.1097/01 .NURSE.0000435202.96023.d6 This article reviews bladder function and discusses the four main types of UI in adults. The client assessment and ­nursing interventions presented are based on the type of UI: stress, urge, mixed, and overflow.

Avent, Y. (2012). Understanding urinary diversions. Nursing made Incredibly Easy!, 10(4), 47–52. doi:10.1097/01 .NME.0000415018.34438.86 Ball, J., Bindler, R. C., & Cowen, K. J. (2012). Principles of pediatric nursing: Caring for children (5th ed.). Upper Saddle River, NJ: Pearson. Bulechek, G. M., Butcher, H. K., Dochterman, J. M., & Wagner, C. M. (Eds.). (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Mosby Elsevier. Bullman, S. (2011). Ins and outs of suprapubic catheters—A clinician’s experience. Urologic Nursing, 31(5), 259–264e. Chung, E., & So, K. (2012). In vitro analysis of balloon cuffing phenomenon: Inherent biophysical properties of catheter material or mechanics of catheter balloon deflation? Surgical Innovation, 19, 175–180. doi:10.1177/1553350611399589 Fisher, J. (2010). The importance of effective catheter securement. British Journal of Nursing, 19(Suppl. 8), S14–S18. Herdman, T. H., & Kamitsuru, S. (Eds.). (2014). NANDA International nursing diagnoses: Definitions & classification, 2015–2017. Oxford, United Kingdom: Wiley-Blackwell. Herter, R., & Kazer, M. W. (2010). Best practices in urinary catheter care. Home Healthcare Nurse, 28, 342–349. doi:10.1097/NHH.0b013e3181df5d79 Institute for Healthcare Improvement. (2011). How-to-guide: Prevent catheter-associated urinary tract infections. ­Cambridge, MA: Author. The Joint Commission. (2013). Hospital: 2014 national patient safety goals. Retrieved from http://www.jointcommission .org/standards_information/npsgs.aspx Keyock, K. L., & Newman, D. K. (2011). Understanding stress urinary incontinence. The Nurse Practitioner, 36(10), 24–36. doi:10.1097/01.NPR.0000405281.55881.7a Kyle, G. (2011). The use of urinary sheaths in male incontinence. British Journal of Nursing, 20(6), 338. Lee, F. M., & Carter, J. R. (2013). Reducing CAUTIs with a bladder retraining program. Nursing made Incredibly Easy!, 11(6), 53–54.

Related Research Bernard, M. S., Hunter, K. F., & Moore, K. N. (2012). A review of strategies to decrease the duration of indwelling urethral catheters and potentially reduce the incidence of catheterassociated urinary tract infections. Urologic Nursing, 32(1), 29–37. Blanchette, K. A. (2012). Exploration of nursing care strategies for the management of urinary incontinence in hospitalized women. Urologic Nursing, 32(5), 256–259, 271. Felix, H. C., Thostenson, J. D., Bursac, Z., & Bradway, C. (2013). Effect of weight on indwelling catheter use among long-term care facility residents. Urologic Nursing, 33(4), 194–200. doi:10.7257/1053-816X.2013.33.4.194 Lowe, N. K., & Ryan-Wenger, N. A. (2012). Uncomplicated UTIs in women. The Nurse Practitioner, 37(5), 41–48. doi:10.1097/01.NPR.0000413483.52003.f8 Nichols, T. R., & Layton, M. (2012). Life management and quality of life issues for those with urinary incontinence. International Journal of Urological Nursing, 6, 66–71. doi:10.1111/j.1749-771X.2012.01141.x

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Magers, T. L. (2013). Using evidence-based practice to reduce catheter-associated urinary tract infections. American Journal of Nursing, 113(6), 34–42. doi:10.1097/01 .NAJ.0000430923.07539.a7 Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Mosby. National Association for Continence. (2013). What is incontinence? Retrieved from http://www.nafc.org/ bladder-bowel-health/what-is-incontinence National Association for Continence. (2014). The basic types of incontinence. Retrieved from http://www.nafc.org/ bladder-bowel-health/types-of-incontinence Norfolk, S., & Wootton, J. (2012). Nocturnal enuresis in children. Nursing Standard, 27(10), 49–56. doi:10.7748/ ns2012.11.27.10.49.c9400 Oman, K. S., Makic, M. B, Fink, R., Schraeder, N., Hulett, T., Keech, T., & Wald, H. (2012). Nurse-directed interventions to reduce catheter-associated urinary tract infections. American Journal of Infection Control, 40, 548–553. doi:10.1016/j.ajic.2011.07.018 Palese, A., Buchini, S., Deroma, L., & Barbone, F. (2010). The effectiveness of the ultrasound bladder scanner in reducing urinary tract infections: A metaanalysis. Journal of Clinical Nursing, 19, 2970–2979. doi:10.1111/j.1365-2702.2010.03281.x Schultz, J. (2012). Rethink urinary incontinence in older women. Nursing, 42(11), 32–40. doi:10.1097/01 .NURSE.0000421371.52320.aa Seckel, M. A. (2013). Maintaining urinary catheters: What does the evidence say? Nursing, 43(2), 63–65. doi:10.1097/01 .NURSE.0000425872.18314.db Wenger, J. E. (2010). Cultivating quality: Reducing rates of catheter-associated urinary tract infection. American Journal of Nursing, 110(8), 40–45. doi:10.1097/01 .NAJ.0000387691.47746.b5 Wilson, M. (2012). Addressing the problems of long-term urethral catheterization: Part 2. British Journal of Nursing, 21(1), 16–25.

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Selected Bibliography Bardsley, A. (2013). Maintaining continence for people with ­dementia. Nursing & Residential Care, 15(11), 716–723. Barlow, W., & Shepard, L. H. (2014). Care of the patient with bladder cancer. Nursing made Incredibly Easy!, 12(5), 40-48. doi:10.1097/01.NME.0000452685.17977.66 Davis, C., Chrisman, J., & Walden, P. (2012). To scan or not to scan? Detecting urinary retention. Nursing made Incredibly Easy!, 10(4), 53–54. doi:10.1097/01 .NME.0000415016.88696.9d

Jacques, E. (2013). Treating nocturnal enuresis in children and young people. British Journal of School Nursing, 8(6), 275–278. Jindal, T., Kamal, M. R., Mandal, S. N., & Karmakar, D. (2012). Catheter-induced urethral erosion. Urologic Nursing, 32(2), 100–101. Mangnall, J. (2012). OptiLube active. The role of lubricants in urinary catheterization. British Journal of Community ­Nursing, 17(9), 414–420. Nazarko, L. (2012). Catheter-associated urinary tract infection. Nursing & Residential Care, 14(11), 578–583. Uberoi, V., Calixte, N., Coronel, V. R., Furlong, D, J., Orlando, R. P., & Lerner, L. B. (2013). Reducing urinary

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catheter days. Nursing, 43(1), 16–20. doi:10.1097/01 .NURSE.0000423971.46518.4d Wilde, M. H., Bliss, D. Z., Booth, J., Cheater, F. M., & Tannenbaum, C. (2014). Self-management of urinary and fecal incontinence. American Journal of Nursing, 114(1), 38–45. doi:10.1097/01.NAJ.0000441794.78032.f9 Yoon, P. D., Brown, K. M., Kim, L. H., Doyle, A., & Rashid, P. (2013). Primary mono-symptomatic nocturnal enuresis: A review of management. Australian and New Zealand ­Continence Journal, 19(3), 78–84.

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Fecal Elimination

LEARNING OUTCOMES After completing this chapter, you will be able to: 1. Describe the physiology of defecation. 2. Distinguish normal from abnormal characteristics and ­constituents of feces. 3. Identify factors that influence fecal elimination and patterns of defecation. 4. Identify common causes and effects of selected fecal ­elimination problems. 5. Describe methods used to assess fecal elimination. 6. Identify examples of nursing diagnoses, outcomes, and ­interventions for clients with elimination problems. 7. Identify measures that maintain normal fecal elimination patterns.

8. Describe the purpose and action of commonly used enema solutions. 9. Describe essentials of fecal stoma care for clients with an ostomy. 10. Recognize when it is appropriate to delegate assistance with fecal elimination to unlicensed assistive personnel. 11. Verbalize the steps used in: a. Administering an enema. b. Changing a bowel diversion ostomy appliance. 12. Demonstrate appropriate documentation and reporting related to fecal elimination.

KEY TERMS bedpan, 1249 bowel incontinence, 1242 carminatives, 1252 cathartics, 1249 chyme, 1236 colostomy, 1244 commode, 1249 constipation, 1241

defecation, 1237 diarrhea, 1242 enema, 1252 fecal impaction, 1241 fecal incontinence, 1242 feces, 1236 flatulence, 1243 flatus, 1237

INTRODUCTION

Nurses frequently are consulted or involved in assisting clients with elimination problems. These problems can be embarrassing to clients and can cause considerable discomfort. The elimination of feces is a prominent public topic in North America. For example, laxative advertisements, describing such feelings as tiredness due to irregularity, keep the subject in the public consciousness. Some older adults are preoccupied with their bowels. People who have had a bowel movement once a day for 75 years can view missing one day as a serious problem.

PHYSIOLOGY OF DEFECATION

Elimination of the waste products of digestion from the body is essential to health. The excreted waste products are referred to as feces or stool.

Large Intestine

The large intestine extends from the ileocecal (ileocolic) valve, which lies between the small and large intestines, to the anus. The colon (large intestine) in the adult is generally about 125 to 150 cm (50 to 60 in.) long. It has seven parts: the cecum; ascending, transverse, and descending colons; sigmoid colon; rectum; and anus (Figure 49–1 •).

gastrocolic reflex, 1239 gastrostomy, 1244 haustra, 1236 haustral churning, 1237 hemorrhoids, 1237 ileostomy, 1244 ingestion, 1236 jejunostomy, 1244

laxatives, 1241 mass peristalsis, 1237 meconium, 1238 ostomy, 1244 peristalsis, 1237 stoma, 1244 stool, 1236 suppositories, 1251

The large intestine is a muscular tube lined with mucous membrane. The muscle fibers are both circular and longitudinal, permitting the intestine to enlarge and contract in both width and length. The longitudinal muscles are shorter than the colon and therefore cause the large intestine to form pouches, or haustra. The colon’s main functions are the absorption of water and nutrients, the mucoid protection of the intestinal wall, and fecal elimination. The contents of the colon normally represent foods ingested over the previous 4 days, although most of the waste products are excreted within 48 hours of ingestion (the act of taking in food). The waste products leaving the stomach through the small intestine and then passing through the ileocecal valve are called chyme. The ileocecal valve, located at the junction of the ileum of the small intestine and the first part of the large intestine, regulates the flow of chyme into the large intestine and prevents backflow into the ileum. As much as 1,500 mL of chyme passes into the large intestine daily, and all but about 100 mL is reabsorbed in the proximal half of the colon. The 100 mL of fluid is excreted in the feces. The colon also serves a protective function in that it secretes mucus. This mucus contains large amounts of bicarbonate ions. The mucous secretion is stimulated by excitation of parasympathetic nerves. During extreme stimulation—for example, as a result of emotions—large amounts of mucus are secreted, resulting in

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Transverse colon Ascending colon

Descending colon

Sigmoid colon Cecum

Appendix

Rectum

Figure 49–1 • The large intestine. From Medical Terminology: A Living Language, 5th ed., by B. F. Fremgen and S. S. Frucht, 2013, Upper Saddle River, NJ: Pearson Education, Inc.

the passage of stringy mucus with little or no feces. Mucus serves to protect the wall of the large intestine from trauma by the acids formed in the feces, and it serves as an adherent for holding the fecal material together. Mucus also protects the intestinal wall from bacterial activity. The colon acts to transport along its lumen the products of digestion, which are eventually eliminated through the anal canal. These products are flatus and feces. Flatus is largely air and the by-products of the digestion of carbohydrates. Three types of movements occur in the large intestine: haustral churning, colon peristalsis, and mass peristalsis. Haustral churning involves movement of the chyme back and forth within the haustra. In addition to mixing the contents, this action aids in the absorption of water and moves the contents forward to the next haustra. Peristalsis is wavelike movement produced by the circular and longitudinal muscle fibers of the intestinal walls; it propels the intestinal contents forward. Colon peristalsis is very sluggish and is thought to move the chyme very little along the large intestine. Mass peristalsis, the third type of colonic movement, involves a wave of powerful muscular contraction that moves over large areas of the colon. Usually mass peristalsis occurs after eating, stimulated by the presence of food in the stomach and small intestine. In adults, mass peristaltic waves occur only a few times a day.

Rectum and Anal Canal

The rectum in the adult is usually 10 to 15 cm (4 to 6 in.) long; the most distal portion, 2.5 to 5 cm (1 to 2 in.) long, is the anal canal. The rectum has folds that extend vertically. Each of the vertical folds contains a vein and an artery. It is believed that these folds help retain feces within the rectum. When the veins become distended, as can occur with repeated pressure, a condition known as hemorrhoids occurs (Figure 49–2 •). The anal canal is bounded by an internal and an external sphincter muscle (Figure 49–3 •). The internal sphincter is under involuntary control, and the external sphincter normally is voluntarily controlled. The internal sphincter muscle is innervated by the autonomic nervous system; the external sphincter is innervated by the somatic nervous system.

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External hemorrhoid

Internal hemorrhoid

Figure 49–2 • Internal and external hemorrhoids.

Defecation

Defecation is the expulsion of feces from the anus and rectum. It is also called a bowel movement. The frequency of defecation is highly individual, varying from several times per day to two or three times per week. The amount defecated also varies from person to person. When peristaltic waves move the feces into the sigmoid colon and the rectum, the sensory nerves in the rectum are stimulated and the individual becomes aware of the need to defecate.

CLINICAL ALERT! Individuals (especially children) may use very different terms for a bowel movement. The nurse may need to try several different common words before finding one the client understands.

When the internal anal sphincter relaxes, feces move into the anal canal. After the individual is seated on a toilet or bedpan, the external anal sphincter is relaxed voluntarily. Expulsion of the feces is

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Rectum

Anal-rectal ridge

Internal anal sphincter

Anal columns

External anal sphincter

Anal valve Anal canal

A

the large intestine, there is not time for most of the water in the chyme to be reabsorbed and the feces will be more fluid, containing perhaps 95% water. Normal feces require a normal fluid intake; feces that contain less water may be hard and difficult to expel. Feces are normally brown, chiefly due to the presence of stercobilin and urobilin, which are derived from bilirubin (a red pigment in bile). Another factor that affects fecal color is the action of bacteria such as Escherichia coli or staphylococci, which are normally present in the large intestine. The action of microorganisms on the chyme is also responsible for the odor of feces. Table 49–1 lists the characteristics of normal and abnormal feces. The amount of gas produced per day varies among ­individuals; passing gas around 13 to 21 times a day is normal (National Digestive Diseases Information Clearinghouse, 2013). The gases include carbon dioxide, methane, hydrogen, oxygen, and nitrogen. Some are swallowed with food and fluids taken by mouth, others are formed through the action of bacteria on the chyme in the large intestine, and other gas diffuses from the blood into the gastrointestinal tract.

FACTORS THAT AFFECT DEFECATION

Rectum

Defecation patterns vary at different stages of life. Circumstances of diet, fluid intake and output, activity, psychological factors, defecation habits, medications, diagnostic and medical procedures, pathologic conditions, and pain also affect defecation.

Development

Newborns and infants, toddlers, children, and older adults are groups within which members have similarities in elimination patterns. External anal sphincter Anal canal B

Figure 49–3 • The rectum, anal canal, and anal sphincters: A, open; B, closed.

assisted by contraction of the abdominal muscles and the diaphragm, which increases abdominal pressure, and by contraction of the muscles of the pelvic floor, which moves the feces through the anal canal. Normal defecation is facilitated by (a) thigh flexion, which increases the pressure within the abdomen, and (b) a sitting position, which increases the downward pressure on the rectum. If the defecation reflex is ignored, or if defecation is consciously inhibited by contracting the external sphincter muscle, the urge to defecate normally disappears for a few hours before occurring again. Repeated inhibition of the urge to defecate can result in expansion of the rectum to accommodate accumulated feces and eventual loss of sensitivity to the need to defecate. Constipation can be the ultimate result.

Feces

Normal feces are made of about 75% water and 25% solid materials. They are soft but formed. If the feces are propelled very quickly along

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NEWBORNS AND INFANTS Meconium is the first fecal material passed by the newborn, normally up to 24 hours after birth. It is black, tarry, odorless, and sticky. Transitional stools, which follow for about a week, are generally greenish yellow; they contain mucus and are loose. Infants pass stool frequently, often after each feeding. Because the intestine is immature, water is not well absorbed and the stool is soft, liquid, and frequent. When the intestine matures, bacterial flora increase. After solid foods are introduced, the stool becomes less frequent and firmer. Infants who are breast-fed have light yellow to golden feces, and infants who are taking formula will have dark yellow or tan stool that is more formed. TODDLERS Some control of defecation starts at 1 1/2 to 2 years of age. By this time, children have learned to walk, and the nervous and muscular systems are sufficiently well developed to permit bowel control. A desire to control daytime bowel movements and to use the toilet generally starts when the child becomes aware of (a) the discomfort caused by a soiled diaper and (b) the sensation that indicates the need for a bowel movement. Daytime control is typically attained by age 2 1/2, after a process of toilet training. SCHOOL-AGE CHILDREN AND ADOLESCENTS School-age children and adolescents have bowel habits similar to those of adults. Patterns of defecation vary in frequency, quantity, and

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TABLE 49–1   Characteristics of Normal and Abnormal Feces Characteristic

Normal

Abnormal

Possible Cause

Color

Adult: brown

Clay or white

Absence of bile pigment (bile obstruction); ­ iagnostic study using barium d

Infant: yellow

Black or tarry

Drug (e.g., iron); bleeding from upper gastrointestinal tract (e.g., stomach, small intestine); diet high in red meat and dark green vegetables (e.g., spinach)

Red

Bleeding from lower gastrointestinal tract (e.g., rectum); some foods (e.g., beets)

Pale

Malabsorption of fats; diet high in milk and milk products and low in meat

Orange or green

Intestinal infection

Hard, dry

Dehydration; decreased intestinal motility r­esulting from lack of fiber in diet, lack of exercise, ­emotional upset, laxative abuse

Diarrhea

Increased intestinal motility (e.g., due to irritation of the colon by bacteria)

Narrow, pencil-shaped, or stringlike stool

Obstructive condition of the rectum

Consistency

Formed, soft, semisolid, moist

Shape

Cylindrical (contour of rectum) about 2.5 cm (1 in.) in diameter in adults

Amount

Varies with diet (about 100–400 g/day)

Odor

Aromatic: affected by ingested food and individual’s own ­bacterial flora

Pungent

Infection, blood

Constituents

Small amounts of undigested roughage, sloughed dead ­bacteria and epithelial cells, fat, protein, dried constituents of digestive juices (e.g., bile ­pigments, inorganic matter)

Pus Parasites Blood Large quantities of fat Foreign objects

Mucus Bacterial infection Inflammatory condition Gastrointestinal bleeding Malabsorption Accidental ingestion

consistency. Some school-age children may delay defecation because of an activity such as play.

OLDER ADULTS Toner and Claros (2012) state that “up to half of all older adults suffer from constipation” (p. 32). This is due, in part, to reduced activity levels, inadequate fluid and fiber intake, and muscle weakness. Many older people believe that “regularity” means a bowel movement every day. Those who do not meet this criterion often seek over-the-counter (OTC) preparations to relieve what they believe to be constipation. Older adults should be advised that normal patterns of bowel elimination vary considerably. For some, a normal pattern may be every other day; for others, twice a day. Constipation can be relieved by increasing the fiber intake to 20 to 35 grams per day, unless contraindicated (Tabloski & Connell, 2014). Adequate roughage in the diet, adequate exercise, and 6 to 8 glasses of fluid daily are other essential preventive measures for constipation. A cup of hot water or tea at a regular time in the morning is helpful for some. Responding to the gastrocolic reflex (increased peristalsis of the colon after food has entered the stomach) is also an important consideration. For example, toileting is recommended 30 minutes after meals, especially after breakfast when the gastrocolic reflex is strongest (Toner & Claros, 2012).

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The older adult should be warned that consistent use of laxatives inhibits natural defecation reflexes and is thought to cause rather than cure constipation. The habitual user of laxatives eventually requires larger or stronger doses because the effect is progressively reduced with continual use. Laxatives may also interfere with the body’s electrolyte balance and decrease the absorption of certain vitamins. The reasons for constipation can range from lifestyle habits (e.g., lack of exercise) to serious malignant disorders (e.g., colorectal cancer). The nurse should evaluate any complaints of constipation carefully for each individual. A change in bowel habits over several weeks with or without weight loss, pain, or fever should be referred to a primary care provider for a complete medical evaluation. See Clinical ­Manifestations for risk factors and symptoms of colorectal cancer.

Diet

Sufficient bulk (cellulose, fiber) in the diet is necessary to provide fecal volume. Inadequate intake of dietary fiber contributes to the risk of developing obesity, type 2 diabetes, coronary artery disease, and colon cancer. Fiber is classified into two categories: insoluble fiber and soluble fiber. Insoluble fiber promotes the movement of material through the digestive system and increases stool bulk. Sources

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CLINICAL MANIFESTATIONS Colorectal Cancer RISK FACTORS • Nonmodifiable • Age (risk increases after age 50) • Race (African Americans and Jews of Eastern European descent) • Personal or family history of colorectal polyps • Personal history of inflammatory bowel disease • Modifiable • Cigarette smoking • Poor diet (e.g., low in fiber and high in fat; high amounts of red meats and/or processed meats) • Lack of physical activity • Heavy consumption of alcohol SYMPTOMS Inform clients to see their primary care provider if they have any of the following: • A change in bowel habits such as diarrhea, constipation, or ­narrowing of the stool that lasts for more than a few days • A feeling of needing to have a bowel movement that is not ­relieved by doing so • Rectal bleeding or blood in the stool (often, though, the stool will look normal) • Cramping or steady abdominal pain • Weakness and fatigue • Unexpected weight loss From “The Facts About Colorectal Cancer,” by P. Walden, 2011, Nursing made Incredibly Easy!, 9(5), pp. 37–44; “What You Need to Know About Cancer of the Colon and Rectum,” by National Cancer Institute, n.d. Retrieved from http://www.cancer.gov/cancertopics/wyntk/colon-and-rectal/ page1/AllPages#4; “What Are the Risk Factors for Colorectal Cancer?” by American Cancer Society, 2014b. Retrieved from http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/ colorectal-cancer-risk-factors; and “Signs and Symptoms of Colorectal Cancer,” by American Cancer Society, 2014a. Retrieved from http://www.cancer.org/cancer/colonandrectumcancer/ detailedguide/colorectal-cancer-signs-and-symptoms.

Spicy foods can produce diarrhea and flatus in some individuals. Excessive sugar can also cause diarrhea. Other foods that may influence bowel elimination include the following: • • •

Gas-producing foods, such as cabbage, onions, cauliflower, bananas, and apples Laxative-producing foods, such as bran, prunes, figs, chocolate, and alcohol Constipation-producing foods, such as cheese, pasta, eggs, and lean meat.

Fluid Intake and Output

Even when fluid intake is inadequate or output (e.g., urine or vomitus) is excessive for some reason, the body continues to reabsorb fluid from the chyme as it passes along the colon. The chyme becomes drier than normal, resulting in hard feces. In addition, reduced fluid intake slows the chyme’s passage along the intestines, further increasing the reabsorption of fluid from the chyme. Healthy fecal elimination usually requires a daily fluid intake of 2,000 to 3,000 mL. If chyme moves abnormally quickly through the large intestine, however, there is less time for fluid to be absorbed into the blood; as a result, the feces are soft or even watery.

Activity

Activity stimulates peristalsis, thus facilitating the movement of chyme along the colon. Weak abdominal and pelvic muscles are often ineffective in increasing the intra-abdominal pressure during defecation or in controlling defecation. Weak muscles can result from lack of exercise, immobility, or impaired neurologic functioning. Clients confined to bed are often constipated.

Psychological Factors of insoluble fiber include whole-wheat flour, wheat bran, nuts, and many vegetables. Soluble fiber dissolves in water to form a gel-like material. It can help lower blood cholesterol and glucose levels (Mayo Clinic, 2012). Sources of soluble fiber include oats, peas, beans, apples, citrus fruits, carrots, barley, and psyllium. The Mayo Clinic recommends the following daily amount of fiber: Men ages 50 and younger: 38 grams Men ages 51 and older: 30 grams Women ages 50 and younger: 25 grams Women ages 51 and older: 21 grams. It is important to drink plenty of water because fiber works best when it absorbs water. Bland diets and low-fiber diets are lacking in bulk and therefore create insufficient residue of waste products to stimulate the reflex for defecation. Low-residue foods, such as rice, eggs, and lean meats, move more slowly through the intestinal tract. Increasing fluid intake with such foods increases their rate of movement. Certain foods are difficult or impossible for some people to digest. This inability results in digestive upsets and, in some instances, the passage of watery stools. Irregular eating can also impair regular defecation. Individuals who eat at the same times every day usually have a regularly timed, physiological response to the food intake and a regular pattern of peristaltic activity in the colon.

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Some people who are anxious or angry experience increased peristaltic activity and subsequent nausea or diarrhea. In contrast, people who are depressed may experience slowed intestinal motility, resulting in constipation. How a person responds to these emotional states is the result of individual differences in the response of the enteric nervous system to vagal stimulation from the brain.

Defecation Habits

Early bowel training may establish the habit of defecating at a regular time. Many people defecate after breakfast, when the gastrocolic reflex causes mass peristaltic waves in the large intestine. If a person ignores this urge to defecate, water continues to be reabsorbed, making the feces hard and difficult to expel. When the normal defecation reflexes are inhibited or ignored, these conditioned reflexes tend to be progressively weakened. When habitually ignored, the urge to defecate is ultimately lost. Adults may ignore these reflexes because of the pressures of time or work. Hospitalized clients may suppress the urge because of embarrassment about using a bedpan, because of lack of privacy, or because defecation is too uncomfortable.

Medications

Some drugs have side effects that can interfere with normal elimination. Some cause diarrhea; others, such as large doses of certain tranquilizers and repeated administration of morphine and codeine, cause

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constipation because they decrease gastrointestinal activity through their action on the central nervous system. Iron supplements act more locally on the bowel mucosa and can cause constipation or diarrhea. Some medications directly affect elimination. Laxatives are medications that stimulate bowel activity and so assist fecal elimination. Other medications soften stool, facilitating defecation. Certain medications suppress peristaltic activity and may be used to treat diarrhea. Medications can also affect the appearance of the feces. Any drug that causes gastrointestinal bleeding (e.g., aspirin products) can cause the stool to be red or black. Iron salts lead to black stool because of the oxidation of the iron; antibiotics may cause a gray-green discoloration; and antacids can cause a whitish discoloration or white specks in the stool. Pepto-Bismol, a common OTC drug, causes stools to be black.

Diagnostic Procedures

Before certain diagnostic procedures, such as visualization of the colon (colonoscopy or sigmoidoscopy), the client is restricted from ingesting food or fluid. The client may also be given a cleansing enema prior to the examination. In these instances normal defecation usually will not occur until eating resumes.

Anesthesia and Surgery

General anesthetics cause the normal colonic movements to cease or slow by blocking parasympathetic stimulation to the muscles of the colon. Clients who have regional or spinal anesthesia are less likely to experience this problem. Surgery that involves direct handling of the intestines can cause temporary cessation of intestinal movement. This condition, called ileus, usually lasts 24 to 48 hours. Listening for bowel sounds that reflect intestinal motility is an important nursing assessment following surgery.

Pathologic Conditions

Spinal cord injuries and head injuries can decrease the sensory stimulation for defecation. Impaired mobility may limit the client’s ability to respond to the urge to defecate and the client may experience constipation. Or, a client may experience fecal incontinence because of poorly functioning anal sphincters.

Pain

Clients who experience discomfort when defecating (e.g., following hemorrhoid surgery) often suppress the urge to defecate to avoid the pain. Such clients can experience constipation as a result. Clients taking narcotic analgesics for pain may also experience constipation as a side effect of the medication.

FECAL ELIMINATION PROBLEMS

Four common problems are related to fecal elimination: constipation, diarrhea, bowel incontinence, and flatulence.

Constipation

Constipation may be defined as fewer than three bowel move-

ments per week. This infers the passage of dry, hard stool or the passage of no stool. It occurs when the movement of feces through the

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BOX 49–1

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Sample Defining Characteristics of Constipation

Decreased frequency of defecation Hard, formed stools Straining at stool; painful defecation Reports of rectal fullness or pressure or incomplete bowel evacuation • Abdominal pain, cramps, or distention • Anorexia, nausea • Headache • • • •

large intestine is slow, thus allowing time for additional reabsorption of fluid from the large intestine. Associated with constipation are difficult evacuation of stool and increased effort or straining of the voluntary muscles of defecation. The person may also have a feeling of incomplete stool evacuation after defecation. However, it is important to define constipation in relation to the person’s regular elimination pattern. Some people normally defecate only a few times a week; other people defecate more than once a day. Careful assessment of the person’s habits is necessary before a diagnosis of constipation is made. Box 49–1 lists the common defining characteristics of constipation. Many causes and factors contribute to constipation. Among them are the following: • • • • • • • • • • • • • •

Insufficient fiber intake Insufficient fluid intake Insufficient activity or immobility Irregular defecation habits Change in daily routine Lack of privacy Chronic use of laxatives or enemas Irritable bowel syndrome (IBS) Pelvic floor dysfunction or muscle damage Poor motility or slow transit Neurologic conditions (e.g., Parkinson’s disease), stroke, or paralysis Emotional disturbances such as depression or mental confusion Medications such as opioids, iron supplements, antihistamines, antacids, and antidepressants Habitual denial and ignoring the urge to defecate.

Constipation can cause health problems for some clients. In children constipation is often associated with changes in activity, diet, and toileting habits (Ball, Bindler, & Cowen, 2014). Straining associated with constipation often is accompanied by holding the breath. This Valsalva maneuver can present serious problems to people with heart disease, brain injuries, or respiratory disease. Holding the breath while bearing down increases intrathoracic pressure and vagal tone, slowing the pulse rate.

FECAL IMPACTION Fecal impaction is a mass or collection of hardened feces in the folds of the rectum. Impaction results from prolonged retention and accumulation of fecal material. In severe impactions the feces accumulate and extend well up into the sigmoid colon and beyond. A client who has a fecal impaction will experience the passage of liquid fecal seepage (diarrhea) and no normal stool. The liquid portion of

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DRUG CAPSULE

Emollient or Surfactant   docusate calcium (Surfak)  docusate sodium (Colace) CLIENT WITH DRUGS FOR TREATING THE LOWER GASTROINTESTINAL TRACT Docusates lower the surface tension of fecal material, which allows water and lipids to penetrate the stool, resulting in a softer fecal mass. They do not stimulate peristalsis. Docusates are commonly used for prevention of constipation and to decrease the strain of defecation in individuals who should avoid straining during bowel movements (e.g., cardiac disease [prevent Valsalva maneuver], eye surgery, rectal surgery). NURSING RESPONSIBILITIES • Assess the client for abdominal distention, bowel sounds, and usual bowel movement frequency. • Evaluate the effectiveness of medication.

the feces seeps out around the impacted mass. Impaction can also be assessed by digital examination of the rectum, during which the hardened mass can often be palpated. Along with fecal seepage and constipation, symptoms include frequent but nonproductive desire to defecate and rectal pain. A generalized feeling of illness results; the client becomes anorexic, the abdomen becomes distended, and nausea and vomiting may occur. The causes of fecal impaction are usually poor defecation habits and constipation. Also, the administration of medications such as anticholinergics and antihistamines will increase the client’s risk in the development of a fecal impaction. The barium used in radiologic examinations of the upper and lower gastrointestinal tracts can also be a causative factor. Therefore, after these examinations, laxatives or enemas are usually given to ensure removal of the barium.

CLIENT AND FAMILY TEACHING Advise the client to drink a glass of fluid (e.g., water, juice, milk) with each dose. • Explain that it may take 1 to 3 days to soften fecal material. • Advise the client not to take docusate within 2 hours of other laxatives, especially mineral oil, because it may cause increased absorption of the mineral oil. • Discuss other forms of bowel regulation (e.g., increasing fiber intake, fluid intake, and activity). •

Note: Prior to administering any medication, review all aspects with a current drug handbook or other reliable source.

Digital examination of the impaction through the rectum should be done gently and carefully. Although digital rectal examination is within the scope of nursing practice, some agency policies require a primary care provider’s order for digital manipulation and removal of a fecal impaction. Although fecal impaction can generally be prevented, treatment of impacted feces is sometimes necessary. When fecal impaction is suspected, the client is often given an oil retention enema, a cleansing enema 2 to 4 hours later, and daily additional cleansing enemas, suppositories, or stool softeners. If these measures fail, manual removal is often necessary.

it difficult or impossible to control the urge to defecate. Diarrhea and the threat of incontinence are sources of concern and embarrassment. Often, spasmodic cramps are associated with diarrhea. Bowel sounds are increased. With persistent diarrhea, irritation of the anal region extending to the perineum and buttocks generally results. Fatigue, weakness, malaise, and emaciation are the results of prolonged diarrhea. When the cause of diarrhea is irritants in the intestinal tract, diarrhea is thought to be a protective flushing mechanism. It can create serious fluid and electrolyte losses in the body, however, that can develop within frighteningly short periods of time, particularly in infants, small children, and older adults. Clostridium difficile–associated disease, which produces mucoid and foul-smelling diarrhea, has been increasing in recent years. Clients at the highest risk for the development of C. difficile include immunosuppressed individuals, clients on chemotherapy, and those who have recently used antimicrobial agents, usually fluoroquinolones (Grossman & Mager, 2010). Older adults are at the greatest risk due to underlying disease(s) and greater exposure in hospitals and extended care facilities (Diggs & Surawicz, 2010). Infection control against C. difficile infection includes hand hygiene, contact precautions, and cleaning of surfaces with a bleach solution. All individuals involved in the care of the client need to be reminded to wash their hands with soap and water because alcohol-based hand gels are not effective against C. difficile. Also, wearing gloves when coming into contact with soiled linens is needed to prevent the spread of the bacteria and spores that exist with C. difficile (Grossman & Mager, 2010). Table 49–2 lists some of the major causes of diarrhea and the physiological responses of the body. The irritating effects of diarrhea stool increase the risk for skin breakdown. Therefore, the area around the anal region should be kept clean and dry and be protected with zinc oxide or other ointment. In addition, a fecal collector can be used (see page 1231).

Diarrhea

Bowel Incontinence

CLINICAL ALERT! An older adult with a fecal impaction may show symptoms of delirium. Assess for fecal impaction if the client with constipation problems has a sudden change in mental status.

Diarrhea refers to the passage of liquid feces and an increased fre-

quency of defecation. It is the opposite of constipation and results from rapid movement of fecal contents through the large intestine. Rapid passage of chyme reduces the time available for the large intestine to reabsorb water and electrolytes. Some people pass stool with increased frequency, but diarrhea is not present unless the stool is relatively unformed and excessively liquid. The person with diarrhea finds

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Bowel incontinence, also called fecal incontinence, refers to

the loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter. The incontinence may occur at specific times, such as after meals, or it may occur irregularly. Two types of bowel incontinence are described: partial and major. Partial incontinence is the inability to control flatus or to prevent minor soiling. Major incontinence is the inability to control feces of normal consistency.

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TABLE 49–2   Major Causes of Diarrhea Cause

Physiological Effect

Psychological stress (e.g., anxiety)

Increased intestinal motility and mucous secretion

Medications

Inflammation and infection of mucosa due to overgrowth of pathogenic intestinal microorganisms

Antibiotics

Irritation of intestinal mucosa

Iron

Irritation of intestinal mucosa

Cathartics

Incomplete digestion of food or fluid

Allergy to food, fluid, drugs

Increased intestinal motility and mucous secretion

Intolerance of food or fluid

Reduced absorption of fluids

Diseases of the colon (e.g., malabsorption syndrome, Crohn’s disease)

Inflammation of the mucosa often leading to ulcer formation

Fecal incontinence is generally associated with impaired functioning of the anal sphincter or its nerve supply, such as in some neuromuscular diseases, spinal cord trauma, and tumors of the external anal sphincter muscle. The prevalence of bowel incontinence increases with age. Seven percent of women under the age of 40 years’ experience bowel incontinence. That percentage increases to 22% or more by the sixth decade of life. In nursing homes the rate exceeds 50% and a significant number experience both fecal and urinary incontinence (Gallagher  & Thompson, 2012, p. 95). Bowel incontinence is an emotionally distressing problem that can ultimately lead to social isolation. Afflicted individuals withdraw into their homes or, if in the hospital, the confines of their room, to minimize the embarrassment associated with soiling. Several surgical procedures are used for the treatment of fecal incontinence. These include repair of the sphincter and bowel diversion or colostomy.

Flatulence

The three primary sources of flatus are (1) action of bacteria on the chyme in the large intestine, (2) swallowed air, and (3) gas that diffuses between the bloodstream and the intestine. Most gases that are swallowed are expelled through the mouth by eructation (belching). However, large amounts of gas can accumulate in the stomach, resulting in gastric distention. The gases formed in the large intestine are chiefly absorbed through the intestinal capillaries into the circulation. Flatulence is the presence of excessive flatus in the intestines and leads to stretching and inflation of the intestines (intestinal distention). Flatulence can occur in the colon from a variety of causes, such as foods (e.g., cabbage, onions), abdominal surgery, or narcotics. If the gas is propelled by increased colon activity before it can be absorbed, it may be expelled through the anus. If excessive gas cannot be expelled through the anus, it may be necessary to insert a rectal tube to remove it.

Evidence-Based Practice Is There a Difference Between Two Methods of Ostomy Care Instruction?

EVIDENCE-BASED PRACTICE

First-time ostomy clients have a great deal of new knowledge and skills to learn about living with and caring for an ostomy. Crawford et al. (2012) described the traditional method of instruction for new ostomy clients at their institution. That is, a certified wound ostomy continence nurse (CWOCN) spent three individual hour-long sessions with each new ostomy client. This was time intensive for the nurses and resulted in fatigue for the postoperative ostomy clients. They wanted to investigate the use of a unique, self-designed, integrated method of teaching incorporating a DVD. A review of the literature found that individual instruction versus DVD instruction has been previously studied. Only one study, however, addressed the subject of nurse involvement along with a DVD method, and there were no studies concerning ostomy clients and DVD instruction. The purpose of their randomized controlled study was to compare two methods of ostomy care instruction to determine their effect on clients’ knowledge, skills, and confidence related to ostomy care. Both methods of instruction included one-on-one sessions with a CWOCN at the client’s bedside. The “nurse instruction” group received three one-on-one sessions and the “nurse instruction plus DVD” group received two one-on-one sessions plus one session of nurse-guided video instruction in between. A post-test experimental design was used to compare the two instructional methods. The study setting was two acute care hospitals in the Midwest. Subjects included adult clients, 21 years or older, with new fecal ostomies, either a colostomy or ileostomy. All 68 clients were

independent in activities of daily living prior to their ostomy surgery. The subjects were randomly assigned to one of the instruction groups. A detailed instructional guide was prepared for the CWOCN investigators to ensure that all clients in the study received the same ostomy care information during the teaching sessions. Three instruments were used to assess the subjects’ knowledge, skills, and confidence in providing ostomy self-care. First was a knowledge test where scores were recorded as a percentage of correct answers. Direct observation was used to evaluate skills in four areas: emptying the pouch, caring for the stoma site, sizing and preparing pouching products, and applying the ostomy appliance. Finally, the subjects completed a visual analog scale indicating their levels of confidence in providing ostomy self-care. The results of the data analysis revealed that the nurse instruction plus DVD technique was as effective as the nurse instruction method.

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IMPLICATIONS This study confirmed the results of previous studies that found that video instruction was equally effective for increasing knowledge when compared to traditional instructional methods. It is important to remember that the authors designed an instructional method that incorporated DVD instruction as an adjunct to nurse instruction, not as a replacement for nurse instruction. The integrated DVD method offers flexibility in meeting the learning needs of the postoperative ostomy client and their family, especially after hospital discharge.

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BOWEL DIVERSION OSTOMIES

An ostomy is an opening for the gastrointestinal, urinary, or respiratory tract onto the skin. There are many types of intestinal ostomies. A gastrostomy is an opening through the abdominal wall into the stomach. A jejunostomy opens through the abdominal wall into the jejunum, an ileostomy opens into the ileum (small bowel), and a colostomy opens into the colon (large bowel). Gastrostomies and jejunostomies are generally performed to provide an alternate feeding route. The purpose of bowel ostomies is to divert and drain fecal material. Bowel diversion ostomies are often classified according to (a) their status as permanent or temporary, (b) their anatomic location, and (c) the construction of the stoma, the opening created in the abdominal wall by the ostomy. A stoma is generally red in color and moist. Initially, slight bleeding may occur when the stoma is touched and this is considered normal. A person does not feel the stoma because there are no nerve endings in the stoma.

The location of the ostomy influences the character and management of the fecal drainage. The farther along the bowel, the more formed the stool (because the large bowel reabsorbs water from the fecal mass) and the more control over the frequency of stomal discharge can be established. For example: •

•

•

Permanence

Colostomies can be either temporary or permanent. Temporary colostomies are generally performed for traumatic injuries or inflammatory conditions of the bowel. They allow the distal diseased portion of the bowel to rest and heal. Permanent colostomies are performed to provide a means of elimination when the rectum or anus is nonfunctional as a result of a birth defect or a disease such as cancer of the bowel. CLINICAL ALERT! Surgery to reconnect the ends of the bowel of a temporary ostomy may be called a take-down.

•

An ileostomy produces liquid fecal drainage. Drainage is constant and cannot be regulated. Ileostomy drainage contains some digestive enzymes, which are damaging to the skin. For this reason, ileostomy clients must wear an appliance continuously and take special precautions to prevent skin breakdown. Compared to colostomies, however, odor is minimal because fewer bacteria are present. An ascending colostomy is similar to an ileostomy in that the drainage is liquid and cannot be regulated, and digestive enzymes are present. Odor, however, is a problem requiring control. A transverse colostomy produces a malodorous, mushy drainage because some of the liquid has been reabsorbed. There is usually no control. A descending colostomy produces increasingly solid fecal drainage. Stools from a sigmoidostomy are of normal or formed consistency, and the frequency of discharge can be regulated. People with a sigmoidostomy may not have to wear an appliance at all times, and odors can usually be controlled.

The length of time that an ostomy is in place also helps to determine the consistency of the stool, particularly with transverse and descending colostomies. Over time, the stool becomes more formed because the remaining functioning portions of the colon tend to compensate by increasing water reabsorption.

Surgical Construction of the Stoma Anatomic Location

An ileostomy generally empties from the distal end of the small intestine. A cecostomy empties from the cecum (the first part of the ascending colon). An ascending colostomy empties from the ascending colon, a transverse colostomy from the transverse colon, a descending colostomy from the descending colon, and a sigmoidostomy from the sigmoid colon (Figure 49–4 •).

Stoma constructions are described as single, loop, divided, or doublebarreled colostomies. The single stoma is created when one end of bowel is brought out through an opening onto the anterior abdominal wall. This is referred to as an end or terminal colostomy; the stoma is permanent (Figure 49–5 •).

Transverse colostomy Ascending colostomy Descending colostomy Ileostomy Cecostomy Sigmoidostomy Rectal stump

Figure 49–4 • The locations of bowel diversion ostomies.

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Figure 49–5 • End colostomy. The diseased portion of bowel is ­removed and a rectal pouch remains.

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Figure 49–6 • Loop colostomy. Courtesy of Cory Patrick Hartley, RN.

Figure 49–7 • Divided colostomy with two separated stomas.

In the loop colostomy, a loop of bowel is brought out onto the abdominal wall and supported by a plastic bridge or by a piece of rubber tubing (Figure 49–6 •). A loop stoma has two openings: the proximal or afferent end, which is active, and the distal or efferent end, which is inactive. The loop colostomy is usually performed in an emergency procedure and is often situated on the right transverse colon. It is a bulky stoma that is more difficult to manage than a single stoma. The divided colostomy consists of two edges of bowel brought out onto the abdomen but separated from each other (Figure 49–7 •). The opening from the digestive or proximal end is the colostomy. The distal end in this situation is often referred to as a mucous fistula, since this section of bowel continues to secrete mucus. The divided colostomy is often used in situations where spillage of feces into the distal end of the bowel needs to be avoided.

Figure 49–8 • Double-barreled colostomy.

The double-barreled colostomy resembles a double-barreled shotgun (Figure 49–8 •). In this type of colostomy, the proximal and distal loops of bowel are sutured together for about 10 cm (4 in.) and both ends are brought up onto the abdominal wall.

LIFESPAN CONSIDERATIONS Factors in Potential Bowel Elimination Problems CHILDREN • Successful toilet training can prevent many problems with elimination. The family should be assessed for “readiness to train.” Assess the child’s physical, cognitive, and interpersonal skills, and parental readiness. Does the child have sphincter control (usually by 18 to 24 months)? Does the child understand the meaning of toileting? Is the child able to express him- or herself and does the child demonstrate interest in learning? Are parents ready to work with the child? • Encourage a regular toileting routine for children. When toilet training, ensure that toddlers can rest their feet comfortably on the floor or a footstool, and are not frightened or pressured while toileting. • An acute episode of dehydration and constipation (often related to an illness) can lead to chronic stool problems. ­Constipation can cause painful defecation, which causes the child to withhold stool, leading to more severe constipation, more pain on defecation, more withholding, and so on. ­Breaking the cycle by helping ease defecation is important to prevent long-term problems.

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OLDER ADULTS • Poor fluid intake and inability to eat a high-fiber diet, due to swallowing or chewing difficulties, are often causes of constipation. • Medications that are commonly taken by older adults such as antacids, many antihypertensives, antidepressants, diuretics, and narcotics for pain also contribute to constipation. • Clients receiving tube feedings can experience diarrhea. To alleviate it, they require a change of formula, a change in its strength, or a change in the speed or temperature of tube ­feeding administration. • Clients receiving laxative preparation for x-rays or other ­procedures may experience fluid and electrolyte imbalances due to diarrhea. • Individuals with cognitive impairment, such as Alzheimer’s ­disease, may be unaware of what and when they eat or drink or of their bowel habits. It is important that caregivers monitor the person’s bowel elimination patterns. • Individuals with impaired mobility may have difficulty getting to the bathroom or using a regular toilet. A raised toilet seat and other devices, such as bars to assist in ambulation, may be very helpful. The decrease in activity may also contribute to constipation.

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ANATOMY & PHYSIOLOGY REVIEW Small and Large Intestines Review the figure and reflect back on your anatomy and physiology courses. Pyloric sphincter Duodenum Transverse colon Ascending colon

Descending colon

Small intestine (jejunum and ileum) Sigmoid colon Cecum

Small and large intestines.

Appendix

Rectum

From Medical Terminology: A Living Language, 5th ed., by B. F. Fremgen and S. S. Frucht, 2013, Upper Saddle River, NJ: Pearson Education, Inc.

QUESTIONS 1. What are the primary functions of the small intestine? 2. What are the primary functions of the large intestine? 3. What part of the small intestine connects to the colon? 4. What consistency would the stool be in a client with an ileostomy and why?

●◯●

NURSING MANAGEMENT

Assessing Assessment of fecal elimination includes taking a nursing history; performing a physical examination of the abdomen, rectum, and anus; and inspecting the feces. The nurse also should review any data obtained from relevant diagnostic tests.

Nursing History A nursing history for fecal elimination helps the nurse ascertain the client’s normal pattern. The nurse elicits a description of usual feces and any recent changes and collects information about any past or current problems with elimination, the presence of an ostomy, and factors influencing the elimination pattern. Examples of questions to elicit this information are shown in the Assessment Interview. The number of questions to ask is adapted to the individual client, according to the client’s responses in the first three categories. For example, questions about factors influencing elimination might be addressed only to clients who are experiencing problems. When eliciting data about the client’s defecation pattern, the nurse needs to understand that the time of defecation and the amount of feces expelled are as individual as the frequency of defecation.

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5. Compare and contrast the consistency of stool in a ­transverse colostomy and a descending colostomy. 6. How would you describe the stool discharged from a sigmoidostomy? See student resource website for answers.

Often, the patterns individuals follow depend largely on early training and on convenience.

Physical Examination Physical examination of the abdomen in relation to fecal elimination problems includes inspection, auscultation, percussion, and palpation with specific reference to the intestinal tract. Auscultation precedes palpation because palpation can alter peristalsis. Examination of the rectum and anus includes inspection and palpation. Physical examination of the abdomen, rectum, and anus is discussed in Chapter 30 . Inspecting the Feces Observe the client’s stool for color, consistency, shape, amount, odor, and the presence of abnormal constituents. Table 49–1, earlier in this chapter, summarizes normal and abnormal characteristics of stool and possible causes. Diagnostic Studies Diagnostic studies of the gastrointestinal tract include direct visualization techniques, indirect visualization techniques, and laboratory tests for abnormal constituents (see Chapter 34 ).

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ASSESSMENT INTERVIEW  Fecal Elimination DEFECATION PATTERN • When do you usually have a bowel movement? • Has this pattern changed recently? DESCRIPTION OF FECES AND ANY CHANGES • Have you noticed any changes in the color, texture (hard, soft, watery), shape, or odor of your stool recently? FECAL ELIMINATION PROBLEMS • What problems have you had or do you now have with your bowel movements (constipation, diarrhea, excessive flatulence, seepage, or incontinence)? • When and how often does it occur? • What do you think causes it (food, fluids, exercise, emotions, medications, disease, surgery)? • What have you tried to solve the problem, and how effective was it? FACTORS INFLUENCING ELIMINATION • Use of elimination aids. What routines do you follow to maintain your usual defecation pattern? Do you use natural aids such as specific foods or fluids (e.g., a glass of hot lemon juice before breakfast), laxatives, or enemas to maintain elimination?

•

• •

• •

Diet. What foods do you believe affect defecation? What foods do you typically eat? What foods do you avoid? Do you take meals at regular times? Fluid. What amount and kind of fluid do you take each day (e.g., 6 glasses of water, 2 cups of coffee)? Exercise. What is your usual daily exercise pattern? (­Obtain specifics about exercise rather than asking whether it is ­sufficient; ideas of what is sufficient vary among individuals.) Medications. Have you taken any medications that could affect the intestinal tract (e.g., iron, antibiotics)? Stress. Are you experiencing any stress? Do you think this ­affects your defecation pattern? How?

PRESENCE AND MANAGEMENT OF OSTOMY • What is your usual routine with your colostomy/ileostomy? • What type of appliance do you wear and did you bring a spare with you? • What problems, if any, do you have with it? • How can the nurses help you manage your colostomy/ ileostomy?

Diagnosing

Planning

NANDA International (Herdman & Kamitsuru, 2014) includes the following diagnostic labels for fecal elimination problems:

The major goals for clients with fecal elimination problems are to:

• • • • • •

Bowel Incontinence Constipation Risk for Constipation Perceived Constipation Diarrhea Dysfunctional Gastrointestinal Motility.

Clinical application of selected diagnoses is shown at the end of the chapter in the Nursing Care Plan and Concept Map. Fecal elimination problems may affect many other areas of human functioning and as a consequence may be the etiology of other NANDA diagnoses. Examples follow: • Risk for Deficient Fluid Volume and/or Risk for Electrolyte Imbal-

•

•

•

• •

ance related to a. Prolonged diarrhea b. Abnormal fluid loss through ostomy Risk for Impaired Skin Integrity related to a. Prolonged diarrhea b. Bowel incontinence c. Bowel diversion ostomy Situational Low Self-Esteem related to a. Ostomy b. Fecal incontinence c. Need for assistance with toileting Disturbed Body Image related to a. Ostomy b. Bowel incontinence Deficient Knowledge (Bowel Training, Ostomy Management) related to lack of previous experience Anxiety related to a. Lack of control of fecal elimination secondary to ostomy b. Response of others to ostomy.

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• Maintain or restore normal bowel elimination pattern. • Maintain or regain normal stool consistency. • Prevent associated risks such as fluid and electrolyte imbalance,

skin breakdown, abdominal distention, and pain.

Appropriate preventive and corrective nursing interventions that relate to these must be identified. Specific nursing activities associated with each of these interventions can be selected to meet the client’s individual needs. Examples of clinical applications of these using NANDA, NIC, and NOC designations are shown in the Nursing Care Plan at the end of the chapter.

Planning for Home Care Clients who have bowel diversion ostomies, who wear pouches, or who have other ongoing elimination problems will need continuing care in the home setting. In preparation for discharge, the nurse needs to assess the client’s and family’s ability to meet specific care needs. The Home Care Assessment outlines the specific assessment data required before developing a home care plan. Using the assessment data, the nurse designs a teaching plan for the client and family (see Client Teaching).

Implementing Promoting Regular Defecation The nurse can help clients achieve regular defecation by attending to (a) the provision of privacy, (b) timing, (c) nutrition and fluids, (d) ­exercise, and (e) positioning. See Client Teaching for healthy habits related to bowel elimination. Privacy

Privacy during defecation is extremely important to many people. The nurse should therefore provide as much privacy as possible for such clients but may need to stay with those who are too weak to be left alone. Some clients also prefer to wipe, wash, and dry themselves

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Home Care Assessment  Fecal Elimination CLIENT AND ENVIRONMENT • Self-care abilities for toileting: ability to get to the toilet, to ­manipulate clothing for toileting, to perform toileting hygiene, and to flush the toilet • Mechanical aids required: walker, cane, wheelchair, raised toilet seat, grab bars, bedpan, commode • Mechanical barriers that limit access to the toilet or are unsafe: poor lighting, cluttered pathway to bathroom, narrow doorway for wheelchair, and so on • Bowel elimination problem: alterations in characteristics of ­feces, diarrhea, constipation, incontinence, presence of ostomy, and methods of handling these • Level of knowledge: planned bowel management or training program, prescribed medications, ostomy care, dietary alterations, and fluid and exercise requirements or restrictions • Facilities: adequacy of bathroom facilities to facilitate toileting hygiene and ostomy care and to contain potentially infectious fecal effluent or stool

PATIENT-CENTERED CARE FAMILY • Caregiver availability and skills: people able to assist with toileting, medications, ostomy care, or other prescribed therapeutic measures • Family role changes and coping: effect on financial status, ­parenting and spousal roles, sexuality, social roles • Alternate potential primary or respite caregivers: for example, other family members, volunteers, church members, paid caregivers or housekeeping services; available community respite care (adult day care, senior centers) COMMUNITY • Availability of and familiarity with possible sources of assistance: equipment and supply companies, financial assistance, home health agencies

CLIENT TEACHING

Fecal Elimination FACILITATING TOILETING • Ensure safe and easy access to the toilet. Make sure lighting is appropriate, scatter rugs are removed or securely fastened, and so on. • Facilitate instruction as needed about transfer techniques. • Suggest ways that garments can be adjusted to make disrobing easier for toileting (e.g., Velcro closing on clothing). MONITORING BOWEL ELIMINATION PATTERN • Instruct the client, if appropriate, to keep a record of time and frequency of stool passage, any associated pain, and color and consistency of the stool. DIETARY ALTERATIONS • Provide information about required food and fluid alterations to promote defecation or to manage diarrhea. MEDICATIONS • Discuss problems associated with overuse of laxatives, if ­appropriate, and the use of alternatives to laxatives, ­suppositories, and enemas. • Discuss the addition of a fiber supplement if the client is taking a constipating medication.

CLIENT TEACHING

Healthy Defecation • • • • • •

Establish a regular exercise regimen. Include high-fiber foods, such as vegetables, fruits, and whole grains, in the diet. Maintain fluid intake of 2,000 to 3,000 mL/day. Do not ignore the urge to defecate. Allow time to defecate, preferably at the same time each day. Avoid OTC medications to treat constipation and diarrhea.

after defecating. A nurse may need to provide water and a washcloth and towel for this purpose. Timing

A client should be encouraged to defecate when the urge is recognized. To establish regular bowel elimination, the client and nurse

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MEASURES SPECIFIC TO ELIMINATION PROBLEM • Provide instructions associated with specific elimination ­problems and treatment, such as: • Constipation • Diarrhea • Ostomy care. COMMUNITY AGENCIES AND OTHER SOURCES OF HELP • Make appropriate referrals to home care or community care for assistance with resources such as installation of grab bars and raised toilet seats, structural alterations for wheelchair access, homemaker or home health aide services to assist with ADLs, and an enterostomal therapy nurse for assistance with stoma care and selection of ostomy appliances. • Provide information about companies where durable medical equipment (e.g., raised toilet seats, commodes, bedpans, ­urinals) can be purchased, rented, or obtained free of charge, and where medical supplies such as incontinence pads or ­ostomy irrigating supplies and appliances can be obtained. • Suggest additional sources of information and help such as ­ostomy self-help and support groups or clubs.

can discuss when mass peristalsis normally occurs and provide time for defecation. Many people have well-established routines. Other activities, such as bathing and ambulating, should not interfere with the defecation time. Nutrition and Fluids

The diet a client needs for regular normal elimination varies, depending on the kind of feces the client currently has, the frequency of defecation, and the types of foods that the client finds assist with normal defecation. For Constipation  Increase daily fluid intake, and instruct the client to drink hot liquids, warm water with a squirt of fresh lemon, and fruit juices, especially prune juice. Include fiber in the diet, that is, foods such as raw fruit, bran products, and whole-grain cereals and bread. For Diarrhea  Encourage oral intake of fluids and bland food. Eating small amounts can be helpful because small amounts are more easily

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CLIENT TEACHING

Managing Diarrhea Drink at least 8 glasses of water per day to prevent dehydration. Consider drinking a few glasses of electrolyte replacement fluids a day. • Eat foods with sodium and potassium. Most foods contain sodium. Potassium is found in meats and many vegetables and fruits, especially purple grape juice, tomatoes, potatoes, bananas, cooked peaches, and apricots. • Increase foods containing soluble fiber, such as rice, oatmeal, and skinless fruits and potatoes. • Avoid alcohol and beverages with caffeine, which aggravate the problem. • Limit foods containing insoluble fiber, such as high-fiber whole-wheat and whole-grain breads and cereals, and raw fruits and vegetables. • Limit fatty foods. • Thoroughly clean and dry the perianal area after passing stool to prevent skin irritation and breakdown. Use soft toilet tissue to clean and dry the area. Apply a dimethicone-based cream or alcohol-free barrier film as needed. • If possible, discontinue medications that cause diarrhea. • When diarrhea has stopped, reestablish normal bowel flora by eating fermented dairy products, such as yogurt or buttermilk. • Seek a primary care provider consultation right away if weakness, dizziness, or loose stools persist more than 48 hours.

absorbed. Excessively hot or cold fluids should be avoided because they stimulate peristalsis. In addition, highly spiced foods and highfiber foods can aggravate diarrhea. See Client Teaching for details about managing diarrhea. For Flatulence  Limit carbonated beverages, the use of drinking straws, and chewing gum—all of which increase the ingestion of air. Gas-forming foods, such as cabbage, beans, onions, and cauliflower, should also be avoided. Exercise

Regular exercise helps clients develop a regular defecation pattern. A client with weak abdominal and pelvic muscles (which impede normal defecation) may be able to strengthen them with the following isometric exercises: • In a supine position, the client tightens the abdominal muscles as

though pulling them inward, holding them for about 10 seconds and then relaxing them. This should be repeated 5 to 10 times, four times a day, depending on the client’s health. • Again in a supine position, the client can contract the thigh muscles and hold them contracted for about 10 seconds, repeating the exercise 5 to 10 times, four times a day. This helps the client confined to bed gain strength in the thigh muscles, thereby making it easier to use a bedpan. Positioning

Although the squatting position best facilitates defecation, on a toilet seat the best position for most people seems to be leaning forward. For clients who have difficulty sitting down and getting up from the toilet, an elevated toilet seat can be attached to a regular toilet. Clients then do not have to lower themselves as far onto the seat and do not have to lift as far off the seat. Elevated toilet seats can be purchased for use in the home.

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Figure 49–9 • A commode with overlying seat.

A bedside commode, a portable chair with a toilet seat and a receptacle beneath that can be emptied, is often used for the adult client who can get out of bed but is unable to walk to the bathroom. Some commodes have wheels and can slide over the base of a regular toilet when the waste receptacle is removed, thus providing clients the privacy of a bathroom. Some commodes have a seat and can be used as a chair (Figure 49–9 •). Potty chairs are available for children. Clients restricted to bed may need to use a bedpan, a receptacle for urine and feces. Female clients use a bedpan for both urine and feces; male clients use a bedpan for feces and a urinal for urine. The two main types of bedpans are the regular high-back pan and the slipper, or fracture, pan (Figure 49–10 •). The slipper pan has a low back and is used for clients unable to raise their buttocks because of physical problems or therapy that contraindicates such movement. Many older adults benefit from the use of a slipper pan. See Practice Guidelines for the techniques of giving and removing a bedpan.

Teaching About Medications The most common categories of medications affecting fecal elimination are cathartics and laxatives, antidiarrheals, and antiflatulents. Cathartics and Laxatives

Cathartics are drugs that induce defecation. They can have a strong, purgative effect. A laxative is mild in comparison to a cathartic, and it produces soft or liquid stools that are sometimes accompanied by abdominal cramps. Examples of cathartics are castor oil, cascara,

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Figure 49–10 • Left, The high-back or regular bedpan; right, the slipper or fracture pan.

PRACTICE GUIDELINES

Giving and Removing a Bedpan • • • • • •

•

• •

Provide privacy. Wear clean gloves. If the bedpan is metal, warm it by rinsing it with warm water. Adjust the bed to a height appropriate to prevent back strain. Elevate the side rail on the opposite side to prevent the client from falling out of bed. Ask the client to assist by flexing the knees, resting the weight on the back and heels, and raising the buttocks, or by using a trapeze bar, if present. Help lift the client as needed by placing one hand under the lower back, resting your elbow on the mattress, and using your forearm as a lever. Lubricate the back of the bedpan with a small amount of hand lotion or liquid soap to reduce tissue friction and shearing. Place a regular bedpan so that the client’s buttocks rest on the smooth, rounded rim. Place a slipper pan with the flat, low end under the client’s buttocks (Figure 49–11 •).

Figure 49–11 • Placing a slipper pan under the buttocks.

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•

•

• •

•

For the client who cannot assist, obtain the assistance of another nurse to help lift the client onto the bedpan or place the client on his or her side, place the bedpan against the buttocks (Figure 49–12 •), and roll the client back onto the bedpan. To provide a more normal position for the client’s lower back, elevate the client’s bed to a semi-Fowler’s position, if permitted. If elevation is contraindicated, support the client’s back with pillows as needed to prevent hyperextension of the back. Cover the client with bed linen to maintain comfort and dignity. Provide toilet tissue, place the call light within reach, lower the bed to the low position, elevate the side rail if indicated, and leave the client alone. Answer the call light promptly.

Figure 49–12 • Placing a regular bedpan against the client’s buttocks.

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PRACTICE GUIDELINES

Giving and Removing a Bedpan—continued •

•

•

Do not leave anyone on a bedpan longer than 15 minutes unless they are able to remove the pan themselves. Lengthy stays on a bedpan can cause skin breakdown. When removing the bedpan, return the bed to the position used when giving the bedpan, hold the bedpan steady to prevent spillage of its contents, cover the bedpan, and place it on the adjacent chair. If the client needs assistance, apply gloves and wipe the client’s perineal area with several layers of toilet tissue. If a specimen is to be collected, discard the soiled tissue into a moisture-proof receptacle other than the bedpan. For female clients, clean from the urethra toward the anus to prevent transferring rectal ­microorganisms into the urinary meatus.

phenolphthalein, and bisacodyl. Table 49–3 describes the different types of laxatives. Laxatives are contraindicated in the client who has nausea, cramps, colic, vomiting, or undiagnosed abdominal pain. Clients need to be informed about the dangers of laxative use. Continual use of laxatives to encourage bowel evacuation weakens the bowel’s natural responses to fecal distention, resulting in chronic constipation. To eliminate chronic laxative use, it is usually necessary to teach the client about dietary fiber, regular exercise, taking sufficient fluids, TABLE 49–3 

• • • • •

•

Wash the perineal area of dependent clients with soap and water as indicated and thoroughly dry the area. For all clients, offer warm water, soap, a washcloth, and a towel to wash the hands. Assist the client to a comfortable position, empty and clean the bedpan, and return it to the bedside. Remove and discard your gloves and wash your hands. Spray the room with air freshener as needed to control odor unless contraindicated because of respiratory problems or allergies. Document color, odor, amount, and consistency of urine and feces, and the condition of the perineal area.

and establishing regular defecation habits. In addition, any medication regimen should be examined to see whether it could cause constipation. Some laxatives are given in the form of suppositories. These act in various ways: by softening the feces, by releasing gases such as carbon dioxide to distend the rectum, or by stimulating the nerve endings in the rectal mucosa. The best results can be obtained by inserting the suppository 30 minutes before the client’s usual defecation time or when the peristaltic action is greatest, such as after breakfast.

Types of Laxatives

Type

Action

Examples

Pertinent Teaching Information

Bulk forming

Increases the fluid, gaseous, or solid bulk in the intestines.

Psyllium hydrophilic mucilloid (Metamucil), methylcellulose (Citrucel)

May take 12 or more hours to act. Sufficient fluid must be taken. Safe for long-term use.

Osmotic/saline

Draws water into the intestine by osmosis, distends bowel, and stimulates peristalsis. Almost no water or electrolytes are absorbed as solution moves through the intestines and the large fluid volume flushes feces from the colon (Daniels & Schmelzer, 2013).

Four major types of osmotic laxatives: lactulose, sodium phosphate (tablet form only requiring a prescription; OsmoPrep, Visicol), magnesium salts (magnesium citrate), and sodium sulfate (SUPREP) Electrolyte-free polyethylene glycol 3350 (PEG 3350) (MiraLAX) PEG-ES (GoLYTELY; NuLYTELY)

May be rapid acting. Can cause fluid and electrolyte imbalance, particularly in older people and children with cardiac and renal disease. Use caution when giving to older adults. A laxative that is helpful in the treatment of constipation. It is a powder that is tasteless when mixed in a flavored liquid such as juice. Used for cleaning of the colon before colonoscopy. Requires drinking a large volume (4 L), which may be difficult for clients to tolerate. Has an unpleasant taste.

Stimulant/irritant

Irritates the intestinal mucosa or stimulates nerve endings in the wall of the intestine, ­causing rapid propulsion of the contents.

Bisacodyl (Dulcolax, Correctol), senna (Senokot, Ex-Lax), cascara, castor oil

Acts more quickly than bulk-forming agents. Fluid is passed with the feces. May cause cramps. Use only for short periods of time. Prolonged use may cause fluid and electrolyte imbalance.

Stool softener or surfactant

Softens and delays the drying of the stool; causes more ­water and fat to be absorbed into the stool.

Docusate sodium (Colace) Docusate calcium (Surfak)

Slow-acting; may take several days.

Lubricant

Lubricates the stool and colon mucosa.

Mineral oil (Haley’s M-O)

Prolonged use inhibits the absorption of some fat-soluble vitamins.

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BOX 49–2 •

• •

• • •

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Guidelines for Using Antidiarrheal Medications

If the diarrhea persists for more than 3 or 4 days, determine the underlying cause. Using a medication such as an opiate when the cause is an infection, toxin, or poison may prolong diarrhea. Long-term use of OTC medications (e.g., loperamide ­hydrochloride [Imodium]) can produce dependence. Some antidiarrheal agents can cause drowsiness (e.g., ­diphenoxylate hydrochloride [Lomotil]) and should not be used when driving an automobile or running machinery. Kaolin-pectin preparations (e.g., Kaopectate) may absorb nutrients. Bulk laxatives and other absorbents may be used to help bind toxins and absorb excess bowel liquid. Bismuth preparations (e.g., Pepto-Bismol), often used to treat “traveler’s diarrhea,” may contain aspirin and should not be given to children and teenagers with chickenpox, influenza, and other viral infections.

Antidiarrheal Medications

These medications slow the motility of the intestine or absorb excess fluid in the intestine. Guidelines for using antidiarrheals are shown in Box 49–2. Antiflatulent Medications

Antiflatulent agents such as simethicone do not decrease the formation of flatus but they do coalesce the gas bubbles and facilitate their passage by belching through the mouth or expulsion through the anus. A combination of simethicone and loperamide (Imodium Advanced) is effective in relieving abdominal bloating and gas associated with acute diarrhea; however, no convincing evidence has been shown for common flatulence (“Relief from intestinal gas,” 2013). Carminatives are herbal oils known to act as agents that help expel gas from the stomach and intestines. Suppositories can also be given to relieve flatus by increasing intestinal motility.

Decreasing Flatulence There are a number of ways to reduce or expel flatus, including exercise, moving in bed, ambulation, and avoiding gas-producing foods. Movement stimulates peristalsis and the escape of flatus and reabsorption of gases in the intestinal capillaries.

Certain medication can decrease flatulence. Probiotics may be helpful in the management of flatulence and bloating. Because each probiotic is a different mixture of bacteria, they need to be treated as different medications. Recent studies have shown different probiotics to be helpful for various gastrointestinal disorders (Lacy, Gabbard, & Crowell, 2011). Bismuth subsalicylate (Pepto-Bismol) can be effective; however, it should not be used as a continuous treatment because it contains aspirin and could cause salicylate toxicity. Alpha-galactosidase (Beano) is effective for reducing flatulence caused by eating fermentable carbohydrates (e.g., beans, bran, fruit).

Administering Enemas An enema is a solution introduced into the rectum and large intestine. The action of an enema is to distend the intestine and sometimes to irritate the intestinal mucosa, thereby increasing peristalsis and the excretion of feces and flatus. The enema solution should be at 37.7°C (100°F) because a solution that is too cold or too hot is uncomfortable and causes cramping. Enemas are classified into four groups: cleansing, carminative, retention, and return-flow enemas. Cleansing Enema

Cleansing enemas are intended to remove feces. They are given chiefly to: • Prevent the escape of feces during surgery. • Prepare the intestine for certain diagnostic tests such as x-ray or

visualization tests (e.g., colonoscopy).

• Remove feces in instances of constipation or impaction.

Cleansing enemas use a variety of solutions. Table 49–4 lists commonly used solutions. Hypertonic solutions exert osmotic pressure, which draws fluid from the interstitial space into the colon. The increased volume in the colon stimulates peristalsis and hence defecation. A commonly used hypertonic enema is the commercially prepared Fleet phosphate enema. Hypotonic solutions (e.g., tap water) exert a lower osmotic pressure than the surrounding interstitial fluid, causing water to move from the colon into the interstitial space. Before the water moves from the colon, it stimulates peristalsis and defecation. Because the water moves out of the colon, the tap water enema should not be repeated because of the danger of circulatory

TABLE 49–4   Commonly Used Enema Solutions Solution

Constituents

Action

Time to Take Effect

Adverse Effects

Hypertonic

90–120 mL of solution (e.g., sodium phosphate [Fleet])

Draws water into the colon.

5–10 min

Retention of sodium

Hypotonic

500–1,000 mL of tap water

Distends colon, stimulates peristalsis, and softens feces.

15–20 min

Fluid and electrolyte imbalance; water intoxication

Isotonic

500–1,000 mL of normal saline

Distends colon, stimulates peristalsis, and softens feces.

15–20 min

Possible sodium retention

Soapsuds

500–1,000 mL (3–5 mL soap to 1,000 mL water)

Irritates mucosa, distends colon.

10–15 min

Irritates and may damage mucosa

Oil (mineral, olive, cottonseed)

90–120 mL

Lubricates the feces and the colonic mucosa.

0.5–3 h

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overload when the water moves from the interstitial space into the circulatory system. SAFETY ALERT!

SAFETY

Special precautions must be used to alert nurses to possible contraindications when Fleet enemas are prescribed for clients with renal failure. The label on the Fleet enema warns that using more than one enema every 24 hours can be harmful. Clients and family may underestimate the risks for a client with decreased renal function because a Fleet enema can be obtained over the counter in stores (Cohen, 2012).

Isotonic solutions, such as physiological (normal) saline, are considered the safest enema solutions to use. They exert the same osmotic pressure as the interstitial fluid surrounding the colon. Therefore, there is no fluid movement into or out of the colon. The instilled volume of saline in the colon stimulates peristalsis. Soapsuds enemas stimulate peristalsis by increasing the volume in the colon and irritating the mucosa. Only pure soap (i.e., Castile soap) should be used in order to minimize mucosa irritation. Some enemas are large volume (i.e., 500 to 1,000 mL) for an adult and others are small volume (90 to 120 mL), including hypertonic solutions. The amount of solution administered for a high-volume enema will depend on the age and medical condition of the individual. For example, clients with certain cardiac or renal diseases would be adversely affected by significant fluid retention that might result from large-volume hypotonic enemas. Cleansing enemas may also be described as high or low. A high enema is given to cleanse as much of the colon as possible. The client changes from the left lateral position to the dorsal recumbent position and then to the right lateral position during administration so that the solution can follow the large intestine. The low enema is used to clean the rectum and sigmoid colon only. The client maintains a left lateral position during administration. The force of flow of the solution is governed by (a) the height of the solution container, (b) size of the tubing, (c) viscosity of the fluid, and (d) resistance of the rectum. The higher the solution container is held above the rectum, the faster the flow and the greater the force (pressure) in the rectum. During most adult enemas, the solution container should be no higher than 30 cm (12 in.) above the rectum. During a high cleansing enema, the solution container is usually held 30 to 49 cm (12 to 18 in.) above the rectum because the fluid is instilled farther to clean the entire bowel.

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Carminative Enema

A carminative enema is given primarily to expel flatus. The solution instilled into the rectum releases gas, which in turn distends the rectum and the colon, thus stimulating peristalsis. For an adult, 60 to 80 mL of fluid is instilled. Retention Enema

A retention enema introduces oil or medication into the rectum and sigmoid colon. The liquid is retained for a relatively long period (e.g., 1 to 3 hours). An oil retention enema acts to soften the feces and to lubricate the rectum and anal canal, thus facilitating passage of the feces. Antibiotic enemas are used to treat infections locally, anthelmintic enemas to kill helminths such as worms and intestinal parasites, and nutritive enemas to administer fluids and nutrients to the rectum. Return-Flow Enema

A return-flow enema, also called a Harris flush, is occasionally used to expel flatus. Alternating flow of 100 to 200 mL of fluid into and out of the rectum and sigmoid colon stimulates peristalsis. This process is repeated five or six times until the flatus is expelled and abdominal distention is relieved. From a holistic perspective, it is important for the nurse to remember that clients may perceive this type of procedure as a significant violation of personal space. Cultural sensitivity pertaining to personal space, gender of the caregiver, and the potential meaning of the structures and fluids found in this private area of the body needs to be considered. Keep in mind the client’s potential discomfort with the gender of the caregiver and try to accommodate the client’s preferences whenever possible. When it is not possible to honor the client’s wishes, respectfully explain the circumstances. A gentle, ­matter-of-fact approach is often most helpful. Also, insertion of anything foreign into an orifice of a client’s body may trigger memories of past abuse. Monitor the client for emotional responses to the procedure (both subtle and extreme) because this could indicate a history of trauma and require appropriate referral for counseling. Simply asking the client to describe the experience will give the nurse more information for possible referral. Skill 49–1 describes how to administer an enema. CLINICAL ALERT! Some clients may wish to administer their own enemas. If this is appropriate, the nurse validates the client’s knowledge of correct ­ technique and assists as needed.

Administering an Enema PURPOSE • To achieve one or more of the following actions: cleansing, carminative, retention, or return-flow

• •

Whether the client has sphincter control Whether the client can use a toilet or commode or must remain in bed and use a bedpan

SKILL 49–1

ASSESSMENT Assess • When the client last had a bowel movement and the amount, color, and consistency of the feces • Presence of abdominal distention

Continued on page 1254

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SKILL 49–1

Administering an Enema—continued PLANNING Before administering an enema, determine that there is a primary care provider’s order. At some agencies, a primary care provider must order the type of enema and the time to give it, for example, the morning of an examination. At other agencies, enemas are given at the nurse’s discretion (i.e., as necessary on a prn order). In addition, determine the presence of kidney or cardiac disease that contraindicates the use of a hypotonic or hypertonic solution.

DELEGATION Administration of some enemas may be delegated to unlicensed assistive personnel (UAP). However, the nurse must ensure the personnel are competent in the use of standard precautions. Abnormal findings such as inability to insert the rectal tip, client inability to retain the solution, or unusual return from the enema must be validated and interpreted by the nurse.

Equipment • Disposable linen-saver pad • Bath blanket • Bedpan or commode • Clean gloves • Water-soluble lubricant if tubing not prelubricated • Paper towel Large-Volume Enema • Solution container with tubing of correct size and tubing clamp • Correct solution, amount, and temperature Small-Volume Enema • Prepackaged container of enema solution with lubricated tip

IMPLEMENTATION Preparation • Lubricate about 5 cm (2 in.) of the rectal tube (some commercially prepared enema sets already have lubricated nozzles). Rationale: Lubrication facilitates insertion through the sphincter and minimizes trauma. • Run some solution through the connecting tubing of a large-­ volume enema set and the rectal tube to expel any air in the tubing, then close the clamp. Rationale: Air instilled into the ­rectum, although not harmful, causes unnecessary distention. Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments. Indicate that the client may experience a feeling of fullness while the solution is being administered. ­Explain the need to hold the solution as long as possible. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Apply clean gloves. 4. Provide for client privacy. 5. Assist the adult client to a left lateral position, with the right leg as acutely flexed as possible ❶, with the linen-saver pad under the buttocks. Rationale: This position facilitates the flow of solution by gravity into the sigmoid and descending colon, which are on the left side. Having the right leg acutely flexed provides for adequate exposure of the anus. 6. Insert the enema tube. • For clients in the left lateral position, lift the upper buttock. ❷ Rationale: This ensures good visualization of the anus.

❷ Inserting the enema tube.

❸ Inserting the enema tube following the direction of the rectum. Insert the tube smoothly and slowly into the rectum, directing it toward the umbilicus. ❸ Rationale: The angle follows the normal contour of the rectum. Slow insertion prevents spasm of the sphincter. • Insert the tube 7 to 10 cm (3 to 4 in.). Rationale: Because the anal canal is about 2.5 to 5 cm (1 to 2 in.) long in the adult, insertion to this point places the tip of the tube beyond the anal sphincter into the rectum. •

❶ Assuming a left lateral position for an enema. Note the commercially prepared enema.

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Administering an Enema—continued If resistance is encountered at the internal sphincter, ask the client to take a deep breath, then run a small amount of solution through the tube. Rationale: This relaxes the ­internal anal sphincter. • Never force tube or solution entry. If instilling a small amount of solution does not permit the tube to be advanced or the solution to freely flow, withdraw the tube. Check for any stool that may have blocked the tube during insertion. If present, flush it and retry the procedure. You may also perform a digital rectal examination to determine if there is an impaction or other mechanical blockage. If resistance persists, end the procedure and report the resistance to the primary care provider and nurse in charge. 7. Slowly administer the enema solution. • Raise the solution container, and open the clamp to allow fluid flow. or • Compress a pliable container by hand. • During most low enemas, hold or hang the solution ­container no higher than 30 cm (12 in.) above the ­rectum. Rationale: The higher the solution container is held above the rectum, the faster the flow and the greater the force (pressure) in the rectum. During a high enema, hang the solution container about ,30 to 49 cm (12 to18 in.). Rationale: Fluid must be instilled farther for a high enema to clean the entire bowel. See agency protocol. • Administer the fluid slowly. If the client complains of ­fullness or pain, lower the container or use the clamp to stop the flow for 30 seconds, and then restart the flow at a slower rate. Rationale: Administering the enema slowly and stopping the flow momentarily decreases the likelihood of ­intestinal spasm and premature ejection of the solution. • If you are using a plastic commercial container, roll it up as the fluid is instilled. This prevents subsequent suctioning of the solution. ❹ • After all the solution has been instilled or when the client cannot hold any more and feels the desire to defecate (the urge to defecate usually indicates that sufficient fluid has been administered), close the clamp, and remove the enema tube from the anus. • Place the enema tube in a disposable towel as you ­withdraw it. 8. Encourage the client to retain the enema. • Ask the client to remain lying down. Rationale: It is easier for the client to retain the enema when lying down than when sitting or standing, because gravity promotes drainage and peristalsis. • Request that the client retain the solution for the appropriate amount of time, for example, 5 to 10 minutes for a cleansing enema or at least 30 minutes for a retention enema. 9. Assist the client to defecate. • Assist the client to a sitting position on the bedpan, ­commode, or toilet. A sitting position facilitates the act of defecation. • Ask the client who is using the toilet not to flush it. The nurse needs to observe the feces. •

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SKILL 49–1

EVALUATION • Perform a detailed follow-up based on findings that deviated from expected or normal for the client. Relate findings to

❹ Rolling up a commercial enema container.

If a specimen of feces is required, ask the client to use a bedpan or commode. • Remove and discard gloves. • Perform hand hygiene. 10. Document the type and volume, if appropriate, of enema given. Describe the results. •

SAMPLE DOCUMENTATION 8/2/2015 1000. States last BM five days ago. Abdomen distended and firm. Bowel sounds hypoactive. Fleet enema, given per order, resulted in large amount of firm brown stool. States he “feels ­better.” –––––––––––––––––––––––––––––––––––––– M. Lopez, RN Variation: Administering an Enema to an Incontinent Client Occasionally a nurse needs to administer an enema to a client who is unable to control the external sphincter muscle and thus cannot retain the enema solution for even a few minutes. In that case, after the enema tube is inserted, the client assumes a supine position on a bedpan. The head of the bed can be elevated slightly, to 30 degrees if necessary for easier breathing, and pillows used to support the client’s head and back. Variation: Administering a Return-Flow Enema For a return-flow enema, the solution (100 to 200 mL for an adult) is instilled into the client’s rectum and sigmoid colon. Then the solution container is lowered so that the fluid flows back out through the rectal tube into the container, pulling the flatus with it. The inflow–outflow process is repeated five or six times (to stimulate peristalsis and the expulsion of flatus), and the solution is replaced several times during the procedure if it becomes thick with feces. Document the type of solution; length of time the solution was retained; the amount, color, and consistency of the returns; and the relief of flatus and abdominal distention in the client record using forms or checklists supplemented by narrative notes when appropriate.

­ revious assessment data if available. Report significant deviap tions from expected to the primary care provider.

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LIFESPAN CONSIDERATIONS

Administering an Enema

INFANTS/CHILDREN • Provide a careful explanation to the parents and child before the procedure. An enema is an intrusive procedure and therefore threatening to the child. • The enema solution should be isotonic (usually normal saline). Some hypertonic commercial solutions (e.g., Fleet phosphate enema) can lead to hypovolemia and electrolyte imbalances. In addition, the osmotic effect of the enema may produce diarrhea and subsequent metabolic acidosis. • Infants and small children do not exhibit sphincter control and need to be assisted in retaining the enema. The nurse administers the enema while the infant or child is lying with the buttocks over the bedpan, and the nurse firmly presses the buttocks together to prevent the immediate expulsion of the solution. Older children can usually hold the solution if they understand what to do and are not required to hold it for too long a period. It may be necessary to ensure that the bathroom is available for an ambulatory child before starting the procedure or to have a bedpan ready. • Enema temperature should be 37.7°C (100°F) unless otherwise ordered. • Large-volume enemas consist of 50 to 200 mL in children less than 18 months old; 200 to 300 mL in children 18 months to 5 years; and 300 to 500 mL in children 5 to 12 years old.

For infants and small children, the dorsal recumbent position is frequently used. Position them on a small padded bedpan with support for the back and head. Secure the legs by placing a diaper under the bedpan and then over and around the thighs. Place the underpad under the client’s buttocks to protect the bed linen, and drape the client with the bath blanket. • Insert the tube 5 to 7.5 cm (2 to 3 in.) in the child and only 2.5 to 3.75 cm (1 to 1.5 in.) in the infant. • For children, lower the height of the solution container ­appropriately for the age of the child. See agency protocol. • To assist a small child in retaining the solution, apply firm ­pressure over the anus with tissue wipes, or firmly press the buttocks together. •

OLDER ADULTS • Older adults may fatigue easily. • Older adults may be more susceptible to fluid and electrolyte imbalances. Use tap water enemas with great caution. • Monitor the client’s tolerance during the procedure, watching for vagal episodes (e.g., slow pulse) and dysrhythmias. • Protect older adults’ skin from prolonged exposure to moisture. • Assist older clients with perineal care as indicated.

Home Care Considerations  Administering an Enema Teach the caregiver or client the following: • To make a saline solution, mix 1 teaspoon of table salt with 500 mL of tap water.

Digital Removal of a Fecal Impaction Digital removal involves breaking up the fecal mass digitally and removing it in portions. Because the bowel mucosa can be injured during this procedure, some agencies restrict and specify the personnel permitted to conduct digital disimpactions. Rectal stimulation is also contraindicated for some people because it may cause an excessive vagal response resulting in cardiac arrhythmia. Before disimpaction it is suggested an oil retention enema be given and held for 30 minutes. After a disimpaction, the nurse can use various interventions to remove remaining feces, such as a cleansing enema or the insertion of a suppository. CLINICAL ALERT! Clients with a history of cardiac disease and/or dysrhythmias may be at risk with digital stimulation to remove an impaction. If in doubt, the nurse should check with the primary care provider before performing the procedure.

Because manual removal of an impaction can be painful, the nurse may use, if the agency permits, 1 to 2 mL of lidocaine (­Xylocaine) gel on a gloved finger inserted into the anal canal as far as the nurse can reach. The lidocaine will anesthetize the anal canal and rectum and should be inserted 5 minutes before the disimpaction. Disimpacting the client requires great sensitivity and a caring, yet matter-of-fact, approach. Be aware of personal facial expressions or anything that may convey distaste or disgust to the client. When dealing with fecal matter, many clients feel a sense of shame that relates to childhood

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PATIENT-CENTERED CARE Use enemas only as directed. Do not rely on them for regular bowel evacuation. • Prior to administration, make sure a bedpan, commode, or ­toilet is nearby. •

experiences that may have been traumatic in some way. ­Control issues may also be triggered, and can manifest in many ways. Confusion and negative feelings are easily triggered in both client and nurse. Awareness and an ability to discuss these issues with a client, when appropriate, are important to providing sensitive care. Self-­awareness will help the nurse be more therapeutically present to the client. For digital removal of a fecal impaction: 1. If indicated, obtain assistance from a second person who can comfort the client during the procedure. 2. Ask the client to assume a right or left side-lying position, with the knees flexed and the back toward the nurse. When the person lies on the right side, the sigmoid colon is uppermost; thus, gravity can aid removal of the feces. Positioning on the left side allows easier access to the sigmoid colon. 3. Place a disposable absorbent pad under the client’s buttocks and a bedpan nearby to receive stool. 4. Drape the client for comfort and to avoid unnecessary exposure of the body. 5. Apply clean gloves and liberally lubricate the gloved index finger. 6. Gently insert the index finger into the rectum and move the finger along the length of the rectum. 7. Loosen and dislodge stool by gently massaging around it. Break up stool by working the finger into the hardened mass, taking care to avoid injury to the mucosa of the rectum. 8. Carefully work stool downward to the end of the rectum and remove it in small pieces. Continue to remove as much fecal

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material as possible. Periodically assess the client for signs of fatigue, such as facial pallor, diaphoresis, or change in pulse rate. Manual stimulation should be minimal. 9. Following disimpaction, assist the client to clean the anal area and buttocks. Then assist the client onto a bedpan or commode for a short time because digital stimulation of the rectum often induces the urge to defecate.

Bowel Training Programs For clients who have chronic constipation, frequent impactions, or fecal incontinence, bowel training programs may be helpful. The program is based on factors within the client’s control and is designed to help the client establish normal defecation. Such matters as food and fluid intake, exercise, and defecation habits are all considered. Before beginning such a program, clients must understand it and want to be involved. The major phases of the program are as follows: • Determine the client’s usual bowel habits and factors that help and •

•

• •

hinder normal defecation. Design a plan with the client that includes the following: a. Fluid intake of about 2,500 to 3,000 mL/day b. Increase in fiber in the diet c. Intake of hot drinks, especially just before the usual defecation time d. Increase in exercise. Maintain the following daily routine for 2 to 3 weeks: a. Administer a cathartic suppository (e.g., Dulcolax) 30 minutes before the client’s defecation time to stimulate peristalsis. b. When the client experiences the urge to defecate, assist the client to the toilet or commode or onto a bedpan. Note the length of time between the insertion of the suppository and the urge to defecate. c. Provide the client with privacy for defecation and a time limit; 30 to 40 minutes is usually sufficient. d. Teach the client to lean forward at the hips, to apply pressure on the abdomen with the hands, and to bear down for defecation. These measures increase pressure on the colon. Straining should be avoided because it can cause hemorrhoids. Provide positive feedback when the client successfully defecates. Refrain from negative feedback if the client fails to defecate. Offer encouragement to the client and convey that patience is ­often required. Many clients require weeks or months of training to achieve success.

Fecal Incontinence Pouch To collect and contain large volumes of liquid feces, the nurse may place a fecal incontinence collector pouch around the anal area (­Figure 49–13 •). The purpose of the pouch is to prevent progressive perianal skin irritation and breakdown and frequent linen changes necessitated by incontinence. In many agencies, the pouch is replacing the traditional approach to this problem; that is, inserting a large Foley catheter into the client’s rectum and inflating the balloon to keep it in place—a practice that may damage the rectal sphincter and rectal mucosa. A rectal catheter also increases peristalsis and incontinence by stimulating sensory nerve fibers in the rectum. A fecal collector is secured around the anal opening and may or may not be attached to drainage. Pouches are best applied before the perianal skin becomes excoriated. If perianal skin excoriation is

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Figure 49–13 • A drainable fecal collector pouch.

present, the nurse either (a) applies a dimethicone-based moisturebarrier cream or alcohol-free barrier film to the skin to protect it from feces until it heals and then applies the pouch, or (b) applies a skin barrier or hydrocolloid barrier underneath the pouch to achieve the best possible seal. Nursing responsibilities for clients with a rectal pouch include (a) regular assessment and documentation of the perianal skin ­status, (b) changing the bag every 72 hours or sooner if there is leakage, (c) maintaining the drainage system, and (d) providing explanations and support to the client and support people. Some clients (e.g., post-stroke, post-trauma, quadriplegia, or paraplegia) may be treated for fecal incontinence with surgical repair of a damaged sphincter or an artificial bowel sphincter. The artificial sphincter consists of three parts: a cuff around the anal canal, a pressure-regulating balloon, and a pump that inflates the cuff (­Figure 49–14 •). The cuff is inflated to close the sphincter,

Pump

Balloon reservoir

Cuff

Figure 49–14 • Inflatable artificial sphincter.

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maintaining continence. To have a bowel movement, the client deflates the cuff. The cuff automatically reinflates in 10 minutes. Management of this device is usually specific to the device; contact the manufacturing company for details. Administering enemas and rectal medications may be harmful with this device in place. Ensure safety of these practices with the device instruction guide provided by the device manufacturer.

Ostomy Management Clients with fecal diversions need considerable psychological support, instruction, and physical care. This section is limited to the nurse’s physical interventions of stoma assessment, application of an appliance to collect feces and protect skin, and promotion of self-care. Many agencies have access to a wound ostomy continence nurse (WOCN) to assist these clients. If possible, clients should meet with the WOCN prior to the surgery to assist in the placement of the colostomy. National organizations (e.g., United Ostomy Associations of America) have support groups whose mission is to improve the quality of life of people who have, or will have, an ostomy. Members of local chapters of such an organization have been known to meet and visit with a client who has a new ostomy. It is common for a client with a new ostomy to feel frightened and alone. Talking with another person who has gone through a similar experience may help the client realize that he or she is not alone and others are willing to listen and help.

or drainable (Figure 49–17 •). A drainable pouch usually has a clip where the end of the pouch is folded over the clamp and clipped (­Figure 49–18 •). Newer drainable pouches have an integrated closure system instead of a clamp. The client folds up the end of the pouch three times and presses firmly to seal the pouch. Drainable pouches are usually used by people who need to empty the pouch more than twice a day. Closed pouches are often used by people who have a regular stoma discharge (e.g., sigmoid colostomy) and only have to empty the pouch 1 or 2 times a day. Some people find it easier to change a closed pouch than emptying a drainable pouch, which requires some dexterity. Odor control is essential to clients’ self-esteem. As soon as clients are ambulatory, they can learn to work with the ostomy in the bathroom to avoid odors at the bedside. Selecting the appropriate kind of appliance promotes odor control. An intact appliance contains odors. Most pouches contain odor-barrier material. Some pouches also have a pouch filter that allows gas out of the pouch but not the odor. Ostomy appliances can provide a leakproof seal for about 3 to 7 days (Avent, 2012). The pouch should be changed on a routine basis,

Stoma and Skin Care

Care of the stoma and skin is important for all clients who have ostomies. The fecal material from a colostomy or ileostomy is irritating to the peristomal skin. This is particularly true of stool from an ileostomy, which contains digestive enzymes. It is important to assess the peristomal skin for irritation each time the appliance is changed. Any irritation or skin breakdown needs to be treated immediately. The skin is kept clean by washing off any excretion and drying thoroughly. An ostomy appliance should protect the skin, collect stool, and control odor. The appliance consists of a skin barrier and a pouch. Some clients may prefer to also wear an adjustable ostomy belt, which attaches to an ostomy pouch to hold the pouch firmly in place (Figure 49–15 •). Appliances can be one piece where the skin barrier is already attached to the pouch (Figure 49–16 A •), or an appliance can consist of two pieces: a separate pouch with a flange and a separate skin barrier with a flange where the pouch fastens to the barrier at the flange (Figure 49–16 B). The pouch can be removed without removing the skin barrier when using a two-piece appliance. Pouches can be closed

A

B

Figure 49–16 • A, A one-piece ostomy appliance or pouching ­system; B, a two-piece ostomy appliance or pouching system.

A

Figure 49–15 • Adjustable ostomy belt.

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B

Figure 49–17 • A, A closed pouch; B, a drainable pouch.

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Figure 49–18 • Applying a pouch clamp.

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before leakage occurs. The most common routine for changing the appliance is twice weekly (Hollister, Inc., 2011). Some manufacturers recommend removing the pouch and skin barrier twice a week to clean and inspect the peristomal skin unless stool leaks onto the peristomal skin, necessitating a change. If the skin is erythematous, eroded, denuded, or ulcerated, the pouch should be changed every 24 to 48 hours to allow appropriate treatment of the skin. More frequent changes are recommended if the client complains of pain or discomfort. The type of ostomy and amount of output influence how often the pouch is emptied. The pouch is emptied when it is one third to one half full. If the pouch overfills, it can cause separation of the skin barrier from the skin and allow stool to come in contact with the skin. This results in the entire appliance needing to be removed and a new one applied. Skill 49–2 explains how to change a bowel diversion ostomy appliance.

Changing a Bowel Diversion Ostomy Appliance

ASSESSMENT Determine the following: • The type of ostomy and its placement on the abdomen. Surgeons often draw diagrams when there are two stomas. If there is more than one stoma, it is important to confirm which is the functioning stoma. • The type and size of appliance currently used and the special barrier substance applied to the skin, according to the nursing care plan. Assess • Stoma color: The stoma should appear red, similar in color to the mucosal lining of the inner cheek and slightly moist. Very pale or darker-colored stomas with a dusky bluish or purplish hue indicate impaired blood circulation to the area. Notify the surgeon immediately. • Stoma size and shape: Most stomas protrude slightly from the abdomen. New stomas normally appear swollen, but swelling generally decreases over 2 or 3 weeks or for as long as PLANNING Review features of the appliance to ensure that all parts are present and functioning correctly.

DELEGATION Care of a new ostomy is not delegated to UAP. However, aspects of ostomy function are observed during usual care and may be recorded by a WOCN in addition to the unit nurse. Abnormal findings must be validated and interpreted by the nurse. In some agencies, UAP may remove and replace well-established ostomy appliances.

• •

• •

• •

6 weeks. Failure of swelling to recede may indicate a problem, for example, blockage. Stomal bleeding: Slight bleeding initially when the stoma is touched is normal, but other bleeding should be reported. Status of peristomal skin: Any redness and irritation of the ­peristomal skin—the 5 to 13 cm (2 to 5 in.) of skin surrounding the stoma—should be noted. Transient redness after removal of adhesive is normal. Amount and type of feces: Assess the amount, color, odor, and consistency. Inspect for abnormalities, such as pus or blood. Complaints: Complaints of burning sensation under the skin ­barrier may indicate skin breakdown. The presence of abdominal discomfort and/or distention also needs to be determined. Learning needs of the client and family members regarding the ostomy and self-care. The client’s emotional status, especially strategies used to cope with the body image changes and the ostomy.

SKILL 49–2

PURPOSES • To assess and care for the peristomal skin • To collect stool for assessment of the amount and type of output • To minimize odors for the client’s comfort and self-esteem

Equipment • Clean gloves • Bedpan • Moisture-proof bag (for disposable pouches) • Cleaning materials, including warm water, mild soap (optional), washcloth, towel • Tissue or gauze pad • Skin barrier (optional) • Stoma measuring guide • Pen or pencil and scissors • New ostomy pouch with optional belt • Tail closure clamp • Deodorant for pouch (optional) Continued on page 1260

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Changing a Bowel Diversion Ostomy Appliance—continued IMPLEMENTATION Preparation 1. Determine the need for an appliance change. • Assess the used appliance for leakage of stool. Rationale: Stool can irritate the peristomal skin. • Ask the client about any discomfort at or around the stoma. Rationale: A burning sensation may indicate breakdown beneath the faceplate of the pouch. • Assess the fullness of the pouch. Rationale: The weight of an overly full bag may loosen the skin barrier and separate it from the skin, causing the stool to leak and irritate the ­peristomal skin. 2. If there is pouch leakage or discomfort at or around the stoma, change the appliance. 3. Select an appropriate time to change the appliance. • Avoid times close to meal or visiting hours. Rationale: Ostomy odor and stool may reduce appetite or embarrass the client. • Avoid times immediately after meals or the administration of any medications that may stimulate bowel evacuation. Rationale: It is best to change the pouch when drainage is least likely to occur. • The best time to change a pouching system is first thing in the morning or 2 to 4 hours after meals, when the bowel is least active (Scemons, 2013, p. 37). Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments. Changing an ostomy appliance should not cause discomfort, but it may be distasteful to the client. Communicate acceptance and support to the client. It is important to change the appliance competently and quickly. Include support people as appropriate. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Apply clean gloves. 4. Provide for client privacy preferably in the bathroom, where clients can learn to deal with the ostomy as they would at home. 5. Assist the client to a comfortable sitting or lying position in bed or preferably a sitting or standing position in the bathroom. Rationale: Lying or standing positions may facilitate smoother pouch application, that is, avoid wrinkles. 6. Unfasten the belt if the client is wearing one. 7. Empty the pouch and remove the ostomy skin barrier. • Empty the contents of a drainable pouch through the ­bottom opening into a bedpan or toilet. Rationale: Emptying before removing the pouch prevents spillage of stool onto the client’s skin. • If the pouch uses a clamp, do not throw it away because it can be reused. • Assess the consistency, color, and amount of stool. • Peel the skin barrier off slowly, beginning at the top and working downward, while holding the client’s skin taut. Rationale: Holding the skin taut minimizes client discomfort and prevents abrasion of the skin. • Discard the disposable pouch in a moisture-proof bag. 8. Clean and dry the peristomal skin and stoma. • Use toilet tissue to remove excess stool. • Use warm water, mild soap (optional), and a washcloth to clean the skin and stoma. ❶ Check agency practice on the use of soap. Rationale: Soap is sometimes not advised because it can be irritating to the skin. If soap is allowed, do not use deodorant or moisturizing soaps. Rationale: They may interfere with the adhesives in the skin barrier.

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❶ Cleaning the skin. Courtesy of Cory Patrick Hartley, RN.

❷ A guide for measuring the stoma. Courtesy of Cory Patrick Hartley, RN.

Dry the area thoroughly by patting with a towel. Rationale: Excess rubbing can abrade the skin. 9. Assess the stoma and peristomal skin. • Inspect the stoma for color, size, shape, and bleeding. • Inspect the peristomal skin for any redness, ulceration, or irritation. Transient redness after the removal of adhesive is normal. 10. Place a piece of tissue or gauze over the stoma, and change it as needed. Rationale: This absorbs any seepage from the stoma while the ostomy appliance is being changed. 11. Prepare and apply the skin barrier (peristomal seal). • Use the guide ❷ to measure the size of the stoma. • On the backing of the skin barrier, trace a circle the same size as the stomal opening. • Cut out the traced stoma pattern to make an opening in the skin barrier. ❸ Make the opening no more than 1/8 inch larger than the stoma (Piras & Hurley, 2011). Rationale: This allows space for the stoma to expand slightly when ­functioning and minimizes the risk of stool contacting ­peristomal skin. • Remove the backing to expose the sticky adhesive side. The backing can be saved and used as a pattern when making an opening for future skin barriers. •

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Changing a Bowel Diversion Ostomy Appliance—continued

SKILL 49–2

❸ The nurse is making a stoma opening on a disposable one-piece pouch.

❺ Pressing the skin barrier of a disposable one-piece pouch for 30 seconds to activate the adhesives in the skin barrier.

Record pertinent assessments and interventions. Report any increase in stoma size, change in color indicative of circulatory impairment, and presence of skin irritation or erosion. Record on the client’s chart discoloration of the stoma, the appearance of the peristomal skin, the amount and type of drainage, the client’s reaction to the procedure, the client’s experience with the ostomy, and skills learned by the client.

SAMPLE DOCUMENTATION

❹ Centering the skin barrier over the stoma.

8/3/2015 0900 Colostomy bag changed. Moderate to large amount of semi-formed brown stool. Stoma reddish color. No redness or irritation around stoma. Client looked at stoma today and started asking questions as to how she will be able to change the pouch when she is home. Asked if she would like to do the next changing of the pouch. Stated “yes.” –––––––––––––––––––––––––––––––––––– G. Hsu, RN

Courtesy of Cory Patrick Hartley, RN.

For a One-Piece Pouching System • Center the one-piece skin barrier and pouch over the stoma, and gently press it onto the client’s skin for 30 seconds. ❹, ❺ Rationale: The heat and pressure help activate the ­adhesives in the skin barrier. For a Two-Piece Pouching System • Center the skin barrier over the stoma and gently press it onto the client’s skin for 30 seconds. • Remove the tissue over the stoma before applying the pouch. • Snap the pouch onto the flange or skin barrier wafer. • For drainable pouches, close the pouch according to the manufacturer’s directions. • Remove and discard gloves. Perform hand hygiene. 12. Document the procedure in the client record using forms or checklists supplemented by narrative notes when appropriate. EVALUATION • Relate findings to previous data if available. Adjust the teaching plan and nursing care plan as needed. Reinforce the ­teaching each time the care is performed. Encourage and support selfcare as soon as possible because clients should be able to perform self-care by discharge. Rationale: Client learning is facilitated by consistent nursing interventions.

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Variation: Emptying a Drainable Pouch • Empty the pouch when it is one third to one half full of stool or gas. Rationale: Emptying before it is overfull helps avoid breaking the seal with the skin and stool then coming in contact with the skin. • While wearing gloves, hold the pouch outlet over a bedpan or toilet. Lift the lower edge up. • Unclamp or unseal the pouch. • Drain the pouch. Loosen feces from sides by moving fingers down the pouch. • Clean the inside of the tail of the pouch with a tissue or a ­premoistened towelette. • Apply the clamp or seal the pouch. • Dispose of used supplies. • Remove and discard gloves. • Perform hand hygiene. • Document the amount, consistency, and color of stool.

•

Perform detailed follow-up based on findings that deviated from expected or normal for the client. Report significant deviations from normal to the primary care provider.

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Home Care Considerations  Changing an Ostomy Appliance Provide the client with the names and phone numbers of a WOCN, supply vendor, and other resource people to contact when needed. Provide pertinent Internet resources for information and support. • Inform the client of signs to report to a health care provider (e.g., peristomal redness, skin breakdown, and changes in s­ tomal color). • Provide client and family education regarding care of the ­ostomy and appliance when traveling. •

Colostomy Irrigation

A colostomy irrigation, similar to an enema, is a form of stoma management used only for clients who have a sigmoid or descending colostomy. The purpose of irrigation is to distend the bowel sufficiently to stimulate peristalsis, which stimulates evacuation. When a regular evacuation pattern is achieved, the wearing of a colostomy pouch is unnecessary. Currently, colostomy irrigations are not routinely taught to most clients. Routine daily irrigations for control of the time of elimination ultimately become the client’s decision. Some clients prefer to control the time of elimination through rigid dietary regulation and not be bothered with irrigations, which can take up to an hour to complete. When regulation by irrigation is chosen, it should be done at the same time each day. Control by irrigations also necessitates some control of the diet. For example, laxative foods that might cause an unexpected evacuation need to be avoided. For most clients, a relatively small amount of fluid (300 to 500 mL) stimulates evacuation. For others, up to 1,000 mL may be needed because a colostomy has no sphincter and the fluid tends to return as it is instilled. This problem is reduced by the use of a cone on the irrigating catheter. The cone helps to hold the fluid within the

PATIENT-CENTERED CARE

Educate the client and family regarding infection control precautions, including proper disposal of used pouches since these cannot be flushed down a toilet. • Younger clients may have special concerns about odor and appearance. Provide information about ostomy care and ­community support groups. A visit from someone who has had an ostomy under similar circumstances may be helpful. •

bowel during the irrigation. Clients who choose to practice colostomy irrigation need to be motivated to master the procedure. In addition, good manual dexterity and eyesight, along with uninterrupted time (approximately 60 minutes) is needed (Williams, 2011). These requirements may deter clients from using this alternative method of regaining bowel control.

Evaluating The goals established during the planning phase are evaluated according to specific desired outcomes, also established in that phase. If outcomes are not achieved, the nurse should explore the reasons. The nurse might consider some or all of the following questions: • Were the client’s fluid intake and diet appropriate? • Was the client’s activity level appropriate? • Are prescribed medications or other factors affecting the gastro-

intestinal function?

• Do the client and family understand the provided instructions

well enough to comply with the required therapy?

• Were sufficient physical and emotional support provided?

NURSING CARE PLAN   Altered Bowel Elimination Assessment Data

Nursing Diagnosis

Desired Outcomes

NURSING ASSESSMENT Mrs. Emma Brown is a 78-year-old widow of 9 months. She lives alone in a low-income housing complex for older adults. Her two children live with their families in a city approximately 150 miles away. She has always enjoyed cooking for her family; however, now that she is alone, she does not cook for herself. As a result, she has developed irregular eating patterns and tends to prepare soup-and-toast meals. She gets little exercise and has had bouts of insomnia since her husband’s death. For the past month, Mrs. Brown has been having a problem with constipation. She states she has a bowel movement about every 3 to 4 days and her stools are hard and painful to excrete. Mrs. Brown decides to attend the health fair sponsored by the housing complex and seeks assistance from the county public health nurse.

Constipation related to ­low-fiber diet and inactivity (as evidenced by infrequent, hard stools; painful defecation; abdominal distention)

Bowel Elimination [0501], not ­compromised as evidenced by: • Ease of stool passage • Stool soft and formed • Passage of stool without aids

Physical Examination

Diagnostic Data

CBC: Hgb 10.8 Height: 162 cm (5940) Urinalysis negative Weight: 65 kg (143 lb) Temperature: 36.2°C (97.2°F) Pulse: 82 beats/min Respirations: 20/min Blood pressure: 128/74 mmHg Active bowel sounds, abdomen slightly distended

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Chapter 49  •  Fecal Elimination

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NURSING CARE PLAN  Altered Bowel Elimination—continued Nursing Interventions*/Selected Activities

Rationale

CONSTIPATION/IMPACTION MANAGEMENT [0450] Identify factors (e.g., medications, bed rest, diet) that may cause or contribute to constipation.

Assessing causative factors is an essential first step in teaching and planning for improved bowel elimination.

Encourage increased fluid intake, unless contraindicated.

Sufficient fluid intake is necessary for the bowel to absorb sufficient amounts of liquid to promote proper stool consistency.

Evaluate medication profile for gastrointestinal side effects.

Constipation is a common side effect of many drugs including narcotics and antacids.

Teach Mrs. Brown how to keep a food diary.

An appraisal of food intake will help identify if Mrs. Brown is eating a well-balanced diet and consuming adequate amounts of fluid and fiber. Excessive meat or refined food intake will produce small, hard stools.

Instruct Mrs. Brown on a high-fiber diet, as appropriate.

Fiber absorbs water, which adds bulk and softness to the stool and speeds up passage through the intestines.

Instruct her on the relationship of diet, exercise, and fluid intake to constipation and impaction.

Fiber without adequate fluid can aggravate, not facilitate, bowel function.

Exercise Promotion [0200] Encourage verbalization of feelings about exercise or need for exercise.

Perceptions of the need for exercise may be influenced by misconceptions, cultural and social beliefs, fears, or age.

Determine Mrs. Brown’s motivation to begin/continue an exercise program.

Individuals who have been successful in an exercise program can assist Mrs. Brown by providing incentive and enhancing motivation. For example, a walking partner may be beneficial.

Inform Mrs. Brown about the health benefits and ­physiological effects of exercise.

Activity influences bowel elimination by improving muscle tone and stimulating peristalsis.

Instruct her about appropriate types of exercise for her level of health, in collaboration with a primary care provider.

Any individual beginning an exercise program should consult a primary care provider primarily for a cardiac evaluation. Mrs. Brown’s age and lack of activity should be considered in planning the level of activity.

Assist Mrs. Brown to set short-term and long-term goals for the exercise program.

Realistic goal setting provides direction and motivation.

Evaluation Outcome not met. Mrs. Brown has kept a food diary and is able to identify the need for more fluid and fiber, but has not consistently included fiber in her diet. She has started a walking program with a neighbor but is only able to walk for 10 minutes at a time twice a week. She states her last bowel movement was 3 days ago. *The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention. Outcomes, interventions, and activities selected are only a sample of those suggested by NOC and NIC and should be further individualized for each client.

APPLYING CRITICAL THINKING 1. You learn that Mrs. Brown’s stools have been liquid, in very small amounts, and at infrequent intervals, generally occurring when she feels the urge to defecate. What additional data are important to obtain from her? 2. What nursing intervention is most appropriate before making suggestions to correct or prevent the problem she is experiencing? 3. What suggestions can you give her about maintaining a regular bowel pattern? 4. Explain why cathartics and laxatives are generally contraindicated for people in Mrs. Brown’s situation. See Critical Thinking Possibilities on student resource website.

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CONCEPT MAP Altered Bowel Elimination

EB 78 y.o. female

• Recent widow, lives alone. C/O hard, painful stools q3–4 days x 1 month. Irregular eating pattern.

assess

• • • • •

Height: 162 cm (5'4") Weight: 65 kg (143 lb) Temperature: 36.2°C (97.2°F) Pulse: 82 Respirations: 20/min

• • • • •

BP: 128/74 Active bowel sounds Abdomen slightly distended CBC: Hgb 10.8 UA - negative

generate nursing diagnosis Constipation r/t low-fiber diet and inactivity (aeb infrequent, hard stools; painful defecation; abdominal distention)

outcome

Bowel Elimination aeb • Comfort of stool passage • Stool soft and formed • Passage of stool without aids

evaluation

nursing intervention

Outcome not met • Mrs. B. has kept a food diary and is able to identify the need for more fluid and fiber but has not consistently included fiber in her diet • She has started a walking program with a neighbor but is only able to walk for 10 minutes at a time twice a week • She states her last bowel movement was 3 days ago

nursing intervention

Constipation/Impaction Management

Exercise Promotion

activity activity

activity activity

activity

Encourage increased fluid intake, unless contraindicated

activity

activity Evaluate medication profile for gastrointestinal side effects

activity

Identity factors (e.g., medications, bed rest, diet) that may cause or contribute to constipation

Instruct her on the relationship of diet, exercise, and fluid intake to constipation and impaction

Instruct on a high-fiber diet, as appropriate activity

Teach how to keep a food diary

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Determine her motivation to begin/continue exercise program

activity Instruct about appropriate types of exercise for her level of health, in collaboration with a primary care provider

activity

Encourage verbalization of feelings about exercise or need for exercise

Assist her to set short-term and long-term goals for the exercise program

Inform her about the health benefits and physiologic effects of exercise

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Chapter 49 Review CHAPTER HIGHLIGHTS • Primary functions of the large intestine are the absorption of water

• A function of the nurse is to assist clients with diet and bowel prep-

and nutrients, the mucoid protection of the intestinal wall, and fecal elimination. Patterns of fecal elimination vary greatly among people, but a regular pattern of fecal elimination with formed, soft stools is essential to health and a sense of well-being. Various factors affect defecation: developmental level, diet, fluid intake, activity and exercise, psychological factors, defecation habits, medications, diagnostic and medical procedures, pathologic conditions, and pain. Common fecal elimination problems include constipation, diarrhea, bowel incontinence, and flatulence. Each has specific defining characteristics and contributing causes that often relate to or are identical to the factors that affect defecation. Lack of exercise, irregular defecation habits, and overuse of laxatives are all thought to contribute to constipation. Sufficient fluid and fiber intake are required to keep feces soft. An adverse effect of constipation is straining during defecation, during which the Valsalva maneuver may be used. Cardiac problems may ensue. An adverse effect of prolonged diarrhea is fluid and electrolyte imbalance. Assessment relative to fecal elimination includes a nursing history; physical examination of the abdomen, rectum, and anus; and in some situations, visualization studies and inspection and analysis of stool for abnormal constituents such as blood. A nursing history includes data about the client’s defecating pattern, description of feces and any changes, problems associated with elimination, and data about possible factors altering bowel elimination. When inspecting the client’s stool, the nurse must observe its color, consistency, shape, amount, odor, and the presence of abnormal constituents.

aration before endoscopic and radiographic studies of the large intestine. NANDA-approved nursing diagnoses that relate specifically to altered bowel elimination include Bowel Incontinence, Risk for Constipation, Constipation, Perceived Constipation, Diarrhea, and Dysfunctional Gastrointestinal Motility. However, because altered elimination patterns affect several areas of human functioning, diagnoses such as Risk for Deficient Fluid Volume, Risk for Electrolyte Imbalance, Risk for Impaired Skin Integrity, Situational Low Self-Esteem, Disturbed Body Image, Deficient Knowledge, and Anxiety may also apply. Normal defecation is often facilitated in both well and ill clients by providing privacy, teaching clients to attend to defecation urges promptly, assisting clients to normal sitting positions whenever possible, encouraging appropriate food and fluid intake, and scheduling regular exercise. Nursing strategies include administering cathartics and antidiarrheals; administering cleansing, carminative, retention, or returnflow enemas; applying protective skin agents; monitoring fluid and electrolyte balance; and instructing clients in ways to promote normal defecation. The purpose of an enema is to increase peristalsis and the excretion of feces and flatus. Enemas are classified into four groups: cleansing, carminative, retention, and return-flow enemas. Digital removal of an impaction should be carried out gently because of vagal nerve stimulation and subsequent depressed cardiac rate. A primary care provider’s order is often necessary. Clients who have bowel diversion ostomies require special care, with attention to psychological adjustment, diet, and stoma and skin care. A variety of stoma management methods is available to these clients, depending on the type and position of the ostomy.

•

•

•

•

•

• •

•

•

•

•

•

•

•

•

TEST YOUR KNOWLEDGE 1. A client asks the RN why it is more difficult to use a bedpan for defecating than sitting on the toilet. Which of the following is the best response? 1. The sitting position decreases the contractions of the muscles of the pelvic floor. 2. The sitting position increases the downward pressure on the rectum, making it easier to pass stool. 3. The sitting position increases the pressure within the abdomen. 4. The sitting position inhibits the urge to urinate, allowing one to defecate. 2. An older client tells the nurse that in order to have a daily bowel movement, the client uses laxatives most days of the week. What should the nurse tell this client? Select all that apply. 1. Normal patterns of elimination are different for everyone. 2. Increase fiber intake to 20–35 grams a day. 3. Engage in enjoyable exercise. 4. Ignore the urge to have a bowel movement. 5. Have 6–8 glasses of fluid daily. 3. A client has received an oil retention enema. The nurse should instruct the client that the enema will take effect within what time? 1. 1-3 hours 2. 10-20 minutes

3. 5-10 minutes 4. 10-15 minutes 4. The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy? 1. The stoma extends 1/2 in. above the abdomen. 2. The skin under the appliance looks red briefly after removing the appliance. 3. The stoma color is a deep red-purple. 4. The ascending colostomy delivers liquid feces. 5. Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection? 1. The client will wear a medical alert bracelet for antibiotic allergy. 2. The client will return to his or her previous fecal elimination pattern. 3. The client will verbalize the need to take an antidiarrheal medication prn. 4. The client will increase intake of insoluble fiber such as grains, rice, and cereals.

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6. A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action? 1. Prepare to irrigate the colostomy. 2. After assessing the stoma and surrounding skin, notify the surgeon. 3. Assess bowel sounds and administer antiemetic. 4. Administer a bulk-forming laxative, and encourage increased fluids and exercise. 7. The nurse assesses a client’s abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling “bloated.” The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema? 1. Soapsuds 2. Retention 3. Return flow 4. Oil retention 8. Which of the following is most likely to validate that a client is experiencing intestinal bleeding? 1. Large quantities of fat mixed with pale yellow liquid stool 2. Brown, formed stools 3. Semisoft black-colored stools 4. Narrow, pencil-shaped stool

9. Which nursing diagnoses is/are most applicable to a client with fecal incontinence? Select all that apply. 1. Bowel Incontinence 2. Risk for Deficient Fluid Volume 3. Disturbed Body Image 4. Social Isolation 5. Risk for Impaired Skin Integrity 10. A student nurse is assigned to care for a client with a ­sigmoidostomy. The student will assess which ostomy site? ➌

➋

➍ ➊

➎

See Answers to Test Your Knowledge in Appendix A.

READINGS AND REFERENCES Suggested Readings Daniels, G., & Schmelzer, M. (2013). Giving laxatives safely and effectively. MEDSURG Nursing, 22(5), 290–302. This article provides information about the modes of action of various laxatives and strategies to help medical–­surgical nurses increase medication effectiveness and prevent adverse effects. Toner, F., & Claros, E. (2012). Preventing, assessing, and managing constipation in older adults. Nursing, 42(12), 32–39. doi:10.1097/01.NURSE.0000422642.83383.17 The authors point out that half of all older adults suffer from constipation. They provide comprehensive information on understanding the pathophysiology, the classifications of constipation, the Rome II diagnostic criteria, treating constipation, possible complications, and nursing considerations.

Related Research Croswell, E., Bliss, D. Z., & Savik, K. (2010). Diet and eating pattern modifications used by community-living adults to manage their fecal incontinence. Journal of Wound Ostomy Continence Nursing, 37, 677–682. doi:10.1097/ WON.0b013e3181feb017

References American Cancer Society. (2014a). Signs and symptoms of colorectal cancer. Retrieved from http://www .cancer.org/cancer/colonandrectumcancer/detailedguide/ colorectal-cancer-signs-and-symptoms American Cancer Society. (2014b). What are the risk ­factors for colorectal cancer? Retrieved from www .cancer.org/cancer/colonandrectumcancer/detailedguide/ colorectal-cancer-risk-factors Avent, Y. (2012). Understanding fecal diversions. Nursing made Incredibly Easy!, 10(5), 11–16. doi:10.1097/01 .NME.0000418044.19439.98 Ball, J. W., Bindler, R. C., & Cowen, K. J. (2014). Child health nursing partnering with children and families (3rd ed.). ­Upper Saddle River, NJ: Pearson Prentice Hall. Bulechek, G. M., Butcher, H. K., Dochterman, J. M., & Wagner, C. M. (Eds.). (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Mosby Elsevier.

Cohen, M. R. (2012). Fleet enemas: Don’t underestimate the risk. Nursing, 42(12), 12. doi:10.1097/01 .NURSE.0000422652.36748.22 Crawford, D., Texter, T., Hurt, K., Vanaelst, R., Glaza, L., & Vander Laan, K. J. (2012). Traditional nurse instruction versus 2 session nurse instruction plus DVD for teaching ostomy care. Journal of Wound Ostomy Continence Nursing, 39, 529–537. doi:10.1097/WON.0b013e3182659ca3 Diggs, N. G., & Surawicz, C. M. (2010). Clostridium difficile infection: Still principally a disease of the elderly. Therapy, 7, 295–301. doi:10.2217/thy.10.17 Gallagher, D. L., & Thompson, D. L. (2012). Identifying and managing fecal incontinence. Journal of Wound, ­Ostomy & Continence Nursing, 39, 95–97. doi:10.1097/ WON.0b013e31823fe683 Grossman, S., & Mager, D. (2010). Clostridium difficile. Implications for nursing. MEDSURG Nursing, 19, 155–158. Herdman, T. H., & Kamitsuru, S. (Eds.). (2014). NANDA International nursing diagnoses: Definitions & classification, 2015–2017. Oxford, United Kingdom: Wiley-Blackwell. Hollister, Inc. (2011). Understanding your colostomy. Retrieved from http://www.hollister.com/us/ostomy/learning/booklets .asp Lacy, B. E., Gabbard, S. L., & Crowell, M. D. (2011). Pathophysiology, evaluation, and treatment of bloating. Hope, hype, or hot air? Gastroenterology & Hepatology, 7(11), 729–739. Mayo Clinic. (2012). Dietary fiber: Essential for a healthy diet. Retrieved from http://www.mayoclinic.com/health/fiber/ NU00033 Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Mosby Elsevier. National Cancer Institute. (n.d.). What you need to know about cancer of the colon and rectum. Retrieved from http:// www.cancer.gov/cancertopics/wyntk/colon-and-rectal/ page1/AllPages#4 National Digestive Diseases Information Clearinghouse. (2013). Gas in the digestive tract. Retrieved from http://digestive .niddk.nih.gov/ddiseases/pubs/gas Piras, S. E., & Hurley, S. (2011). Ostomy care: Are you prepared? Nursing made Incredibly Easy!, 9(5), 46–48. doi:10.1097/01.NME.0000403198.60545.dd

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Relief from intestinal gas. (2013). Harvard Men’s Health Watch, 18(2), 4. Scemons, D. (2013). The ins and outs of ostomy management. Nursing made Incredibly Easy!, 11(5), 32–42. doi:10.1097/01.NME.0000432867.93012.55 Tabloski, P. A., & Connell, W. F. (2014). Gerontological nursing (3rd ed.). Upper Saddle River, NJ: Pearson. Walden, P. (2011). The facts about colorectal cancer. Nursing made Incredibly Easy!, 9(5), 37–44. doi:10.1097/01 .NME.0000403191.78471.05 Williams, J. (2011). Principles and practices of colostomy ­irrigation. Gastrointestinal Nursing, 9(9), 15–16. doi:10.12968/gasn.2011.9.9.15

Selected Bibliography Black, P. (2011). Choosing the correct stoma appliance. ­Journal of Community Nursing, 25(6), 44. Burch, J. (2012). Stoma care and enhanced recovery. Gastrointestinal Nursing, 10(7), 26–32. doi:10.12968/ gasn.2012.10.7.26 Burch, J. (2013). Choosing the correct accessory for each stoma type: An update. British Journal of Nursing, 22(Suppl. 16), S10–S13. Burch, J. (2013). Stoma complications: An overview. British Journal of Community Nursing, 18, 375–378. Chandler, P., & Lowther, C. (2013). Stoma care: Use of the colostomy Conseal plug. Gastrointestinal Nursing, 11(2), 15–16. doi:10.12968/gasn.2013.11.2.15 Gardiner, A. (2013). Constipation: Causes, assessment and management. Nursing & Residential Care, 15, 410–415. Gardiner, A. (2013). Understanding the functions required to maintain continence. Nursing & Residential Care, 15(5), 250–257. Palmer, S. (2013). Focus on healthy carbs. Environmental ­Nutrition, 36(10), 1–4. Peate, I., & Gault, C. (2013). Clinical skills series/2: Enemas and suppositories. British Journal of Healthcare Assistants, 7(2), 76–81. Slater, R. (2012). Choosing one- and two-piece appliances. Nursing & Residential Care, 14, 410–413. Williams, J. (2012). Inserting suppositories and enemas into a colostomy. Gastrointestinal Nursing, 10(1), 13–14.

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Oxygenation

LEARNING OUTCOMES After completing this chapter, you will be able to: 1. Outline the structure and function of the respiratory system. 2. Describe the processes of breathing (ventilation) and gas exchange (respiration). 3. Explain the role and function of the respiratory system in transporting oxygen and carbon dioxide to and from body tissues. 4. Describe the mechanisms for respiratory regulation. 5. Identify factors influencing respiratory function. 6. Identify four major types of conditions that can alter respiratory function. 7. Describe nursing assessments for oxygenation status. 8. Describe nursing measures to promote respiratory function and oxygenation. 9. Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways,

airway suctioning, and chest tubes to promote respiratory function. 10. State outcome criteria for evaluating client responses to measures that promote adequate oxygenation. 11. Verbalize the steps used in: a. Administering oxygen by cannula, face mask, or face tent. b. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning. c. Suctioning a tracheostomy or endotracheal tube. d. Providing tracheostomy care. 12. Recognize when it is appropriate to delegate aspects of oxygen therapy, suctioning, and tracheostomy care. 13. Demonstrate appropriate documentation and reporting of oxygen therapy, suctioning, and tracheostomy care.

KEY TERMS adventitious breath sounds, 1273 apnea, 1273 atelectasis, 1271 Biot’s (cluster) respirations, 1273 bradypnea, 1273 Cheyne-Stokes respirations, 1273 cyanosis, 1274 diffusion, 1271 dyspnea, 1273 emphysema, 1272 erythrocytes, 1271 eupnea, 1273 expectorate, 1278

hematocrit, 1271 hemoglobin, 1271 hemothorax, 1305 humidifiers, 1278 hypercapnia, 1273 hypercarbia, 1273 hyperinflation, 1298 hyperoxygenation, 1298 hyperventilation, 1298 hypoxemia, 1273 hypoxia, 1274 incentive spirometers, 1280 intrapleural pressure, 1269

INTRODUCTION

Oxygen, a clear, odorless gas that constitutes approximately 21% of the air we breathe, is necessary for proper functioning of all living cells. The absence of oxygen can lead to cellular, tissue, and organism death. Cellular metabolism produces carbon dioxide, which must be eliminated from the body to maintain normal acid–base balance. Delivery of oxygen and removal of carbon dioxide require the integration of several systems including the hematologic, cardiovascular, and respiratory systems. The respiratory system provides the essential first process in this integrated system, that is, movement and transfer of gases between the atmosphere and the blood (Patton & Tibodeau, 2010). Impaired function of the system can significantly

intrapulmonary pressure, 1269 Kussmaul’s breathing, 1273 lung compliance, 1271 lung recoil, 1271 mucus clearance device (MCD), 1283 noninvasive positive pressure ventilation (NPPV), 1287 orthopnea, 1273 oxyhemoglobin, 1271 partial pressure, 1271 pleural effusion, 1305 pneumothorax, 1305

postural drainage, 1283 respiratory membrane, 1269 sputum, 1274 stridor, 1273 suctioning, 1293 surfactant, 1271 tachypnea, 1273 tidal volume, 1271 torr, 1271 vibration, 1282

affect our ability to breathe, transport gases, and participate in everyday activities. Respiration is the process of gas exchange between the individual and the environment and involves four components: 1. Ventilation or breathing, the movement of air in and out of the lungs as we inhale and exhale 2. Alveolar-capillary gas exchange, which involves the diffusion of oxygen and carbon dioxide between the alveoli and the pulmonary capillaries 3. Transport of oxygen and carbon dioxide between the tissues and the lungs 4. Movement of oxygen and carbon dioxide between the systemic capillaries and the tissues.

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STRUCTURE AND PROCESSES OF THE RESPIRATORY SYSTEM

The structure of the respiratory system facilitates gas exchange and protects the body from foreign matter such as particulates and pathogens. The four processes of the respiratory system include pulmonary ventilation, alveolar gas exchange, transport of oxygen and carbon dioxide, and systemic diffusion.

Structure of the Respiratory System

The respiratory system (Figure 50–1 •) is divided structurally into the upper respiratory system and the lower respiratory system. The mouth, nose, pharynx, and larynx compose the upper respiratory system. The lower respiratory system includes the trachea and lungs, with the bronchi, bronchioles, alveoli, pulmonary capillary network, and pleural membranes. Air enters through the nose, where it is warmed, humidified, and filtered. Hairs at the entrance of the nares trap large particles in the air,

and smaller particles are filtered and trapped as air changes direction on contact with the nasal turbinates and septum. Irritants in the nasal passages initiate the sneeze reflex. A large volume of air rapidly exits through the nose and mouth during a sneeze, helping to clear nasal passages. Inspired air passes from the nose through the pharynx. The pharynx is a shared pathway for air and food. It includes both the nasopharynx and the oropharynx, which are richly supplied with lymphoid tissue that traps and destroys pathogens entering with the air. The larynx is a cartilaginous structure that can be identified externally as the Adam’s apple. In addition to its role in providing for speech, the larynx is important for maintaining airway patency and protecting the lower airways from swallowed food and fluids. During swallowing, the inlet to the larynx (the epiglottis) closes, routing food to the esophagus. The epiglottis is open during breathing, allowing air to move freely into the lower airways. Below the larynx, the trachea leads to the right and left main bronchi (primary bronchi) and the other conducting airways of the lungs. Within the lungs, the

Nasopharynx

Nasal cavity

Oropharynx Laryngeal pharynx

Epiglottis

Larynx

Right lung

Esophagus

Right bronchus

Trachea Left lung Left bronchus Mediastinum Terminal bronchiole

Terminal bronchiole

Respiratory bronchioles Diaphragm

Pleura

A

Alveolar duct Alveoli B

Figure 50–1 • A, Organs of the respiratory tract; B, respiratory bronchioles, alveolar ducts, and alveoli.

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Chapter 50  •  Oxygenation

BOX 50–1   The Cough Reflex • • • • • • •

Nerve impulses are sent through the vagus nerve to the medulla. A large inspiration of approximately 2.5 L occurs. The epiglottis and glottis (vocal cords) close. A strong contraction of abdominal and internal intercostal muscles dramatically raises the pressure in the lungs. The epiglottis and glottis open suddenly. Air rushes outward with great velocity. Mucus and any foreign particles are dislodged from the lower respiratory tract and are propelled up and out.

primary bronchi divide repeatedly into smaller and smaller bronchi, ending with the terminal bronchioles. Together these airways are known as the bronchial tree. The trachea and bronchi are lined with mucosal epithelium. These cells produce a thin layer of mucus, the “mucous blanket,” that traps pathogens and microscopic particulate matter. These foreign particles are then swept upward toward the larynx and throat by cilia, tiny hairlike projections on the epithelial cells. The cough reflex is triggered by irritants in the larynx, trachea, or bronchi and is described in Box 50–1. After air passes through the trachea and bronchi, it enters the respiratory bronchioles and alveoli where all gas exchange occurs. This gas exchange or respiratory zone of the lungs includes the respiratory bronchioles (which have scattered air sacs in their walls), the alveolar ducts, and the alveoli (see Figure 50–1). Alveoli have very thin walls, composed of a single layer of epithelial cells covered by a thick mesh of pulmonary capillaries. The alveolar and capillary walls form the respiratory membrane (also known as the alveolar/­capillary membrane), where gas exchange occurs between the air on the ­alveolar side and the blood on the capillary side. The airways move air to and from the alveoli; the right ventricle and pulmonary vascular system transport blood to the capillary side of the membrane. For example, deoxygenated blood leaves the right heart through the pulmonary artery and enters the lungs and capillaries. Oxygenated blood returns via capillaries to the pulmonary vein to the heart (­Figure 50–2 •). The thin, highly permeable membrane of the respiratory membrane (estimated to be not more than 0.0004 mm thick) is essential to normal gas exchange. Thus, fluid or other materials in the alveoli interfere with the respiratory process. The outer surface of the lungs is covered by a thin, double layer of tissue known as the pleura. The parietal pleura lines the thorax and surface of the diaphragm. It doubles back to form the visceral pleura, covering the external surface of the lungs. Between these pleural layers is a potential space that contains a small amount of pleural fluid, a serous lubricating solution. This fluid prevents friction during the movements of breathing and serves to keep the layers adherent through its surface tension.

Pulmonary Ventilation

The first process of the respiratory system, ventilation of the lungs, is accomplished through the act of breathing: inspiration (inhalation) as air flows into the lungs, and expiration (exhalation) as air moves out of the lungs. Adequate ventilation depends on several factors: • •

Clear airways An intact central nervous system (CNS) and respiratory center

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Inspired air Expired air Pulmonary vein

Pulmonary artery From heart and systemic circulation

Alveoli (lungs)

To heart and systemic circulation

CO2 O2

Tissues

Figure 50–2 • Gas exchange occurs between the air on the alveolar side and the blood on the capillary side.

• •

An intact thoracic cavity capable of expanding and contracting Adequate pulmonary compliance and recoil.

A number of mechanisms, including ciliary action and the cough reflex, work to keep airways open and clear. In some cases, however, these defenses may be overwhelmed. The inflammation, edema, and excess mucous production that occur with some types of pneumonia may clog small airways, impairing ventilation of distal alveoli. The respiratory centers of the medulla and pons in the brainstem control breathing. Severe head injury or drugs that depress the central nervous system (e.g., opiates or barbiturates) can affect the respiratory centers, impairing the drive to breathe. Expansion and recoil of the lungs occur passively in response to changes in pressures within the thoracic cavity and the lungs themselves. The intrapleural pressure (pressure in the pleural cavity surrounding the lungs) is always slightly negative in relation to atmospheric pressure. This negative pressure is essential because it creates the suction that holds the visceral pleura and the parietal pleura together as the chest cage expands and contracts. The recoil tendency of the lungs is a major factor in creating this negative pressure. The intrapleural fluid also contributes by causing the pleura to adhere together, much as a film of water can cause two glass slides to stick together. The intrapulmonary pressure (pressure within the lungs) always equalizes with atmospheric pressure. Inspiration occurs when the diaphragm and intercostal muscles contract, increasing the size of the thoracic cavity. The volume of the lungs increases, decreasing intrapulmonary pressure. Air then rushes into the lungs to equalize this pressure with atmospheric pressure. Conversely, when the diaphragm and intercostal muscles relax, the volume of the lungs decreases, intrapulmonary pressure rises, and air is expelled. Normal elastic recoil of the thorax and lungs is essential to exhalation. Disease processes such as chronic obstructive pulmonary disease (COPD) that reduce this elasticity result in forced expirations and may impair the body’s ability to expel carbon dioxide.

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ANATOMY & PHYSIOLOGY REVIEW The Respiratory System The larynx, trachea, bronchi, and lungs with an expanded view showing the structures of an ­alveolus and the pulmonary blood vessels. From Medical Terminology: A Word-Building Approach, 7th ed. (Figure 11.5), by J. Rice, 2012, Upper Saddle River, NJ: Pearson Education, Inc. Reproduced by permission of Pearson Education, Inc., Upper Saddle River, New Jersey.

Larynx Trachea

Right lung

Left lung Right upper lobe (RUL)

Left bronchus

Right bronchus Left upper lobe (LUL)

Right middle lobe (RML)

Indentation for the normal placement of the heart

Left lower lobe (LLL)

Right lower lobe (RLL)

Alveolar sacs Pulmonary artery Pulmonary vein

Capillaries Alveolus

QUESTIONS 1. Pneumonia occurs when microorganisms get into the lower respiratory tract and overwhelm the body’s defenses. Name at least two normal defense mechanisms present in the upper airway that help prevent microorganisms getting into the lower respiratory tract. 2. Microorganisms can travel past the upper respiratory tract defense mechanisms. What defense mechanisms are

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present in the lower respiratory tract that may help the client? 3. The microorganisms have quickly multiplied and overpowered the client’s defense mechanisms. The client has pneumonia and the alveoli are filled with infectious fluid. How will this affect gas exchange at the respiratory or alveolar/ capillary membrane? See student resource website for answers.

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The degree of chest expansion during normal breathing is minimal, requiring little energy expenditure. In adults, approximately 500 mL of air is inspired and expired with each breath. This is known as tidal volume. Breathing during strenuous exercise or some types of heart disease requires greater chest expansion and effort. At this time, more than 1,500 mL of air may be moved with each breath. Accessory muscles of respiration, including the anterior neck muscles, intercostal muscles, and muscles of the abdomen, are employed. Active use of these muscles and noticeable effort in breathing are seen in clients with obstructive pulmonary disease. Diseases such as muscular dystrophy, or trauma such as spinal cord injury, can affect the muscles of respiration, impairing the ability of the thoracic cavity to expand and contract. A gunshot wound or other chest trauma interferes with the crucial atmospheric and intrapleural pressure gradients, causing the lung to collapse. Lung compliance, the expansibility or stretchability of lung tissue, plays a significant role in the ease of ventilation. At birth, the fluid-filled lungs are stiff and resistant to expansion, much as a new balloon is difficult to inflate. With each subsequent breath, the alveoli become more compliant and easier to inflate, just as a balloon becomes easier to inflate after several tries. Lung compliance tends to decrease with aging, making it more difficult to expand alveoli and increasing the risk for atelectasis, or collapse of a portion of the lung. In contrast to lung compliance is lung recoil, the continual tendency of the lungs to collapse away from the chest wall. Just as lung compliance is necessary for normal inspiration, lung recoil is necessary for normal expiration. Although elastic fibers in lung tissue contribute to lung recoil, the surface tension of fluid lining the alveoli has the greatest effect on recoil. Fluid molecules tend to draw together, reducing the size of alveoli. Surfactant, a lipoprotein produced by specialized alveolar cells, acts like a detergent, reducing the surface tension of alveolar fluid. Without surfactant, lung expansion is exceedingly difficult and the lungs collapse. Premature infants whose lungs are not yet capable of producing adequate surfactant often develop respiratory distress syndrome.

Alveolar Gas Exchange

After the alveoli are ventilated, the second phase of the respiratory process—the diffusion of oxygen from the alveoli and into the pulmonary blood vessels—begins. Diffusion is the movement of gases or other particles from an area of greater pressure or concentration to an area of lower pressure or concentration. Pressure differences in the gases on each side of the respiratory membrane obviously affect diffusion. When the pressure of oxygen is greater in the alveoli than in the blood, oxygen diffuses into the blood. The partial pressure (the pressure exerted by each individual gas in a mixture according to its concentration in the mixture) of oxygen (PO2) in the alveoli is about 100 mmHg (sometimes referred to as torr, which is the same as millimeters of mercury), whereas the PO2 in the venous blood of the pulmonary arteries is about 60 mmHg or torr. These pressures rapidly equalize, however, so that the arterial oxygen pressure also reaches about 100 mmHg. By contrast, carbon dioxide in the venous blood entering the pulmonary capillaries has a partial pressure of about 45 mmHg (PCO2), whereas that in the alveoli has a partial pressure of about 40 mmHg. Therefore, carbon dioxide diffuses from the blood into the alveoli, where it can be eliminated with expired air. Partial pressures of oxygen and carbon dioxide are further defined by whether they derive from arterial or venous blood.

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For example, the partial pressure of oxygen in arterial blood is called PaO2 while the partial pressure of oxygen in venous blood is called PvO2. However, blood for partial pressures (blood gases) are usually obtained from arterial blood. Therefore, the abbreviation “PO2” is commonly used for arterial blood oxygen partial pressure.

Transport of Oxygen and Carbon Dioxide

The third part of the respiratory process involves the transport of respiratory gases. Oxygen needs to be transported from the lungs to the tissues, and carbon dioxide must be transported from the tissues back to the lungs. Normally most of the oxygen (97%) combines loosely with hemoglobin (oxygen-carrying red pigment) in the red blood cells (RBCs) and is carried to the tissues as oxyhemoglobin (the compound of oxygen and hemoglobin). Various factors influence the tendency of oxygen to bind with and release from hemoglobin. As oxygen diffuses from capillary blood into tissues, the decreasing partial pressure of oxygen stimulates the hemoglobin to release its attached oxygen molecules. Additionally, changes in blood pH affect the hemoglobin’s ability to bind with and release oxygen. The small amount of oxygen not bound to hemoglobin is dissolved and transported in the plasma as the PaO2. Several factors affect the rate of oxygen transport from the lungs to the tissues: 1. Cardiac output 2. Number of erythrocytes and blood hematocrit 3. Exercise. Any pathologic condition that decreases cardiac output (e.g., damage to the heart muscle, blood loss, or pooling of blood in the peripheral blood vessels) diminishes the amount of oxygen delivered to the tissues. The heart compensates for inadequate output by increasing its pumping rate or heart rate; however, with severe damage or blood loss, this compensatory mechanism may not restore adequate blood flow and oxygen to the tissues. The second factor influencing oxygen transport is the number of erythrocytes or red blood cells (RBCs) and the hematocrit. The hematocrit is the percentage of the blood that is erythrocytes. In men, the number of circulating erythrocytes normally averages about 5 million per cubic milliliter of blood, and in women, about 4.5 million per cubic milliliter. Normally the hematocrit is about 40% to 54% in men and 37% to 50% in women. Excessive increases in the blood hematocrit raise the blood viscosity, reducing the cardiac output and therefore reducing oxygen transport. Excessive reductions in the blood hematocrit, such as occur in anemia, reduce oxygen transport. Exercise also has a direct influence on oxygen transport. In welltrained athletes, oxygen transport can be increased up to 20 times the normal rate, due in part to an increased cardiac output and to increased use of oxygen by the cells. Carbon dioxide, continually produced in the processes of cell metabolism, is transported from the cells to the lungs in three ways. The majority (about 65%) is carried inside the RBCs as bicarbonate (HCO3–) and is an important component of the bicarbonate buffer system (see Chapter 52 ). A moderate amount of carbon dioxide (30%) combines with hemoglobin as carbaminohemoglobin for transport. Smaller amounts (5%) are transported in solution in the plasma and as carbonic acid (the compound formed when carbon dioxide combines with water).

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Systemic Diffusion

The fourth process of respiration is diffusion of oxygen and carbon dioxide between the capillaries and the tissues and cells down to a concentration gradient similar to diffusion at the alveolar-capillary level. As cells consume oxygen, the partial pressure of oxygen in the tissues decreases, causing the oxygen at the arterial end of the capillary to diffuse into the cells. When cells consume more oxygen during exercise or stress, the pressure gradient increases and diffusion is enhanced, allowing the cells to regulate their own flow of oxygen. Carbon dioxide from metabolic processes accumulates in the tissues and diffuses into the capillaries where the partial pressure of carbon dioxide is lower. In reduced blood flow states such as shock, capillary blood flow may decrease, interfering with tissue oxygen delivery.

RESPIRATORY REGULATION

Respiratory regulation includes both neural and chemical controls to maintain the correct concentrations of oxygen, carbon dioxide, and hydrogen ions in body fluids. The nervous system of the body adjusts the rate of alveolar ventilations to meet the needs of the body so that PO2 and PCO2 remain relatively constant. The body’s “respiratory center” is actually a number of groups of neurons located in the medulla oblongata and pons of the brain. A chemosensitive center in the medulla oblongata is highly responsive to increases in blood CO2 or hydrogen ion concentration. By influencing other respiratory centers, this center can increase the activity of the inspiratory center and the rate and depth of respirations. In addition to this direct chemical stimulation of the respiratory center in the brain, special neural receptors sensitive to decreases in O2 concentration are located outside the central nervous system in the carotid bodies (just above the bifurcation of the common carotid arteries) and aortic bodies located above and below the aortic arch. Decreases in arterial oxygen concentrations stimulate these chemoreceptors, and they in turn stimulate the respiratory center to increase ventilation. Of the three blood gases (hydrogen, oxygen, and carbon dioxide) that can trigger chemoreceptors, increased carbon dioxide concentration normally has the strongest effect on stimulating respiration. However, in clients with certain chronic lung ailments such as emphysema, oxygen concentrations, not carbon dioxide concentrations, play a major role in regulating respiration. For some clients, decreased oxygen concentrations are the main stimuli for respiration because the chronically elevated carbon dioxide levels that occur with emphysema “desensitize” the central chemoreceptors. This is sometimes called the hypoxic drive. Increasing the concentration of oxygen depresses the respiratory rate. Thus, oxygen must be administered cautiously to these clients and often at low flow rates. Current theory, however, is that only a small percentage of individuals with COPD actually have depressed CO2 chemoreceptors. Low-flow oxygen therapy may not be enough for many clients with COPD, and chronic hypoxemia shortens survival and quality of life (Makic, Martin, Burns, Philbrick, & Rauen, 2013). CLINICAL ALERT! Oxygen is considered a drug and must be carefully prescribed based on individual client conditions.

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FACTORS AFFECTING RESPIRATORY FUNCTION

Factors that influence oxygenation affect the cardiovascular system as well as the respiratory system. These factors include age, environment, lifestyle, health status, medications, and stress.

Age

Developmental factors have important influences on respiratory function. At birth, profound changes occur in the respiratory systems. The fluid-filled lungs drain, the PCO2 rises, and the neonate takes a first breath. The lungs gradually expand with each subsequent breath, reaching full inflation by 2 weeks of age. Changes of aging that affect the respiratory system of older adults become especially important if the system is compromised by changes such as infection, physical or emotional stress, surgery, anesthesia, or other procedures. These types of changes are seen: • • • • • • • •

Chest wall and airways become more rigid and less elastic. The amount of exchanged air is decreased. The cough reflex and cilia action are decreased. Mucous membranes become drier and more fragile. Decreases in muscle strength and endurance occur. If osteoporosis is present, adequate lung expansion may be compromised. A decrease in efficiency of the immune system occurs. Gastroesophageal reflux disease is more common in older adults and increases the risk of aspiration. The aspiration of stomach contents into the lungs often causes bronchospasm by setting up an inflammatory response.

Environment

Altitude, heat, cold, and air pollution affect oxygenation. The higher the altitude, the lower the PO2 an individual breathes. As a result, the person at high altitudes has increased respiratory and cardiac rates and increased respiratory depth, which usually become most apparent when the individual exercises. Healthy people exposed to air pollution, such as smog or secondhand tobacco smoke, may experience stinging of the eyes, headache, dizziness, and coughing. People who have a history of existing lung disease and altered respiratory function experience varying degrees of respiratory difficulty in a polluted environment. Some are unable to perform self-care in such an environment.

Lifestyle

Physical exercise or activity increases the rate and depth of respirations and hence the supply of oxygen in the body. Sedentary people, by contrast, lack the alveolar expansion and deep-breathing patterns of people with regular activity and are less able to respond effectively to respiratory stressors. Certain occupations predispose an individual to lung disease. For example, silicosis is seen more often in sandstone blasters and potters than in the rest of the population; asbestosis in asbestos workers; anthracosis in coal miners; and organic dust disease in farmers and agricultural employees who work with moldy hay.

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Health Status

In the healthy person, the respiratory system can provide sufficient oxygen to meet the body’s needs. Diseases of the respiratory system, however, can adversely affect the oxygenation of the blood.

Medications

A variety of medications can decrease the rate and depth of respirations. The most common medications having this effect are the benzodiazepine sedative-hypnotics and antianxiety drugs (e.g., diazepam [Valium], lorazepam [Ativan], midazolam [Versed]), barbiturates (e.g., phenobarbital), and opioids such as morphine. When administering these, the nurse must carefully monitor respiratory status, especially when the medication is begun or when the dose is increased. Older clients are at high risk of respiratory depression and, hence, usually require reduced dosages.

Stress

When stress and stressors are encountered, both psychological and physiological responses can affect oxygenation. Some people may hyperventilate in response to stress. When this occurs, arterial PO2 rises and PCO2 falls. The person may experience light-headedness and numbness and tingling of the fingers, toes, and around the mouth as a result. Physiologically, the sympathetic nervous system is stimulated and epinephrine is released during stress. Epinephrine causes the bronchioles to dilate, increasing blood flow and oxygen delivery to active muscles. Although these responses are adaptive in the short term, when stress continues they can be destructive, increasing the risk of cardiovascular disease.

ALTERATIONS IN RESPIRATORY FUNCTION

Respiratory function can be altered by conditions that affect: • • • •

Patency (open airway) The movement of air into or out of the lungs The diffusion of oxygen and carbon dioxide between the alveoli and the pulmonary capillaries The transport of oxygen and carbon dioxide via the blood to and from the tissue cells.

Conditions Affecting the Airway

A completely or partially obstructed airway can occur anywhere along the upper or lower respiratory passageways. An upper airway obstruction—that is, in the nose, pharynx, or larynx—can occur when a foreign object such as food is present, when the tongue falls back into the oropharynx when a person is unconscious, or when secretions collect in the passageways. In the latter instance, the respirations will sound gurgly or bubbly as the air attempts to pass through the secretions. Lower airway obstruction involves partial or complete occlusion of the passageways in the bronchi and lungs most often due to increased accumulation of mucus or inflammatory exudate. Assessing for and maintaining a patent airway is a nursing responsibility, one that often requires immediate action. Partial obstruction of the upper airway passages is indicated by a low-pitched snoring sound during inhalation. Complete obstruction is indicated

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by extreme inspiratory effort that produces no chest movement and an inability to cough or speak. Such a client, in an effort to obtain air, may also exhibit marked sternal and intercostal retractions. Lower airway obstruction is not always as easy to observe. Stridor, a harsh, high-pitched sound, may be heard during inspiration. The client may have altered arterial blood gas levels, restlessness, dyspnea, and adventitious breath sounds (abnormal breath sounds). See Table 30–8, page 556.

Conditions Affecting Movement of Air

The term breathing patterns refers to the rate, volume, rhythm, and relative ease or effort of respiration. Normal respiration ­(eupnea) is quiet, rhythmic, and effortless. Tachypnea (rapid r­ espirations) is seen with fevers, metabolic acidosis, pain, and hypoxemia. ­Bradypnea is an abnormally slow respiratory rate, which may be seen in clients who have taken drugs such as morphine or sedatives, who have metabolic alkalosis, or who have increased intracranial pressure (e.g., from brain injuries). Apnea is the absence of any breathing. Hypoventilation, that is, inadequate alveolar ventilation, may be caused by either slow or shallow breathing, or both. Hypoventilation may occur because of diseases of the respiratory muscles, drugs, or anesthesia. Hypoventilation may lead to increased levels of carbon dioxide (hypercarbia or hypercapnia) or low levels of oxygen (hypoxemia). Hyperventilation is the increased movement of air into and out of the lungs. During hyperventilation, the rate and depth of respirations increase and more CO2 is eliminated than is produced. One particular type of hyperventilation that accompanies metabolic acidosis is Kussmaul’s breathing, by which the body attempts to compensate for increased metabolic acids by blowing off acid in the form of CO2. Hyperventilation can also occur in response to stress or anxiety. Other abnormal breathing patterns may create breathing irregularities. Irregular rhythms include: • Cheyne-Stokes respirations:

•

marked rhythmic waxing and waning of respirations from very deep to very shallow with short periods of apnea commonly caused by chronic diseases, increased intracranial pressure, or drug overdose Biot’s (cluster) respirations: shallow breaths interrupted by apnea; may be seen in clients with CNS disorders.

Orthopnea is the inability to breathe easily unless sitting upright or standing. Difficulty breathing or the feeling of being short of breath (SOB) is called dyspnea. Dyspnea may occur with varying levels of exertion or at rest. The client with dyspnea will generally have observable (objective) signs such as flaring of the nostrils, labored-appearing breathing, increased heart rate, cyanosis, and diaphoresis. Dyspnea has many causes, most of which stem from cardiac or respiratory disorders. Because treatment is aimed at removing the underlying cause, it is important for the nurse to conduct a thorough history of the onset, duration, and precipitating and relieving factors of the client’s dyspnea plus a comprehensive physical examination.

Conditions Affecting Diffusion

Impaired diffusion may affect levels of gases in the blood, particularly oxygen, which does not diffuse as readily as carbon dioxide. ­ ypoxemia, or reduced oxygen levels in the blood, may be caused H

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LIFESPAN CONSIDERATIONS Respiratory Development INFANTS • Respiratory rates are highest and most variable in newborns. The respiratory rate of a neonate is 40 to 80 breaths per minute. • Infant respiratory rates average about 30 per minute. • Because of rib cage structure, infants rely almost exclusively on diaphragmatic movement for breathing. This is seen as abdominal breathing, as the abdomen rises and falls with each breath. CHILDREN • The respiratory rate gradually decreases, averaging around 25 per minute in the preschooler and reaching the adult rate of 12 to 18 per minute by late adolescence. • During infancy and childhood, viral upper respiratory infections (e.g., colds) are common and, fortunately, usually not serious. Infants and preschoolers also are at risk for airway obstruction by foreign objects such as coins and small toys. Cystic fibrosis is a congenital disorder that affects the lungs, causing them to become congested with thick, tenacious (sticky) mucus. Asthma is another chronic disease often identified in childhood. The airways of the asthmatic child react to stimuli such as allergens, exercise, or cold air by constricting, becoming edematous, and producing excessive mucus. Airflow is impaired, and the child may wheeze as air moves through narrowed air passages. OLDER ADULTS • Older adults are at increased risk for acute respiratory diseases such as pneumonia and chronic diseases such as emphysema and chronic bronchitis. COPD may affect older adults, particularly after years of exposure to cigarette smoke or industrial pollutants. Obstructive airway changes are accelerated with the genetic deficiency of the enzyme alpha1-antitrypsin.

CLINICAL MANIFESTATIONS Hypoxia • • • • • •

Rapid pulse Rapid, shallow respirations and dyspnea Increased restlessness or light-headedness Flaring of the nares Substernal or intercostal retractions Cyanosis

by conditions that impair diffusion at the alveolar-capillary level such as pulmonary edema or atelectasis (collapsed alveoli) or by low hemoglobin levels. The cardiovascular system compensates for hypoxemia by increasing the heart rate and cardiac output, to attempt to transport adequate oxygen to the tissues. If the cardiovascular system is unable to compensate or hypoxemia is severe, tissue hypoxia (insufficient oxygen anywhere in the body) results, potentially causing cellular injury or death. Clinical Manifestations lists signs of hypoxia. Cyanosis (bluish discoloration of the skin, nail beds, and mucous membranes due to reduced hemoglobin-oxygen saturation) may be present with hypoxemia or hypoxia. Cyanosis requires two conditions: The blood must contain about 5 g or more of unoxygenated hemoglobin per 100 mL of blood, and the surface blood capillaries must be dilated. Factors that interfere with either of these conditions (e.g., severe anemia or the administration of epinephrine) will eliminate cyanosis as a sign even if the client is experiencing hypoxia. Adequate oxygenation is essential for cerebral functioning. The cerebral cortex can tolerate hypoxia for only 3 to 5 minutes before permanent damage occurs. The face of the acutely hypoxic person

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Pneumonia may not present with the usual symptoms of a fever, but will present with atypical symptoms, such as confusion, weakness, loss of appetite, and increase in heart rate and respirations. Nursing interventions should be directed toward achieving optimal respiratory effort, gas exchange, self-care habits, and wellness. Additionally, nurses play an important role in chronic disease management by assisting clients to cope with and minimize the effects of illnesses such as COPD. • Always encourage wellness and prevention of disease by ­reinforcing the need for good nutrition, exercise, and immunizations, such as for influenza and pneumonia. • Increase fluid intake, if not contraindicated by other problems, such as cardiac or renal impairment. • In hospitalized and immobile clients, encourage ambulation and frequent changing of positions to allow for better lung ­expansion and air and fluid movement. • Teach the client to use deep-breathing and coughing ­techniques for better lung expansion and airway clearance. (See Client Teaching throughout this chapter.) • Pace activities to conserve energy. • Encourage the client to eat more frequent, smaller meals to decrease gastric distention, which can cause pressure on the diaphragm. • Teach the client to avoid extreme hot or cold temperatures, which can further tax the respiratory system. • Teach actions and side effects of drugs, inhalers, and treatments. •

usually appears anxious, tired, and drawn. The person usually assumes a sitting position, often leaning forward slightly to permit greater expansion of the thoracic cavity. With chronic hypoxemia, the client often appears fatigued and is lethargic. The client’s fingers and toes may be clubbed as a result of long-term lack of oxygen in the arterial blood supply. With clubbing, the base of the nail becomes swollen and the ends of the fingers and toes increase in size. The angle between the nail and the base of the nail increases to more than 180 degrees. See Figure 30–10, page 530.

Conditions Affecting Transport

Once oxygen moves into the lungs and diffuses into the capillaries, the cardiovascular system transports the oxygen to all body tissues, and transports CO2 from the cells back to the lungs where it can be exhaled from the body. Conditions that decrease cardiac output, such as congestive heart failure or hypovolemia, affect tissue oxygenation and also the body’s ability to compensate for hypoxemia. ●◯●

NURSING MANAGEMENT

Assessing Nursing assessment of oxygenation status includes a history, physical examination, and review of relevant diagnostic data.

Nursing History A comprehensive nursing history relevant to oxygenation status should include data about current and past respiratory problems; lifestyle; presence of cough, sputum (coughed-up material), or pain; medications for breathing; and presence of risk factors for impaired

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ASSESSMENT INTERVIEW Oxygenation CURRENT RESPIRATORY PROBLEMS • Have you noticed any changes in your breathing pattern (e.g., shortness of breath, difficulty breathing, need to be in upright position to breathe, or rapid and shallow breathing)? • If so, which of your activities might cause these symptom(s) to occur? • How many pillows do you use to sleep at night? HISTORY OF RESPIRATORY DISEASE • Have you had colds, allergies, asthma, tuberculosis, bronchitis, pneumonia, or emphysema? • How frequently have these occurred? How long did they last? And how were they treated? • Have you been exposed to any pollutants? LIFESTYLE • Do you smoke? If so, how much? If not, did you smoke ­previously, and when did you stop? • Does any member of your family smoke? • Is there cigarette smoke or other pollutants (e.g., fumes, dust, coal, asbestos) in your workplace? • Do you use alcohol? If so, how many drinks (mixed drinks, glasses of wine, or beers) do you usually have per day or per week? • Describe your exercise patterns. How often do you exercise and for how long? PRESENCE OF COUGH • How often and how much do you cough? • Is it productive, that is, accompanied by sputum, or ­nonproductive, that is, dry? • Does the cough occur during certain activity or at certain times of the day?

oxygenation status. Examples of interview questions to elicit this information are shown in the Assessment Interview.

Physical Examination In assessing a client’s oxygenation status, the nurse uses all four physical examination techniques: inspection, palpation, percussion, and auscultation. The nurse first observes the rate, depth, rhythm, and quality of respirations, noting the position the client assumes for breathing. The nurse also inspects for variations in the shape of the thorax that may indicate adaptation to chronic respiratory conditions. For example, clients with emphysema frequently develop a barrel chest. The nurse palpates the thorax for bulges, tenderness, or abnormal movements. Palpation is also used to detect vocal (tactile) fremitus. The thorax can be percussed for diaphragmatic excursion (the movement of the diaphragm during maximal inspiration and expiration). However, this is not commonly done in acute care and long-term care settings. The nurse frequently auscultates the chest to assess if the client’s breath sounds are normal or abnormal. See Chapter 30 , Skill 30-11 on page 556 for more information. Diagnostic Studies The primary care provider may order various diagnostic tests to assess respiratory status, function, and oxygenation. Included are sputum specimens, throat cultures, visualization procedures (see Chapter 34 ), venous and arterial blood specimens, and pulmonary function tests. Measurement of arterial blood gases is an important diagnostic procedure (see Chapter 52 ). Specimens of arterial blood are

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DESCRIPTION OF SPUTUM When is the sputum produced? What is the amount, color, thickness, odor? Is it ever tinged with blood?

• • •

PRESENCE OF CHEST PAIN • How does going outside in the heat or the cold affect you? • Do you experience any pain with breathing or activity? • If so, where is the pain located? • Describe the pain. How does it feel? • Does it occur when you breathe in or out? • How long does it last, and how does it affect your breathing? • Do you experience any other symptoms when the pain ­occurs (e.g., nausea, shortness of breath or difficulty breathing, ­light-headedness, palpitations)? • What activities precede your pain? • What do you do to relieve the pain? PRESENCE OF RISK FACTORS • Do you have a family history of lung cancer, cardiovascular ­disease (including strokes), or tuberculosis? • The nurse should also note the client’s weight, activity pattern, and dietary assessment. Risk factors include obesity, sedentary lifestyle, and diet high in saturated fats. MEDICATION HISTORY • Have you taken or do you take any over-the-counter or ­prescription medications for breathing (e.g., bronchodilator, inhalant, narcotic)? • If so, which ones? What are the dosages, times taken, and ­results, including side effects?

normally taken by specialty nurses, respiratory therapists, or medical technicians. Blood for these tests is taken directly from the radial, brachial, or femoral arteries or from catheters placed in these arteries. Because of the relatively high pressure of the blood in these arteries, it is important to prevent hemorrhaging by applying pressure to the puncture site for about 5 minutes after removing the needle. Frequently the noninvasive measurement of oxygen saturation (using a device placed on the fingertip) is sufficient for attaining a measurement of oxygenation of the arterial blood. Pulmonary Function Tests

Pulmonary function tests measure lung volume and capacity. Clients undergoing pulmonary function tests, which are usually carried out by a respiratory therapist, do not require an anesthetic. The client breathes into a machine. The tests are painless, but the client’s cooperation is essential. It requires the ability to follow directions and some hand–eye coordination. Nurses need to explain the tests to clients beforehand and help them to rest afterward because the tests are often tiring. Table 50–1 describes the measurements taken, and Figure 50–3 • shows their relationships and normal adult values.

Diagnosing NANDA International (Herdman & Kamitsuru, 2014) includes the following diagnostic labels for clients with oxygenation problems: • Ineffective Airway Clearance: inability to clear secretions or ob-

structions from the respiratory tract to maintain a clear airway.

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TABLE 50–1  Pulmonary Volumes and Capacities Measurement

Description

Tidal volume (VT)

Volume inhaled and exhaled during normal quiet breathing

Inspiratory reserve volume (IRV)

Maximum amount of air that can be inhaled over and above a normal breath

Expiratory reserve volume (ERV)

Maximum amount of air that can be exhaled following a normal exhalation

Residual volume (RV)

The amount of air remaining in the lungs after maximal exhalation

Total lung capacity (TLC)

The total volume of the lungs at maximum inflation; calculated by adding the VT, IRV, ERV, and RV

Vital capacity (VC)

Total amount of air that can be exhaled after a maximal inspiration; calculated by adding the VT, IRV, and ERV

Inspiratory capacity

Total amount of air that can be inhaled following normal quiet exhalation; calculated by adding the VT and IRV

Functional residual capacity (FRC)

The volume left in the lungs after normal exhalation; calculated by adding the ERV and RV

Minute volume (MV)

The total volume or amount of air breathed in 1 minute

A clinical example using this nursing diagnosis is shown in the Nursing Care Plan and Concept Map at the end of the chapter. • Ineffective Breathing Pattern: inspiration and/or expiration that does not provide adequate ventilation. • Impaired Gas Exchange: excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane. • Activity Intolerance: insufficient physiological or psychological energy to endure or complete required or desired daily activities. The preceding nursing diagnoses may also be the etiology of several other nursing diagnoses, such as these: • Anxiety related to ineffective airway clearance and feeling of • • • • •

suffocation Fatigue related to ineffective breathing pattern Fear related to chronic disabling respiratory illness Powerlessness related to inability to maintain independence in selfcare activities because of ineffective breathing pattern Insomnia related to orthopnea and required O2 therapy Social Isolation related to activity intolerance and inability to travel to usual social activities.

Planning The overall outcomes/goals for a client with oxygenation problems are to: • • • • •

Maintain a patent airway. Improve comfort and ease of breathing. Maintain or improve pulmonary ventilation and oxygenation. Improve the ability to participate in physical activities. Prevent risks associated with oxygenation problems such as skin and tissue breakdown, syncope, acid–base imbalances, and feelings of hopelessness and social isolation.

These outcomes provide direction for planning interventions and as criteria for evaluating client progress. A clinical example of desired outcomes, interventions, and activities is provided in the Nursing Care Plan and Concept Map at the end of the chapter.

Planning for Home Care To provide for continuity of care, the nurse needs to consider the client’s learning needs and needs for assistance with care in the home.

mL 6000

5000

4000

Inspiratory reserve volume 3100 mL

Inspiratory capacity 3600 mL Vital capacity 4800 mL

3000 Tidal volume 500 mL 2000

1000

Expiratory reserve volume 1200 mL Residual volume 1200 mL

Total lung capacity 6000 mL

Functional residual capacity 2400 mL

0

Figure 50–3 • The relationship of lung volumes and capacities. Volumes (mL) shown are for an average adult male; female volumes are 20% to 25% smaller.

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Home Care Assessment Oxygenation CLIENT • Self-care abilities: ability to ambulate and perform ADLs independently • Exercise and activity pattern: type and regularity of usual ­exercise, perceived and actual energy for desired and required leisure activities • Assistive devices required: supplemental oxygen, humidifier, nebulizer treatments, or inhalers; walker, cane, or wheelchair; grab bars, shower chair, and other devices to promote safety and minimize energy expenditure; scale to monitor weight on a regular basis • Home environment for factors that impair airway clearance, gas exchange, or activity tolerance: indoor pollutants such as cigarette smoke, dust, and allergens such as pets; lack of humidity in the air; and barriers such as stairs • Current level of knowledge: importance of avoiding smoking and other pollutants; dietary salt and other restrictions (if ­appropriate); recommended activities; medications; need to limit exposure to respiratory infections; use of prescribed nebulizer, multidose inhaler, powdered dose inhaler, or home oxygen; activity level

Planning incorporates an assessment of the client’s and family’s knowledge and abilities for self-care, financial resources, and evaluation of the need for referrals and for home health services. The Home Care Assessment outlines a home care assessment related to the client’s oxygenation problems and needs. Client Teaching: Home Care Oxygenation addresses the learning needs of the client and family.

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PATIENT-CENTERED CARE FAMILY • Caregiver availability, skills, and responses: ability and willingness to provide care as needed (help with ADLs, providing meals, assisting with transportation and shopping, caring for dependents; performing treatments such as percussion and postural drainage) • Family role changes and coping: effect on financial status, ­parenting and spousal roles, sexuality, social roles • Alternate potential primary or respite caregivers: for example, other family members, volunteers, church members, paid caregivers, or housekeeping services; available community respite care (e.g., adult day care, senior centers) COMMUNITY Environment: usual temperature and humidity, presence of air pollutants such as automobile exhaust, industrial smoke and pollutants, smoke from field burning • Current knowledge of and experience with community ­resources: medical and assistive equipment and supply ­companies, respiratory and physical therapy services, home health agencies, local pharmacies, available financial assistance, support and educational organizations such as the local lung association, COPD support groups •

Implementing Examples of nursing interventions to facilitate pulmonary ventilation may include ensuring a patent airway, positioning, encouraging deep breathing and coughing, and ensuring adequate hydration. Other nursing interventions helpful to ventilation are suctioning, lung inflation techniques, administration of analgesics before deep breathing

CLIENT TEACHING

Home Care Oxygenation MAINTAINING AIRWAY CLEARANCE AND EFFECTIVE GAS EXCHANGE • Emphasize to the client and family the importance of not smoking or lighting any flammable materials (e.g., candles) in the same room. Refer them to smoking cessation programs as needed. For family members resistant to not smoking, emphasize the need to avoid smoking inside the home. • Instruct the client in effective coughing techniques such as controlled coughing or “huff” coughing (see Client Teaching: Forced Expiratory Technique (Huff Coughing) in the Implementing section). • Discuss the significance of changes in sputum, including the amount and characteristics such as color, viscosity, and odor. Instruct the client when to contact a health care provider. • Teach the client to maintain a fluid intake of 2,500 to 3,000 mL (2.5 to 3 qt) per day if not contraindicated due to other health conditions such as heart failure or renal disease. • Instruct the client of the rationale for using and how to use nebulizers or inhalers if prescribed; see Chapter 35 , pages 820–823. • Teach the client and family how to use home oxygen delivery systems emphasizing safety considerations. PROMOTING EFFECTIVE BREATHING • Teach relaxation techniques such as progressive muscle relaxation, meditation, and visualization. Use DVDs as needed. • Help the client identify specific factors that affect breathing such as stress, exposure to allergens or air pollution, and exposure to cold. Assist with identifying possible interventions and measures to avoid these factors.

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MEDICATIONS • Teach the client about prescribed medications, including the rationale for the medications, the dose, the desired and possible adverse effects, and any precautions about using a medication with food, beverages, or other medications. SPECIFIC MEASURES FOR OXYGENATION PROBLEMS • Provide instructions and rationale for specific procedures and problems such as: a. Suctioning oropharyngeal and nasopharyngeal cavities b. Caring for a temporary or permanent tracheostomy c. Preventing the spread of tuberculosis and other respiratory infections to family members and others. REFERRALS • Make appropriate referrals to home health agencies or community social services for assistance in obtaining medical and assistive equipment such as grab bars, respiratory and physical therapy services, and home health or housekeeping services to assist with ADLs. COMMUNITY AGENCIES AND OTHER SOURCES OF HELP • Provide information about where durable medical equipment can be purchased, rented, or obtained free of charge; how to access home oxygen equipment and support services and physical and occupational therapy services; and where to obtain supplies such as tracheostomy supplies or nutritional supplements. • Suggest additional sources of information such as the American Lung Association and the Asthma and Allergy Foundation of America.

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and coughing, postural drainage, and percussion and vibration. Nursing strategies to facilitate the diffusion of gases through the alveolar membrane include encouraging coughing, deep breathing, and suitable activity. A client’s nursing care plan should also include appropriate dependent nursing interventions such as oxygen therapy, tracheostomy care, and maintenance of a chest tube.

Promoting Oxygenation Most people in good health give little thought to their respiratory function. Changing position frequently, ambulating, and exercising usually maintain adequate ventilation and gas exchange. Client Teaching lists other ways to promote healthy breathing. When people become ill, however, their respiratory functions may be inhibited for such reasons as pain and immobility. Shallow respirations inhibit both diaphragmatic excursion and lung distensibility. The result of inadequate chest expansion is pooling of respiratory secretions, which ultimately harbor microorganisms and promote infection. Additionally, shallow respirations may potentiate alveolar collapse, which may cause decreased diffusion of gases and subsequent hypoxemia. This situation is often compounded by giving narcotics for pain, because narcotics further depress the rate and depth of respiration. Interventions by the nurse to maintain the normal respirations of clients include: • • • • •

Positioning the client to allow for maximum chest expansion Encouraging or providing frequent changes in position Encouraging deep breathing and coughing Encouraging ambulation Implementing measures that promote comfort, such as giving pain medications.

The semi-Fowler’s or high-Fowler’s position allows maximum chest expansion in clients who are confined to bed, particularly those with dyspnea. The nurse also encourages clients to turn from side to side frequently, so that alternate sides of the chest are permitted maximum expansion. Clients with severe pneumonia or other pulmonary disease in one lung, if positioned laterally, should be generally positioned with the “good lung down” to improve diffusion of oxygen to the blood from functioning alveoli. Dyspneic clients often sit in bed and lean over their overbed tables (which are raised to a suitable height), usually with a pillow for support. This orthopneic position is an adaptation of the high-Fowler’s position. Some clients also sit upright CLIENT TEACHING

Promoting Healthy Breathing • • • • • • • • • • •

Sit straight and stand erect to permit full lung expansion. Exercise regularly. Breathe through the nose. Breathe in to expand the chest fully. Do not smoke cigarettes, cigars, or pipes. Eliminate or reduce the use of household pesticides and ­irritating chemical substances. Do not incinerate garbage in the house. Avoid exposure to secondhand smoke. Use building materials that do not emit vapors. Make sure furnaces, ovens, and wood stoves are correctly ventilated. Support a pollution-free environment.

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and lean on their arms or elbows, which is called the tripod position. The advantage to these positions is that each one forces the diaphragm down and forward and stabilizes the chest, which reduces the work of breathing. Also, a client in the orthopneic position can press the lower part of the chest against the table to help in exhaling (Figure 50–4 •).

Deep Breathing and Coughing The nurse can facilitate respiratory functioning by encouraging deep-breathing exercises and coughing to remove secretions from the airways. When coughing raises secretions high enough, the client may either expectorate (spit out) or swallow them. Swallowing the secretions is not harmful but does not allow the nurse to view the secretions for documentation purposes or to obtain a specimen for testing. Clients with conditions that increase secretions or impair mobilization of secretions such as chest surgery, COPD, or cystic fibrosis often require encouragement to cough and breathe deeply. Specialized breathing exercises may be prescribed for clients with chronic obstructive diseases as part of their pulmonary rehabilitation. These generally require collaboration with other health care providers. One technique, pursed-lip breathing, may help alleviate dyspnea (Facchiano, Snyder, & Núñez, 2011). The client is taught to breathe in normally through the nose and exhale through pursed lips as if about to whistle, and blow slowly and purposefully, tightening the abdominal muscles to assist with exhalation. Clients may practice by slowly blowing a ping-pong ball across a table or visualizing that they are trying to make a candle flame waver. Normal forceful coughing is highly effective, but some clients may lack the strength or ability to cough normally. Normal forceful coughing involves the client inhaling deeply and then coughing twice while exhaling. Alternative cough techniques such as forced expiratory technique, or huff coughing, may be taught as alternatives for those clients who are unable to perform a normal forceful cough. A client with a pulmonary condition (e.g., COPD) is instructed to exhale through pursed lips and to exhale with a “huff ” sound in mid-exhalation. The huff cough helps prevent the high expiratory pressures that collapse diseased airways. This cough technique is described in Client Teaching. Hydration Adequate hydration maintains the moisture of the respiratory mucous membranes. Normally, respiratory tract secretions are thin and are therefore moved readily by ciliary action. However, when the client is dehydrated or when the environment has a low humidity, the respiratory secretions can become thick and tenacious. Fluid intake should be as great as the client can tolerate. See Chapter 52 for normal daily fluid intake. Humidifiers are devices that add water vapor to inspired air. Room humidifiers provide cool mist to room air. Nebulizers are used to deliver humidity and medications. They may be used with oxygen delivery systems to provide moistened air directly to the client. Their purposes are to prevent mucous membranes from drying and becoming irritated and to loosen secretions for easier expectoration. Medications A number of types of medications can be used for clients with oxygenation problems. Bronchodilators, anti-inflammatory drugs, expectorants, and cough suppressants are some medications that may be used to treat

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Figure 50–4 • Two sitting “tripod” positions that help assist with breathing.

CLIENT TEACHING

Forced Expiratory Technique (Huff Coughing) • • •

• • •

After using a bronchodilator treatment (if prescribed), inhale deeply and hold your breath for a few seconds. Cough twice while exhaling. The first cough loosens the mucus; the second expels secretions. For huff coughing, lean forward and exhale sharply with a “huff” sound mid-exhalation. This technique helps keep your airways open while moving secretions up and out of the lungs. Inhale by taking rapid short breaths in succession (“sniffing”) to prevent mucus from moving back into smaller airways. Rest and breathe slowly between coughs. Try to avoid prolonged episodes of coughing because these may cause fatigue and hypoxia.

respiratory problems. Bronchodilators, including sympathomimetic drugs and xanthines, reduce bronchospasm, opening tight or congested airways and facilitating ventilation. These drugs may be administered orally or intravenously, but the preferred route is by inhalation to prevent many systemic side effects. Because drugs used to dilate the bronchioles and improve breathing are usually drugs that enhance the sympathetic nervous

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system, clients must be monitored for side effects of increased heart rate, blood pressure, anxiety, and restlessness. This is especially important in older adults, who may also have cardiac problems. Some over-the-counter drugs for respiratory problems have these same effects, so clients should be cautioned about taking them without checking with their primary care provider. Another class of drugs used is the anti-inflammatory drugs, such as glucocorticoids. They can be given orally, intravenously, or by inhaler. They work by decreasing the edema and inflammation in the airways and allowing a better air exchange. If both bronchodilators and anti-inflammatory drugs are ordered by inhaler, the client should be instructed to use the bronchodilator inhaler first and then the anti-inflammatory inhaler. If the bronchioles are dilated first, more tissue is exposed on which the anti-inflammatory drugs can act. Newer formulations may combine a long-acting bronchodilator with an inhaled corticosteroid to improve client adherence to therapy because they require less time and less frequent dosing. Another class of drugs is the leukotriene modifiers. These medications suppress the effects of leukotrienes on the smooth muscle of the respiratory tract. Leukotrienes cause bronchoconstriction, mucous production, and edema of the respiratory tract. Expectorants help “break up” mucus, making it more liquid and easier to expectorate. Guaifenesin is a common expectorant found

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A

B

Figure 50–5 • A, Flow-oriented SMI; B, volume-oriented SMI.

in many prescription and nonprescription cough syrups. When frequent or prolonged coughing interrupts sleep, a cough suppressant such as codeine may be prescribed. Other medications can be used to improve oxygenation by improving cardiovascular function. The digitalis glycosides act directly on the heart to improve the strength of contraction and slow the heart rate. Beta-adrenergic stimulating agents such as dobutamine similarly increase cardiac output, thus improving O2 transport. Beta-­adrenergic blocking agents such as propranolol affect the sympathetic nervous system to reduce the workload of the heart. These drugs, however, can negatively affect people with asthma or COPD because they may constrict airways by blocking beta-2 adrenergic receptors.

Incentive Spirometry Incentive spirometers (Figure 50–5 •), also referred to as sustained maximal inspiration devices (SMIs), measure the flow of air inhaled through the mouthpiece and are used to: • • • • •

Improve pulmonary ventilation. Counteract the effects of anesthesia or hypoventilation. Loosen respiratory secretions. Facilitate respiratory gaseous exchange. Expand collapsed alveoli.

SMIs are designed to mimic natural sighing or yawning by encouraging the client to take long, slow, deep breaths. The two general types

Evidence-Based Practice Can Breathing Exercises Have Beneficial Effects on Dyspnea, Exercise Capacity, and Health-Related Quality of Life for Clients with COPD? Some studies have reported positive short-term physiological effects (e.g., improvement in gas exchange and ventilation) of breathing exercises in people with COPD; however, their effects on dyspnea, exercise capacity, and well-being are unclear. Holland, Hill, Jones, and McDonald (2012) conducted a review of literature to determine whether breathing exercises designed to retrain the breathing pattern could reduce dyspnea, increase exercise capacity, and improve well-being for people with COPD. They identified research trials using the Cochrane Airways Group Specialized Register of trials. The search resulted in a total of 16 randomized controlled trials (RCTs) that compared breathing exercises to no breathing exercises or another intervention in clients with COPD. The studies were conducted and published between 1965 and 2012, with 13 of the studies published since 2000. The size of the studies varied from 21 to 324 participants with a total of 1,233 participants, most of whom had severe COPD. The breathing techniques used in the research studies included pursed-lip breathing, diaphragmatic breathing, pranayama yoga breathing, changing the breathing pattern using computerized

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EVIDENCE-BASED PRACTICE

feedback to slow the respiratory rate and increase exhalation time, or combinations of these techniques. The authors concluded that breathing exercises appeared to be safe for people with COPD. Yoga breathing, pursed-lip breathing, and diaphragmatic breathing improved the distance walked in 6 minutes. They found that the effects of breathing exercises on dyspnea and well-being were variable. The authors noted that the “study quality was generally low” and recommended the need for additional rigorously designed RCTs to evaluate breathing exercises in people with COPD. IMPLICATIONS The authors state that there is currently no evidence to suggest that breathing exercises have benefits exceeding those delivered through the whole-body exercise training involved in pulmonary rehabilitation. Individuals with COPD who do not want to go through pulmonary rehabilitation or who do not have access to a pulmonary rehabilitation program may choose to perform breathing exercises.

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DRUG CAPSULE

Sympathomimetics  albuterol (Proventil, Ventolin) CLIENT WITH RESPIRATORY MEDICATIONS THAT CAUSE BRONCHODILATION BY STIMULATING BETA-2 ADRENERGIC RECEPTORS IN THE LUNG The beta-2 adrenergic agonists are called sympathomimetic drugs because they “mimic” the action of sympathetic stimulation to the beta-2 receptors in the smooth muscle of the lung. At therapeutic levels these drugs promote bronchodilation and so relieve bronchospasm. Sympathomimetic agents are useful in the treatment of bronchospasm in reversible obstructive airway diseases such as asthma and bronchitis. They are also useful in preventing exercise-induced bronchospasm. Drugs that block the parasympathetic nervous system (anticholinergics) such as ipratropium (Atrovent) may be used alone or in combination (Combivent) with sympathomimetic agents to provide additional bronchodilation. NURSING RESPONSIBILITIES • Most inhaled sympathomimetics have a very rapid onset and short duration of action, so they are useful for relief of acute ­attacks but not for prophylaxis. • Monitor the client’s respiratory status while administering ­sympathomimetics. This includes respiratory rate, lung sounds, oxygen saturation, and subjective symptoms.

These medications should be used with caution in clients with conditions such as cardiac disease, vascular disease, ­hypertension, hyperthyroidism, and pregnancy. • Monitor the client for common side effects including increased heart rate (due to sympathetic stimulation of the heart) and tremors. • Monitor for other side effects that occur with excessive dosing, which may include CNS stimulation, gastrointestinal upset, ­hypertension, and sweating. •

CLIENT AND FAMILY TEACHING • Caution the client to use the least amount of medication needed to get relief for the shortest time period necessary. This will help prevent adverse effects. • Counsel the client to report immediately any chest pain and/or changes in heart rate or rhythm. • Teach the client and/or family how to use the delivery system. This will most often be a metered-dose inhaler (MDI) or dry powder inhaler (DPI) or nebulizer. • Teach the client to record the frequency and intensity of symptoms. Note: Prior to administering any medication, review all aspects with a current drug handbook or other reliable source.

DRUG CAPSULE

Glucocorticosteroids Inhaled: fluticasone (Flovent) CLIENT WITH RESPIRATORY MEDICATIONS THAT SUPPRESS INFLAMMATION Glucocorticosteroids are administered to clients with oxygenation problems to suppress inflammation. They can be administered either by inhalation, orally, or intravenously. The route of administration depends on the severity of the client’s disorder and the individual’s response. Glucocorticosteroids (steroids) are well absorbed from the respiratory tract so giving them by inhalation is often effective. Steroids suppress the inflammatory response in the airways by decreasing synthesis and release of inflammatory mediators, decreasing activity of inflammatory cells, and decreasing edema. NURSING RESPONSIBILITIES • Glucocorticosteroids are intended for preventive therapy. They will not be useful in an acute attack. • If the client is also taking a sympathomimetic medication, delivery of inhaled corticosteroids (ICS) to the respiratory tract may be enhanced by administering the sympathomimetic first (and waiting 3 to 5 minutes). • It is important to monitor the client’s respiratory status while ­administering steroids. This includes respiratory rate, lung sounds, oxygen saturation, and subjective symptoms. • These medications should be used with caution or not at all in clients with conditions such as allergy, pregnancy, lactation, and systemic infections.

Monitor the client for side effects of the medications. Most commonly this could be an increase in heart rate (due to ­sympathetic stimulation of the heart) and tremors. • The client should be monitored for other side effects, which will usually only occur with excessive dosing and may include CNS stimulation, gastrointestinal upset, hypertension, and sweating. •

CLIENT AND FAMILY TEACHING • Caution the client to use the least amount needed to get relief for the shortest time period necessary. This will help prevent adverse effects. Alternate-day therapy may be recommended to decrease adrenal suppression. • Make sure the client understands that these drugs are not for acute attacks. They are intended to be preventive therapy. • Teach the client and/or family how to use the delivery system. This will most often be a metered-dose inhaler (MDI) or dry powder inhaler (DPI) or nebulizer. • Counsel the client to rinse the mouth after using ICS to ­decrease the risk of oropharyngeal or esophageal fungal ­infections (thrush). • Counsel the client to report adverse effects such as sore throat, hoarseness, and pharyngeal and laryngeal fungal infections. • Teach the client to record the frequency and intensity of symptoms. Note: Prior to administering any medication, review all aspects with a current drug handbook or other reliable source.

CLIENT TEACHING

Using Cough Medications Do not take cough medications in excessive amounts ­because of adverse side effects. • If you have diabetes mellitus, avoid cough syrups that contain sugar or alcohol; these can disturb metabolism. •

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When a cough medicine does not act as expected, consult a health care professional. • Be aware of side effects (e.g., drowsiness) that can make the operation of machinery dangerous. •

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of spirometers are the flow-oriented spirometer and the volume-­ oriented spirometer. The flow-oriented spirometer consists of one or more clear plastic chambers containing freely movable colored balls or disks. The ball or disks are elevated as the client inhales. The longer the inspiratory flow is maintained, the larger the volume, so the client is encouraged to take slow deep breaths. This type of spirometer does not measure the specific volume of air inhaled. Volume-oriented spirometers measure the inhalation volume maintained by the client. When the client inhales, a piston-like plate or accordion-pleated cylinder rises as the client inspires, and markings on the side indicate the volume of inspiration achieved by the client. When using an SMI, the client should be assisted into a position, preferably an upright sitting position in bed or on a chair, that facilitates maximum ventilation. Client Teaching lists instructions for clients in the use of incentive spirometers.

Percussion, Vibration, and Postural Drainage Percussion, vibration, and postural drainage (PVD) are performed according to a primary care provider’s order by nurses, respiratory therapists, physical therapists, or an interdisciplinary team of these health care team members. Percussion, sometimes called clapping, is forceful striking of the skin with cupped hands. Mechanical percussion cups and vibrators are also available. When the hands are used, the fingers and thumb are held together and flexed slightly to form a cup, as one would to scoop up water. Percussion over congested lung areas can mechanically dislodge tenacious secretions from the bronchial walls. Cupped hands trap the air against the CLIENT TEACHING

Using an Incentive Spirometer •

• • •

•

• • • • •

•

Hold or place the spirometer in an upright position. A tilted flow-oriented device requires less effort to raise the balls or disks; a volume-oriented device will not function correctly ­unless upright. Exhale normally. Seal the lips tightly around the mouthpiece. Take in a slow, deep breath to elevate the balls or cylinder, and then hold the breath for 2 seconds initially, increasing to 6 seconds (optimum), to keep the balls or cylinder elevated if possible. For a flow-oriented device, avoid brisk, low-volume breaths that snap the balls to the top of the chamber. Greater lung expansion is achieved with a very slow inspiration than with a brisk, shallow breath, even though it may not elevate the balls or keep them elevated while you hold your breath. Sustained elevation of the balls or cylinder ensures adequate ventilation of the alveoli (lung air sacs). If you have difficulty breathing only through the mouth, a nose clip can be used. Remove the mouthpiece and exhale normally. Cough after the incentive effort. Deep ventilation may loosen secretions, and coughing can facilitate their removal. Relax and take several normal breaths before using the ­spirometer again. Repeat the procedure several times and then four or five times hourly. Practice increases inspiratory volume, maintains alveolar ventilation, and prevents atelectasis (collapse of the air sacs). Clean the mouthpiece with water and shake it dry.

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Figure 50–6 • Percussing the upper posterior chest.

chest. The trapped air then sets up vibrations through the chest wall to the secretions. To percuss a client’s chest, follow these steps: • Cover the area with a towel or gown to reduce discomfort. • Ask the client to breathe slowly and deeply to promote relaxation. • Alternately flex and extend the wrists rapidly to slap the chest

(Figure 50–6 •). • Percuss each affected lung segment for 1 to 2 minutes.

When done correctly, the percussion action should produce a hollow, popping sound. Percussion is avoided over the breasts, sternum, spinal column, and kidneys. Vibration is a series of vigorous quiverings produced by hands that are placed flat against the client’s chest wall. Vibration is used after percussion to increase the turbulence of the exhaled air and thus loosen thick secretions. It is often done alternately with percussion. To vibrate the client’s chest, the nurse follows these steps: • Place hands, palms down, on the chest area to be drained, one

hand over the other with the fingers together and extended ­(Figure 50–7 •). Alternatively, the hands may be placed side by side. • Ask the client to inhale deeply and exhale slowly through the nose or pursed lips.

Figure 50–7 • Vibrating the upper posterior chest.

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• During the exhalation, tense all the hand and arm muscles, and

using mostly the heel of the hand, vibrate (shake) the hands, moving them downward. Stop the vibrating when the client inhales. • Vibrate during five exhalations over one affected lung segment. • After each vibration, encourage the client to cough and expectorate secretions into the sputum container. Postural drainage is the drainage by gravity of secretions from various lung segments. Secretions that remain in the lungs or respiratory airways promote bacterial growth and subsequent infection. They also can obstruct the smaller airways and cause atelectasis. Secretions in the major airways, such as the trachea and the right and left main bronchi, are usually coughed into the pharynx, where they can be expectorated, swallowed, or effectively removed by suctioning. A wide variety of positions is necessary to drain all segments of the lungs, but not all positions are required for every client. Only those positions that drain specific affected areas are used. The lower lobes require drainage most frequently because the upper lobes drain by gravity. Before postural drainage, the client may be given a bronchodilator medication or nebulization therapy to loosen secretions. Postural drainage treatments are scheduled two or three times daily, depending on the degree of lung congestion. The best times include before breakfast, before lunch, in the late afternoon, and before bedtime. It is best to avoid hours shortly after meals because postural drainage at these times can be tiring and can induce vomiting. The nurse needs to evaluate the client’s tolerance of postural drainage by assessing the stability of the client’s vital signs, particularly the pulse and respiratory rates, and by noting signs of intolerance, such as pallor, diaphoresis, dyspnea, nausea, and fatigue. Some clients do not react well to certain drainage positions, and the nurse must make appropriate adjustments. For example, some become dyspneic in Trendelenburg’s position and require only a moderate tilt or a shorter time in that position. The sequence for PVD is usually as follows: positioning, percussion, vibration, and removal of secretions by coughing or suction. Each position is usually assumed for 10 to 15 minutes, although beginning treatments may start with shorter times and gradually increase. Following PVD, the nurse should auscultate the client’s lungs, compare the findings to the baseline data, and document the amount, color, and character of expectorated secretions. Today, kinetic therapy beds with modalities such as vibration and percussion therapy are widely available. These beds provide continuous lateral rotational therapy (CLRT) along with vibration and percussion modules that are programmed to perform for a specific amount of time.

Mucus Clearance Devices A mucus clearance device (MCD) is used for clients with excessive secretions such as cystic fibrosis, COPD, and bronchiectasis (Wang, Zhang, & Li, 2010). The Flutter™ mucus clearance device is an example of one of these devices. The Flutter MCD is a small, handheld device with a hard plastic mouthpiece at one end and a perforated cover at the other end. Inside the device is a steel ball that sits in a circular cone shape (Figure 50–8 •). The client inhales slowly and then, keeping the cheeks firm, exhales fast through the device, causing the steel ball to move up and down. This movement causes vibrations that loosen mucus from the airways and assist its movement up the airways to be expectorated.

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Figure 50–8 • Flutter mucus clearance device.

Oxygen Therapy The medical administration of supplemental oxygen is considered to be a process similar to that of administering medications and requires similar nursing actions. Determining the effectiveness of oxygen therapy involves several measures, including checking vital signs and peripheral blood oxygen saturation (pulse oximetry). Supplemental oxygen is indicated for clients who have hypoxemia due to the reduced ability for diffusion of oxygen through the respiratory membrane, hyperventilation, or substantial loss of lung tissue due to tumors or surgery. Others who may require oxygen are those with severe anemia or blood loss, or similar conditions in which there are inadequate numbers of RBCs or hemoglobin to carry the oxygen. Oxygen therapy is prescribed by the primary care provider, who specifies the concentration, method of delivery, and depending on the method, liter flow per minute (L/min). The order may also call for the nurse to titrate the oxygen to achieve a desired saturation level as measured by pulse oximetry. When administering oxygen as an emergency measure, the nurse may initiate the therapy, and then contact the primary care provider for an order. Oxygen is supplied in two ways in health care facilities: by portable systems (cylinders or tanks) and from wall outlets. Long-term care or assisted living facilities may use similar oxygen supplies or those used more commonly in the home. Clients who require oxygen therapy in the home may use small cylinders of oxygen, oxygen in liquid form, or an oxygen concentrator. Portable oxygen delivery systems are available to increase the client’s independence. Home oxygen therapy services are readily available in most communities. These services generally supply the oxygen and delivery devices, training for the client and family, equipment maintenance, and emergency services should a problem occur. Oxygen administered from a cylinder or wall-outlet system is dry. Dry gases dehydrate the respiratory mucous membranes. Humidifying devices that add water vapor to inspired air are thus an essential adjunct of oxygen therapy, particularly for liter flows over 4 L/min (Figure 50–9 •). These devices provide 20% to 40%

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humidity. A humidifier bottle is attached below the flow meter gauge so that the oxygen passes through water and then through the specific oxygen tubing and equipment prescribed for the client (e.g., nasal cannula or mask). Humidifiers prevent mucous membranes from drying and becoming irritated and loosen secretions for easier expectoration. Oxygen passing through water picks up water vapor before it reaches the client. The more bubbles created during this process, the more water vapor is produced. Very low liter flows (e.g., 1 to 2 L/min by nasal cannula) do not require humidification. When a client is breathing very low flow oxygen, enough atmospheric air is inhaled (which naturally has water vapor in it) to prevent mucosal drying. Oxygen cylinders need to be handled and stored with caution and strapped securely in wheeled transport devices or stands to prevent possible falls and outlet breakages. They should be placed away from traffic areas and heaters. A regulator that releases oxygen at a safe level and at a desirable rate must be attached before the oxygen supply is used. On a cylinder, the contents gauge indicates the pressure or amount of oxygen remaining in the tank and the flow meter or flow indicator indicates the gas flow in liters per minute. A flow meter is also required for wall-outlet systems. To use an oxygen wall-outlet system, carry out these steps:

• Fill the humidifier bottle with distilled or tap water in accordance

with agency protocol. This can be done before coming to the bedside. Some humidifier bottles come prefilled by the manufacturer. • Attach the humidifier bottle to the base of the flow meter (if indicated). • Attach the prescribed oxygen tubing and delivery device to the humidifier. • Regulate the flow meter to the prescribed level. The line for the prescribed flow rate (e.g., 2 L/min) should be in the middle of the ball of the flow meter (Figure 50–11 •). Safety precautions are essential during oxygen therapy (Box  50–2). Although oxygen by itself will not burn or explode, it does facilitate combustion. For example, a bed sheet ordinarily burns slowly when ignited in the atmosphere; however, if saturated with free-flowing oxygen and ignited by a spark, it will burn rapidly and explosively. The greater the concentration of oxygen, the more rapidly fires start and burn, and such fires are difficult to extinguish. Because oxygen is colorless, odorless, and tasteless, people are often unaware of its presence. It is important to teach clients about this aspect of oxygen therapy.

• Attach the flow meter to the wall outlet, exerting firm pressure.

The flow meter should be in the off position (Figure 50–10 •).

Figure 50–10 • Insert flow meter into the wall unit.

Figure 50–9 • An oxygen humidifier attached to a wall outlet oxygen flow meter.

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Figure 50–11 • This flow meter is set to deliver 2 L/min.

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BOX 50–2   Oxygen Therapy Safety Precautions •

•

• •

•

•

• •

For home oxygen use or when the facility permits smoking, teach family members and roommates to smoke only outside or in provided smoking rooms away from the client and ­oxygen equipment. Place cautionary signs reading “No Smoking: Oxygen in Use” on the client’s door, at the foot or head of the bed, and on the oxygen equipment. Instruct the client and visitors about the hazard of smoking with oxygen in use. Make sure that electric devices (such as razors, hearing aids, radios, televisions, and heating pads) are in good working ­order to prevent the occurrence of short-circuit sparks. Avoid materials that generate static electricity, such as woolen blankets and synthetic fabrics. Cotton blankets should be used, and clients and caregivers should be advised to wear cotton fabrics. Avoid the use of volatile, flammable materials, such as oils, greases, alcohol, ether, and acetone (e.g., nail polish ­remover), near clients receiving oxygen. Be sure that electric monitoring equipment, suction machines, and portable diagnostic machines are all electrically grounded. Make known the location of fire extinguishers, and make sure personnel are trained in their use.

Like any medication, oxygen is not completely harmless to the client. Clients can receive an inadequate amount or an excessive amount of oxygen and both can lead to a decline in the client’s condition. An inadequate amount of oxygen (hypoxia) will lead to cell death, and if left untreated can ultimately lead to death. Excessive amounts of oxygen can lead to pulmonary tissue damage, increased duration of mechanical ventilation, and longer ICU and hospital stays (Blakeman, 2013; Kallet, 2012; Martin & Grocott, 2013). Oxygen toxicity can develop from breathing greater than 50% oxygen for 12 hours (Kallet, 2012). The lowest concentration needed to achieve the desired blood oxygen saturation (e.g., greater than 90% or a level prescribed by the primary care provider) should be used.

A

1285

Oxygen Delivery Systems Low-flow and high-flow systems are available to deliver oxygen to the client. The choice of system depends on the client’s oxygen needs, comfort, and developmental considerations. Low-flow systems deliver oxygen via small-bore tubing. Low-flow administration devices include nasal cannulas, face masks, oxygen tents, and transtracheal catheters. Because with these types of devices room air is also inhaled along with the supplemental oxygen, the fraction of inspired oxygen (FiO2) will vary depending on the respiratory rate, tidal volume, and liter flow. High-flow systems supply all the oxygen required during ventilation in precise amounts, regardless of the client’s respirations. The high-flow system used to deliver a precise and consistent FiO2 is the Venturi mask with large-bore tubing. Cannula

The nasal cannula (nasal prongs) is the most common and inexpensive device used to administer oxygen (Figure 50–12 •). The nasal cannula is easy to apply and does not interfere with the client’s ability to eat or talk. It also is relatively comfortable, permits some freedom of movement, and is well tolerated by the client. It delivers a relatively low concentration of oxygen (24% to 45%) at flow rates of 2 to 6 L/min. Above 6 L/min, the client tends to swallow air and the FiO2 is not increased. Limitations of the plain nasal cannula include inability to deliver higher concentrations of oxygen, and that it can be drying and irritating to mucous membranes. Reservoir nasal cannulas are oxygen-conserving devices and are also called Oxymizer oxygen-conserving devices. They are used primarily in the home setting. The reservoir nasal cannula stores oxygen in the reservoir while the client breathes out and then delivers a 100% oxygen bolus when the client breathes in. As a result it delivers a higher oxygen concentration at a lower flow rate than the plain nasal cannula because it conserves oxygen. It can deliver FiO2 of 0.5 or greater, while providing the same benefits of a plain nasal cannula. The two styles of reservoir nasal cannulas (Oxymizers) are the mustache and pendant styles (see Figure 50–12 B and C). Humidification is not necessary with the reservoir nasal cannula, because it collects

B

C

Figure 50–12 • A, Nasal cannula; B, mustache reservoir nasal cannula; C, pendant reservoir nasal cannula.

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water vapor while the client breathes out and returns it when the client breathes in. Administering oxygen by cannula is detailed in Skill 50–1. Face Mask

Face masks that cover the client’s nose and mouth may be used for oxygen inhalation. Most masks are made of clear, pliable plastic that can be molded to fit the face. They are held to the client’s head with elastic bands. Some have a metal clip that can be bent over the bridge of the nose for a snug fit. Exhalation ports on the sides of the mask allow exhaled carbon dioxide to escape. Some masks have reservoir bags, which provide higher oxygen concentrations to the client. A portion of the client’s expired air is directed into the bag. Because this air comes from the upper respiratory passages (e.g., the trachea and bronchi), where it does not take part in gaseous exchange, its oxygen concentration remains the same as that of inspired air. A variety of oxygen masks are marketed:

oxygen reservoir bag that is attached allows the client to rebreathe about the first third of the exhaled air in conjunction with oxygen (­Figure 50–13 B). Thus, it increases the FiO2 by recycling expired oxygen. The partial rebreather bag must not totally deflate during inspiration to avoid carbon dioxide buildup. If this problem occurs, the nurse increases the liter flow of oxygen so that the bag remains one third to one half full. • The nonrebreather mask delivers the highest oxygen concentration possible—95% to 100%—by means other than intubation or mechanical ventilation, at liter flows of 10 to 15 L/min. One-way valves on the mask and between the reservoir bag and the mask prevent the room air and the client’s exhaled air from entering the bag so only the oxygen in the bag is inspired (­Figure 50–13 C). In some cases, one of the side valves is removed so that the client can still inhale room air if the oxygen supply is accidentally cut off. To prevent carbon dioxide buildup, the nonrebreather bag must not totally deflate during inspiration. If it does, the nurse can correct this problem by increasing the liter flow of oxygen.

• The simple face mask delivers oxygen concentrations from 40% to

60% at liter flows of 5 to 8 L/min, respectively (Figure 50–13 A •).

• The partial rebreather mask delivers oxygen concentrations

of 60% to 90% at liter flows of 6 to 10 L/min, respectively. The

B

A

C

D

Figure 50–13 • A, A simple face mask; B, a partial rebreather mask; C, a nonrebreather mask D, a Venturi mask.

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• The Venturi mask delivers oxygen concentrations varying from

24% to 40% or 50% at liter flows of 4 to 10 L/min (Figure 50–13 D). The Venturi mask has wide-bore tubing and color-coded jet adapters that correspond to a precise oxygen concentration and liter flow. For example, in some cases, a blue adapter delivers a 24% concentration of oxygen at 4 L/min, and a green adapter delivers a 35% concentration of oxygen at 8 L/min. However, colors and concentrations may vary by manufacturers so the equipment must be examined carefully. Other manufacturers use a dial or setting for the desired concentration. Turning the oxygen source flow rate higher than specified by the equipment manufacturer will not increase the concentration delivered to the client.

Initiating oxygen by mask is much the same as initiating oxygen by cannula, except that the nurse must find a mask of appropriate size. Smaller sizes are available for children. Administering oxygen by mask or face tent is detailed in Skill 50–1. Limitations of masks include difficulty in achieving a proper fit and poor tolerance by some clients who may complain of feeling hot or “smothering.” Face Tent

Face tents (Figure 50–14 •) can replace oxygen masks when masks are poorly tolerated by clients. Face tents provide varying concentrations of oxygen, for example, 30% to 50% concentration of oxygen at 4 to 8 L/min. Frequently inspect the client’s facial skin for dampness or chafing, and dry and treat as needed. As with face masks, the client’s facial skin must be kept dry. Transtracheal Catheter

A transtracheal catheter is placed through a surgically created tract in the lower neck directly into the trachea. Once the tract has matured (healed), the client removes and cleans the catheter two to four times per day. Oxygen applied to the catheter at greater than 1 L/min should be humidified, and high flow rates, as much as 15 to 20 L/min, can be administered (Figure 50–15 •). Noninvasive Positive Pressure Ventilation (NPPV)

In certain circumstances clients require mechanical assistance to maintain adequate breathing. This assistance may be accomplished by the use of noninvasive positive pressure ventilation (NPPV), delivery of air or oxygen under pressure without the need

Figure 50–14 • An oxygen face tent.

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Figure 50–15 • Transtracheal catheter.

for an invasive tube such as an endotracheal tube or tracheostomy tube. Conditions requiring noninvasive ventilation include acute and chronic respiratory failure, pulmonary edema, COPD, and obstructive sleep apnea. This discussion focuses on the use of noninvasive ventilation devices in the treatment of sleep apnea due to the prevalence of this condition. Sleep apnea affects 12 million Americans. When breathing stops (apnea), the person’s carbon dioxide level rises, breathing is stimulated, and then it resumes. There are varying types of sleep apnea but obstructive sleep apnea (OSA) is the most common. Risk factors include male gender, obesity, and age over 40; however, it can affect anyone at any age, including children. OSA can lead to a number of health problems including hypertension, fatigue, memory problems, other cardiovascular disease, and headaches. If an underlying cause can be treated, OSA may be reduced or eliminated. The most common and least invasive treatment for OSA is positive pressure ventilation. A mask fitted over the client’s nose during sleep provides air under pressure during inhalation and exhalation so that the airway is kept open and cannot collapse. This mask and pump system is called continuous positive airway pressure (CPAP) (Figure 50–16 •). A variation of CPAP is bilevel positive airway

Figure 50–16 • A CPAP machine in use in the client’s home. Custom Medical Stock Photo, Inc.

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pressure (BiPap) in which the pressure delivered during exhalation is less than the pressure delivered during inhalation. The nurse’s primary role in caring for clients using CPAP or BiPAP devices is to ensure optimal functioning and use of the device since it may need to be used nightly for the remainder

of their lives. There may be significant issues with adherence to CPAP therapy due to discomfort or other barriers, so the nurse should provide client education and support and also collaborate with the respiratory therapist and other involved health care providers.

SKILL 50–1

Administering Oxygen by Cannula, Face Mask, or Face Tent Before administering oxygen, check (a) the order for oxygen, including the administering device and the liter flow rate (L/min) or the percentage of oxygen; (b) the levels of oxygen (PaO2) and carbon dioxide (PaCO2) in the client’s arterial blood (PaO2 is normally 80 to

100 mmHg; PaCO2 is normally 35 to 45 mmHg); and (c) whether the client has COPD. Note: If the client has not had arterial blood gases ordered, oxygen saturation should be checked using a noninvasive oximeter.

PURPOSES Cannula • To deliver a relatively low concentration of oxygen when only minimal O2 support is required • To allow uninterrupted delivery of oxygen while the client ingests food or fluids

Face Mask • To provide moderate O2 support and a higher concentration of oxygen and/or humidity than is provided by cannula • To provide a high flow of O2 when attached to a Venturi system Face Tent • To provide high humidity • To provide oxygen when a mask is poorly tolerated

ASSESSMENT See also Skill 30–11, Assessing the Thorax and Lungs, on pages 556–559. Assess • Skin and mucous membrane color: Note whether cyanosis is present, presence of mucus, sputum production, and ­impedance of airflow. • Breathing patterns: Note depth of respirations and presence of tachypnea, bradypnea, or orthopnea. • Chest movements: Note whether there are any intercostal, ­substernal, suprasternal, supraclavicular, or tracheal retractions during inspiration or expiration. • Chest wall configuration (e.g., kyphosis, unequal chest ­expansion, barrel chest). • Lung sounds audible by auscultating the chest and by ear. • Presence of clinical signs of hypoxemia: tachycardia, tachypnea, restlessness, dyspnea, cyanosis, and confusion. Tachycardia and tachypnea are often early signs. Confusion is a later sign of severe oxygen deprivation. • Presence of clinical signs of hypercarbia (hypercapnia): restlessness, hypertension, headache, lethargy, tremor. PLANNING Consult with a respiratory therapist as needed in the beginning and during ongoing care of clients receiving ordered oxygen therapy. In many agencies, the therapist establishes the initial equipment and client teaching.

DELEGATION Initiating the administration of oxygen is considered similar to administering a medication and is not delegated to unlicensed assistive personnel (UAP). However, reapplying the oxygen delivery device may be performed by the UAP, and many aspects of the client’s response to oxygen therapy are observed during usual care and may be recorded by individuals other than the nurse. Abnormal findings must be validated and interpreted by the nurse. The nurse is also responsible for ensuring that the correct delivery method is being used.

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Presence of clinical signs of oxygen toxicity: tracheal irritation and cough, dyspnea, and decreased pulmonary ventilation.

Determine • Vital signs, especially pulse rate and quality, and respiratory rate, rhythm, and depth. • Whether the client has COPD. A high carbon dioxide level in the blood is the normal stimulus to breathe. However, people with COPD may have a chronically high carbon dioxide level, and their stimulus to breathe is hypoxemia. During continuous oxygen administration, arterial blood gas levels of oxygen (PaO2) and carbon dioxide (PaCO2) are measured periodically to monitor hypoxemia. • Results of diagnostic studies such as chest x-ray. • Hemoglobin, hematocrit, and complete blood count. • Oxygen saturation levels. • Arterial blood gases levels, if available. • Pulmonary function tests, if available.

INTERPROFESSIONAL PRACTICE Administering oxygen may be within the scope of practice for specific health care providers. For example, in addition to nurses, respiratory therapists are involved in the care of clients receiving oxygen therapy. Although the respiratory therapist may verbally communicate their findings and plan to the health care team members, the nurse must also know where to locate their documentation in the client’s medical record. Equipment Cannula • Oxygen supply with a flow meter and adapter • Humidifier with distilled water or tap water according to agency protocol • Nasal cannula and tubing • Tape (optional) • Padding for the elastic band

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IMPLEMENTATION Preparation 1. Determine the need for oxygen therapy, and verify the order for the therapy. • Perform a respiratory assessment to develop baseline data if not already available. 2. Prepare the client and support people. • Assist the client to a semi-Fowler’s position if possible. Rationale: This position permits easier chest expansion and hence easier breathing. • Explain that oxygen is not dangerous when safety precautions are observed. Inform the client and support people about the safety precautions connected with oxygen use. Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the effects of the oxygen therapy will be used in planning further care or treatments. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Provide for client privacy, if appropriate. 4. Set up the oxygen equipment and the humidifier. • Attach the flow meter to the wall outlet or tank. The flow meter should be in the off position. • If needed, fill the humidifier bottle. (This can be done before coming to the bedside.) • Attach the humidifier bottle to the base of the flow meter. • Attach the prescribed oxygen tubing and delivery device to the humidifier. 5. Turn on the oxygen at the prescribed rate and ensure proper functioning. • Check that the oxygen is flowing freely through the tubing. There should be no kinks in the tubing, and the connections should be airtight. There should be bubbles in the humidifier as the oxygen flows through. You should feel the oxygen at the outlets of the cannula, mask, or tent. • Set the oxygen at the flow rate ordered. 6. Apply the appropriate oxygen delivery device. Cannula • Put the cannula over the client’s face, with the outlet prongs fitting into the nares and the tubing hooked around the ears (see Figure 50–12 A). • If the cannula will not stay in place, tape it at the sides of the face. • Pad the tubing and band over the ears and cheekbones as needed. Face Mask • Guide the mask toward the client’s face, and apply it from the nose downward. EVALUATION • Perform follow-up based on findings that deviated from expected or normal for the client. Relate findings to previous data if available (e.g., check oxygen saturation to evaluate ­adequate oxygenation).

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Face Tent Oxygen supply with a flow meter and adapter Humidifier with distilled water or tap water according to agency protocol • Face tent of the appropriate size • •

Fit the mask to the contours of the client’s face (see Figure 50–13 A). Rationale: The mask should mold to the face so that very little oxygen escapes into the eyes or around the cheeks and chin. • Secure the elastic band around the client’s head so that the mask is comfortable but snug. • Pad the band behind the ears and over bony prominences. Rationale: Padding will prevent irritation from the mask. Face Tent • Place the tent over the client’s face, and secure the ties around the head (see Figure 50–14). 7. Assess the client regularly. • Assess the client’s vital signs, level of anxiety, color, and ease of respirations, and provide support while the client adjusts to the device. Some clients may complain of claustrophobia. • Assess the client in 15 to 30 minutes, depending on the ­client’s condition, and regularly thereafter. • Assess the client regularly for clinical signs of hypoxia, tachycardia, confusion, dyspnea, restlessness, and ­cyanosis. Review oxygen saturation or arterial blood gas results if they are available. Nasal Cannula • Assess the client’s nares for encrustations and irritation. Apply a water-soluble lubricant as required to soothe the mucous membranes. • Assess the top of the client’s ears for any signs of irritation from the cannula tubing. If present, padding with a gauze pad may help relieve the discomfort. Face Mask or Tent • Inspect the facial skin frequently for dampness or chafing, and dry and treat it as needed. 8. Inspect the equipment on a regular basis. • Check the liter flow and the level of water in the humidifier in 30 minutes and whenever providing care to the client. • Be sure that water is not collecting in dependent loops of the tubing. • Make sure that safety precautions are being followed. 9. Document findings in the client record using forms or checklists supplemented by narrative notes when appropriate. •

SKILL 50–1

Face Mask • Oxygen supply with a flow meter and adapter • Humidifier with distilled water or tap water according to agency protocol • Prescribed face mask of the appropriate size • Padding for the elastic band

SAMPLE DOCUMENTATION 9/16/15 0930 Returned from physical therapy with c/o dyspnea. Resp. 26/min, shallow. P-92, BP 160/98, SpO2 92%. Skin warm, no cyanosis. Lung sounds clear, no retractions. O2 per nasal cannula applied @ 2 L/min. ––––––––––––––––––––––––––––––– P. Isola, RN 9/16/15 1000 No further c/o of dyspnea. Resp. 20/min, P 88, BP 152/92, SpO2 96%. O2 per nasal cannula continues @ 2 L/min. ––––––––––––––––––––––––––––––––––––––––––––––– P. Isola, RN

•

Report significant deviations from normal to the primary care provider.

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LIFESPAN CONSIDERATIONS Oxygen Delivery Equipment INFANTS Oxygen Hood • An oxygen hood is a rigid plastic dome that encloses an infant’s head. It provides precise oxygen levels and high humidity. • The gas should not be allowed to blow directly into the infant’s face, and the hood should not rub against the infant’s neck, chin, or shoulder. CHILDREN Oxygen Tent • The tent consists of a rectangular, clear, plastic canopy with outlets that connect to an oxygen or compressed air source and to a humidifier that moisturizes the air or oxygen. • Because the enclosed tent becomes very warm, some type of cooling mechanism is provided to maintain the temperature at 20°C to 21°C (68°F to 70°F). • Cover the child with a gown or a cotton blanket. Some ­agencies provide gowns with hoods, or a small towel may be

wrapped around the head. The child needs protection from chilling and from the dampness and condensation in the tent. • Flood the tent with oxygen by setting the flow meter at 15 L/min for about 5 minutes. Then, adjust the flow meter ­according to orders. Flooding the tent quickly increases the oxygen to the desired level. • The tent can deliver approximately 30% oxygen. • Children may fight having a mask placed on their faces. They are often fearful when placed in oxygen tents or hoods. These are normal responses that vary based on experience, developmental stage, degree of threat to body image, and ­attachment/abandonment issues. Providing safe toys and a beloved blanket or pillow to hold can help, as can fostering the ­parent–child bond even though separated by the plastic. Encourage parents to interact with their child around and through the tubing and tent.

Home Care Considerations  Home Care Oxygen Equipment Three major oxygen systems for home care use are available in most communities: cylinders or tanks of compressed gas, liquid (­cryogenic) oxygen, and oxygen concentrators. 1. Cylinders (“green tanks”): These are the system of choice for clients who need oxygen episodically (e.g., on a prn basis). Advantages are that cylinders deliver all liter flows (1 to 15 L/min), and oxygen evaporation does not occur during storage. Disadvantages are that the cylinders are heavy and awkward to move, the supply company must be notified when a refill is needed, and they are costly for the high-use client. A size “D” tank weighs about 8 pounds and stores 425 L of oxygen (Figure 50–17 •); an “E” tank holds 680 L and is transported on wheels. The large “H” tank weighs 150 pounds. The gauge on a full tank reads a pressure of at least 2,000 pounds per square inch (psi), and a tank is considered empty when it reads less than 500 psi. 2. Liquid oxygen: Liquid systems have two parts—a large stationary container and a portable unit with a small lightweight tank that is refilled from the stationary unit. Liquid reservoirs store oxygen at –212°C (–350°F) in a smaller amount of space than compressed gas. Advantages are that these reservoirs are lighter in weight and cleaner in appearance than cylinders and they are not as difficult to operate. Disadvantages of liquid oxygen are that many home care medical supply and service companies are not able to handle it, oxygen evaporation occurs when the unit is not used, only low flows (1 to 4 L/min) can be used or freezing occurs, and the portable unit designed to be carried over the shoulder weighs 8 to 10 pounds, a possible burden to the typical COPD client. A wheeled cart can be used to carry the unit but may be awkward. 3. Oxygen concentrators: Concentrators are electrically powered systems that manufacture oxygen from room air. At 1 L/min, such a system can deliver a concentration of about 95% oxygen, but the concentration drops when the flow rate increases (e.g., 75% concentration at 4 L/min). Advantages are that they are more attractive in appearance, resembling furniture rather than medical equipment; they eliminate the need for regular delivery of oxygen or refilling of cylinders; because the supply of oxygen is constant, they alleviate the client’s anxiety about running out of oxygen; and they are the most economical system when continuous use is required. Major disadvantages of

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Figure 50–17 • Using a portable oxygen system at home. Aaron Haupt/Getty Images

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Home Care Considerations  Home Care Oxygen Equipment—continued a concentrator are that it is expensive; it lacks real portability (small units weigh 28 pounds); it tends to be noisy; it is powered by electricity (an emergency backup unit, for example, an oxygen tank, must be provided for clients for whom a power failure could be life threatening); and heat produced by the concentrator motor is a problem for those who live in trailers, small houses, or warm climates, where air conditioners are required. The oxygen concentrator must also be checked periodically with an O2 analyzer to ensure that it is providing an adequate delivery of oxygen. Another type of oxygen concentrator is the oxygen enricher. It uses a plastic membrane that allows water vapor to pass through with the oxygen, thus eliminating the need for a humidifying device. It is also thought to filter out bacteria present in the air. The enricher provides an O2 concentration of 40% at all flow rates, it tends to be quieter than the concentrator, there is less chance of combustion (since the gas is only 40% oxygen), it has only two moving parts (thus decreasing the risk of

Artificial Airways Artificial airways are inserted to maintain a patent air passage for clients whose airways have become or may become obstructed. A patent airway is necessary so that air can flow to and from the lungs. Four of the more common types of airways are oropharyngeal, nasopharyngeal, endotracheal, and tracheostomy.

PATIENT-CENTERED CARE

something going wrong), and a nebulizer can be operated off the enricher because of the high flow rate. Social services or the case manager needs to ensure that the client has appropriate help in choosing a reputable home oxygen vendor. Services furnished should include: • A 24-hour emergency service • Trained personnel to make the initial delivery and instruct the client in safe, appropriate use of the oxygen and maintenance of the equipment • At least monthly follow-up visits to check the equipment and reinstruct the client as necessary • A regular cost review to ensure that the system is the most cost effective one for that client, with routine notification of the primary care provider or home care professional if it seems that another system is more appropriate. The nurse needs to also ensure that the client knows about the financial reimbursements available from Medicare and Medicaid or other insurance agencies.

• Open the client’s mouth and insert the airway along the top of the

tongue.

• When the distal end of the airway reaches the soft palate at the

•

Oropharyngeal and Nasopharyngeal Airways

Oropharyngeal and nasopharyngeal airways are used to keep the upper air passages open when secretions or the tongue may obstruct them (e.g., in a client who is sedated, is semicomatose, or has an altered level of consciousness). These airways are easy to insert and have a low risk of complications. Sizes vary and should be appropriate to the size and age of the client. The nasopharyngeal airway should be well lubricated with water-soluble gel prior to inserting. The oropharyngeal airway may be lubricated with water or saline, if necessary. Oropharyngeal airways (Figure 50–18 •) stimulate the gag reflex and are only used for clients with altered levels of consciousness (e.g., because of general anesthesia, overdose, or head injury). To insert the airway:

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• • • • • •

back of the mouth, rotate the airway 180 degrees downward, and slip it past the uvula into the oral pharynx. If not contraindicated, place the client in a side-lying position or with the head turned to the side to allow secretions to drain out of the mouth. The oropharynx may be suctioned as needed by inserting the suction catheter alongside the airway. Remove and discard gloves. Perform hand hygiene. Do not tape the airway in place; remove it when the client begins to cough or gag. Provide mouth care at least every 2 to 4 hours, keeping suction available at the bedside. As appropriate for the client’s condition, remove the airway every 8 hours to assess the mouth and provide oral care. Reinsert the airway immediately.

• Place the client in a supine or semi-Fowler’s position. • Apply clean gloves. • Hold the lubricated airway by the outer flange, with the distal end

Nasopharyngeal airways are tolerated better by alert clients. They are inserted through the nares, terminating in the oropharynx (Figure 50–19 •). When caring for a client with a nasopharyngeal airway, provide frequent oral and nares care, reinserting the airway

Figure 50–18 • An oropharyngeal airway in place.

Figure 50–19 • A nasopharyngeal airway in place.

pointing up or curved upward.

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nasal ETT oral ETT

Figure 50–20 • An endotracheal tube (ETT).

Figure 50–21 • A tracheostomy tube in place.

in the other naris every 8 hours or as ordered to prevent necrosis of the mucosa.

into the trachea through the neck. A tube is usually inserted through this opening and an artificial airway is created. A tracheostomy is performed using one of two techniques: the traditional open surgical method or via a percutaneous insertion. The percutaneous method can be done at the bedside in a critical care unit. The open technique is done in an operating room where a surgical incision is made in the trachea just below the larynx. A curved tracheostomy tube is inserted to extend through the stoma into the trachea (Figure 50–21 •). Tracheostomy tubes are available in different sizes and may be plastic, silicone, or metal, and cuffed, uncuffed, or fenestrated. A fenestrated tracheostomy tube has an opening that allows air to pass through to the vocal cords, thus allowing the client to communicate. Tracheostomy tubes have an outer cannula that is inserted into the trachea and a flange that rests against the neck. The flange allows the tube to be secured in place with tracheostomy tapes/twill ties or Velcro collars (Figure 50–22 •). All tubes also have an obturator, which is used to insert the outer cannula and is then removed. The obturator, along with a spare tracheostomy tube of the same size and smaller, is kept at the client’s bedside in case the tube becomes dislodged and needs to be reinserted. Some tracheostomy tubes have an

Endotracheal Tubes

Endotracheal tubes (ETTs) are most commonly inserted in clients who have had general anesthetics or for those in emergency situations where mechanical ventilation is required. An ETT is inserted by an anesthesiologist, primary care provider, certified registered nurse anesthetist (CRNA), or respiratory therapist with specialized education. It is inserted through the mouth or the nose and into the trachea, using a laryngoscope as a guide (Figure 50–20 •). The tube terminates just superior to (above) the bifurcation of the trachea into the bronchi. The tube may have an air-filled cuff to prevent air leakage around it. Because an ETT passes through the epiglottis and glottis, the client is unable to speak while it is in place. Nursing interventions for clients with ETTs are shown in Box 50–3. Tracheostomy

Clients who need airway support due to a temporary or permanent condition may have a tracheostomy. A tracheostomy is an opening

BOX 50–3   Nursing Interventions for Clients with Endotracheal Tubes •

•

•

•

• •

Perform hand hygiene before and after contact with the client. Wear gloves when handling respiratory secretions or objects contaminated with respiratory secretions. Assess the client’s respiratory status at least every 2 hours, or more frequently if indicated. Include respiratory rate, rhythm, depth, equality of chest excursion, and lung sounds; level of consciousness; oxygen saturation, percentage of oxygen used and by what means (e.g., ventilator); and skin color in your assessment. Frequently assess nasal and oral mucosa for redness and ­irritation. Report any abnormal findings to the primary care provider. Secure the endotracheal tube with tape or a commercially ­prepared holder to prevent movement of the tube farther into or out of the trachea. Assess the position of the tube frequently. Notify the primary care provider immediately if the tube is dislodged out of the airway. If the tube advances into a main bronchus, it will need to be repositioned to ensure ventilation of both lungs. Unless contraindicated, elevate the head of the bed 30° to 45°. Using sterile technique, suction the endotracheal tube as needed to remove excessive secretions. Perform subglottic suctioning before deflating the cuff of the endotracheal tube

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•

•

• •

• •

or before moving the tube. Wear goggles when performing suctioning. Closely monitor cuff pressure, maintaining a pressure of 20 to 25 mmHg (or as recommended by the tube manufacturer) to minimize the risk of tracheal tissue necrosis. If recommended, deflate the cuff periodically. Provide oral hygiene and nasal care every 2 to 4 hours. Use an oropharyngeal airway to prevent the client from biting down on an oral endotracheal tube. Move oral endotracheal tubes to the opposite side of the mouth every 8 hours or per agency protocol, taking care to maintain the position of the tube in the trachea. This prevents irritation to the oral mucosa. Provide humidified air or oxygen because the endotracheal tube bypasses the upper airways, which normally moisten the air. If the client is on mechanical ventilation, ensure that all alarms are enabled at all times because the client cannot call for help should an emergency occur. Communicate frequently with the client, providing a note pad or picture board for the client to use in communicating. Inform the client and family that an endotracheal tube is usually used as a short-term artificial airway. Instruct the client and family not to manipulate the tube and to call for the nurse if the client is uncomfortable.

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Outer cannula with flange

Inner cannula

Obturator

Figure 50–22 • Components of a tracheostomy tube.

inner cannula that is inserted and locked into place inside the outer cannula. The purpose of the inner cannula is to prevent tube obstruction by allowing regular cleaning or replacement. Many plastic inner cannulas are cleaned with a solution of full or half-strength hydrogen peroxide and sterile water. Some facilities, however, recommend using normal saline only. Morris, Whitmer, and McIntosh (2013) note that it is important to check the manufacturer’s instructions for cleaning tracheostomy tubes because silicone tubes and metal tubes can be damaged by using hydrogen peroxide (p. 21). The outer cannula of the tracheostomy tube remains in place to maintain a patent airway.

Figure 50–23 • A tracheostomy tube with a low-pressure cuff.

CLINICAL ALERT! Some inner cannulas are disposable. These cannulas have a different method of attachment than the nondisposable tubes. Also, the different types of disposable tubes are not interchangeable.

Cuffed tracheostomy tubes are surrounded by an inflatable cuff that produces an airtight seal between the tube and the trachea. This seal prevents aspiration of oropharyngeal secretions and air leakage between the tube and the trachea. Cuffed tubes are often used immediately after a tracheostomy and are essential when ventilating a tracheostomy client with a mechanical ventilator. Children do not require cuffed tubes, because their tracheas are resilient enough to seal the air space around the tube. Low-pressure cuffs (Figure 50–23 •) are commonly used to distribute a low, even pressure against the trachea, thus decreasing the risk of tracheal tissue necrosis. They do not need to be deflated periodically to reduce pressure on the tracheal wall. Foam cuffed tracheostomy tubes (Figure 50–24 •) do not require injected air; instead, when the port is opened, ambient air enters the balloon, which then conforms to the client’s trachea. Air is removed from the cuff prior to insertion or removal of the tube. The nurse provides tracheostomy care for the client with a new or recent tracheostomy to maintain patency of the tube and reduce the risk of infection. Initially a tracheostomy may need to be suctioned (see the section on suctioning that follows) and cleaned as often as every 1 to 2 hours. After the initial inflammatory response subsides, tracheostomy care may only need to be done once or twice a day, depending on the client. For a client with a new tracheostomy, sterile technique should be used when providing tracheostomy care

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Figure 50–24 • A tracheostomy tube with a foam cuff.

in order to prevent infection. After the stoma has healed, clean gloves can be used while changing the dressing and tie tapes. Skill 50–4 later in this chapter describes tracheostomy care. When the client breathes through a tracheostomy, air is no longer heated, humidified, and filtered as it is when passing through the upper airways; therefore, special precautions are necessary. Humidity may be provided with a mist collar (Figure 50–25 •). Clients with long-term tracheostomies may use a heat moisture exchange device known as a “Swedish nose” that fits onto the connector of the inner cannula (Barnett, 2012) (Figure 50–26 •). They may also wear a stoma protector such as a 4×4 gauze held in place with a cotton tie over the stoma or a light scarf to filter air as it enters the tracheostomy.

Suctioning When clients have difficulty handling their secretions or an artificial airway is in place, suctioning may be necessary to clear air passages. Suctioning is the aspiration of secretions through a catheter connected to a suction machine or wall suction outlet. Even though the

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A

B

Figure 50–27 • Types of suction catheters: A, open tipped; B, whistle tipped.

Figure 50–25 • A tracheostomy mist collar.

Figure 50–28 • Oral (Yankauer) suction tube.

Figure 50–26 • Heat moisture exchange device.

upper airways (the oropharynx and nasopharynx) are not sterile, sterile technique is recommended for all suctioning to avoid introducing pathogens into the airways. It is best to check the agency’s policy because some facilities may use clean rather than sterile technique for nasopharyngeal and oropharyngeal suctioning. Oropharyngeal and nasopharyngeal suctioning removes ­secretions from the upper respiratory tract. Nasotracheal suctioning provides closer access to the trachea and requires sterile technique. Skill 50–2 outlines oropharyngeal, nasopharyngeal, and nasotracheal suctioning. Suction catheters may be either open tipped or whistle tipped (Figure 50–27 •). The whistle-tipped catheter is less irritating to respiratory tissues, although the open-tipped catheter may be more effective for removing thick mucous plugs. An oral suction tube, or Yankauer suction tube, is used to suction the oral cavity. Alert clients can be taught how to use this method of oral suctioning themselves (Figure 50–28 •). Most suction catheters have a thumb port on the side to control the suction. The catheter is connected to suction tubing, which in turn is connected to a collection chamber and suction control gauge (Figure 50–29 •).

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Figure 50–29 • A wall suction unit.

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The nurse decides when suctioning is needed by assessing the client for signs of respiratory distress or evidence that the client is unable to cough up and expectorate secretions. Dyspnea, bubbling or rattling (adventitious) breath sounds, poor skin color (pallor, duskiness, or cyanosis), restlessness, tachycardia, or decreased oxygen saturation (SpO2) levels (also called O2 sat) may indicate the need for suctioning. Good nursing judgment and critical thinking are necessary, because suctioning irritates mucous membranes, can increase secretions

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if performed too frequently, and can cause the client’s O2 saturation to drop further, put the client in bronchospasm, and if the client has a head injury, cause the intracranial pressure to increase. In other words, suctioning is based on clinical need versus a fixed schedule. In addition to removing secretions that obstruct the airway and facilitating ventilation, suctioning can be performed to obtain secretions for diagnostic purposes and to prevent infection that may result from accumulated secretions.

Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning • •

To obtain secretions for diagnostic purposes To prevent infection that may result from accumulated secretions

ASSESSMENT Assess for clinical signs indicating the need for suctioning: • Restlessness, anxiety • Noisy respirations • Adventitious (abnormal) breath sounds when the chest is ­auscultated

• • • • •

Change in mental status Skin color Rate and pattern of respirations Pulse rate and rhythm Decreased oxygen saturation

SKILL 50–2

PURPOSES • To remove secretions that obstruct the airway • To facilitate ventilation

PLANNING

DELEGATION Oral suctioning using a Yankauer suction tube can be delegated to UAP and to the client or family, if appropriate, since this is not a sterile procedure. The nurse needs to review the procedure and important points such as not applying suction during insertion of the tube to avoid trauma to the mucous membrane. Oropharyngeal suctioning uses a suction catheter and, although not a sterile procedure, should be performed by a nurse or respiratory therapist. Suctioning can stimulate the gag reflex, hypoxia, and dysrhythmias that may require problem solving. In contrast, nasopharyngeal and nasotracheal suctioning use sterile technique and require application of knowledge and problem solving and should be performed by the nurse or respiratory therapist.

INTERPROFESSIONAL PRACTICE Suctioning a client may be within the scope of practice for specific health care providers. For example, in addition to nurses, respiratory therapists may help suction a client. Although the respiratory therapist may verbally communicate their findings and plan to the health care team members, the nurse must also know where to locate their documentation in the client’s medical record.

IMPLEMENTATION Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Inform the client that suctioning will relieve breathing difficulty and that the procedure is painless but may be uncomfortable and stimulate the cough, gag, or sneeze reflex. Rationale: Knowing that the procedure will relieve breathing problems is often reassuring and enlists the client’s cooperation. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Provide for client privacy.

Equipment Oral and Nasopharyngeal/Nasotracheal Suctioning (Using Sterile Technique) • Towel or moisture-resistant pad • Portable or wall suction machine with tubing, collection ­receptacle, and suction pressure gauge • Sterile disposable container for fluids • Sterile normal saline or water • Goggles or face shield, if appropriate • Moisture-resistant disposal bag • Sputum trap, if specimen is to be collected Oral and Oropharyngeal Suctioning (Using Clean Technique) • Yankauer suction catheter or suction catheter kit • Clean gloves Nasopharyngeal or Nasotracheal Suctioning (Using Sterile Technique) • Sterile gloves • Sterile suction catheter kit (#12 to #18 Fr for adults, #8 to #10 Fr for children, and #5 to #8 Fr for infants) • Water-soluble lubricant • Y-connector

4. Prepare the client. • Position a conscious person who has a functional gag reflex in the semi-Fowler’s position with the head turned to one side for oral suctioning or with the neck hyperextended for nasal suctioning. Rationale: These positions facilitate the insertion of the catheter and help prevent aspiration of secretions. • Position an unconscious client in the lateral position, facing you. Rationale: This position allows the tongue to fall forward, so that it will not obstruct the catheter on insertion. The lateral position also facilitates drainage of secretions from the pharynx and prevents the possibility of aspiration. • Place the towel or moisture-resistant pad over the pillow or under the chin. Continued on page 1296

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Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning—continued 5. Prepare the equipment. • Turn the suction device on and set to appropriate negative pressure on the suction gauge. The amount of negative pressure should be high enough to clear secretions but not too high. Rationale: Too high of a pressure can cause the catheter to adhere to the tracheal wall and cause irritation or trauma. A rule of thumb is to use the lowest amount of ­suction pressure needed to clear the secretions. For Oral and Oropharyngeal Suction • Apply clean gloves. • Moisten the tip of the Yankauer or suction catheter with sterile water or saline. Rationale: This reduces friction and eases ­insertion. • Pull the tongue forward, if necessary, using gauze. • Do not apply suction (that is, leave your finger off the port) during insertion. Rationale: Applying suction during insertion causes trauma to the mucous membrane. • Advance the catheter about 10 to 15 cm (4 to 6 in.) along one side of the mouth into the oropharynx. Rationale: Directing the catheter along the side prevents gagging. • It may be necessary during oropharyngeal suctioning to apply suction to secretions that collect in the mouth and beneath the tongue. • Remove and discard gloves. • Perform hand hygiene. For Nasopharyngeal and Nasotracheal Suction • Open the lubricant. • Open the sterile suction package. a. Set up the cup or container, touching only the outside. b. Pour sterile water or saline into the container. c. Apply the sterile gloves, or apply an unsterile glove on the nondominant hand and then a sterile glove on the dominant hand. Rationale: The sterile gloved hand maintains the sterility of the suction catheter, and the unsterile glove prevents the transmission of the microorganisms to the nurse. • With your sterile gloved hand, pick up the catheter and attach it to the suction unit. ❶ 6. Test the pressure of the suction and the patency of the catheter by applying your sterile gloved finger or thumb to the port or open branch of the Y-connector (the suction control) to create suction. • If needed, apply or increase supplemental oxygen. 7. Lubricate and introduce the catheter. • Lubricate the catheter tip with sterile water, saline, or watersoluble lubricant. Rationale: This reduces friction and eases insertion. • Remove oxygen with the nondominant hand, if appropriate. To suction Suction control Sterile glove

Thumb control To tip To suction

❶ Attaching the catheter to the suction unit.

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Without applying suction, insert the catheter into either naris and advance it along the floor of the nasal cavity. Rationale: This avoids the nasal turbinates. • Never force the catheter against an obstruction. If one nostril is obstructed, try the other. 8. Perform suctioning. • Apply your finger to the suction control port to start suction, and gently rotate the catheter. Rationale: Gentle rotation of the catheter ensures that all surfaces are reached and prevents trauma to any one area of the respiratory mucosa due to prolonged suction. • Apply suction for 5 to 10 seconds while slowly withdrawing the catheter, then remove your finger from the control and remove the catheter. Rationale: Intermittent suction reduces the occurrence of trauma or irritation to the trachea and nasopharynx. • A suction attempt should last only 10 to 15 seconds. During this time, the catheter is inserted, the suction applied and discontinued, and the catheter removed. 9. Rinse the catheter and repeat suctioning as above if necessary. • Rinse and flush the catheter and tubing with sterile water or saline. • Relubricate the catheter, and repeat suctioning until the air passage is clear. • Allow sufficient time between each suction for ventilation and oxygenation. Limit suctioning to 5 minutes in total. Rationale: Applying suction for too long may cause secretions to increase or may decrease the client’s oxygen supply. • Encourage the client to breathe deeply and to cough between suctions. Use supplemental oxygen, if appropriate. Rationale: Coughing and deep breathing help carry secretions from the trachea and bronchi into the pharynx, where they can be reached with the suction catheter. Deep breathing and supplemental oxygen replenish the oxygen supply that was decreased during the suctioning process. 10. Obtain a specimen if required. • Use a sputum trap ❷ as follows: a. Attach the suction catheter to the tubing of the sputum trap. b. Attach the suction tubing to the sputum trap air vent. c. Suction the client. The sputum trap will collect the mucus during suctioning. d. Remove the catheter from the client. Disconnect the ­sputum trap tubing from the suction catheter. Remove the suction tubing from the trap air vent. e. Connect the tubing of the sputum trap to the air vent. Rationale: This retains any microorganisms in the ­sputum trap. • Connect the suction catheter to the tubing. • Flush the catheter to remove secretions from the tubing. 11. Promote client comfort. • Offer to assist the client with oral or nasal hygiene. • Assist the client to a position that facilitates breathing. 12. Dispose of equipment and ensure availability for the next suction. • Dispose of the catheter, gloves, water, and waste container. a. Rinse the suction tubing as needed by inserting the end of the tubing into the used water container. b. Wrap the catheter around your sterile gloved hand and hold the catheter as the glove is removed over it for disposal. • Perform hand hygiene. • Empty and rinse the suction collection container as needed or indicated by protocol. Change the suction tubing and container daily. •

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Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning—continued Ensure that supplies are available for the next suctioning (suction kit, gloves, water or normal saline). 13. Assess the effectiveness of suctioning. • Auscultate the client’s breath sounds to ensure they are clear of secretions. Observe skin color, dyspnea, level of anxiety, and oxygen saturation levels. 14. Document relevant data. • Record the procedure: the amount, consistency, color, and odor of sputum (e.g., foamy, white mucus; thick, greentinged mucus; or blood-flecked mucus) and the client’s respiratory status before and after the procedure. This may include lung sounds, rate and character of breathing, and oxygen saturation. • If the procedure is carried out frequently (e.g., every hour), it may be appropriate to record only once, at the end of the shift; however, the frequency of the suctioning must be recorded. •

SKILL 50–2

SAMPLE DOCUMENTATION

❷ A sputum collection trap.

EVALUATION • Conduct appropriate follow-up, such as appearance of secretions suctioned; breath sounds; respiratory rate, rhythm, and depth; pulse rate and rhythm; and skin color.

12/12/2015 0830 Producing large amounts of thick, tenacious white mucus to back of oral pharynx but unable to expectorate into tissue. Uses Yankauer suction tube as needed. O2 sat increased from 89% before suctioning to 93% after suctioning. RR also decreased from 26 to 18–20 after suctioning. Lungs clear to auscultation throughout all lobes. Continuous O2 at 2 L/min via n/c. Will continue to reassess q hour. –––––––––––––––––––––––––––––––––––––––– L. Webb, RN

• •

Compare findings to previous assessment data if available. Report significant deviations from normal to the primary care provider.

LIFESPAN CONSIDERATIONS Suctioning INFANTS A bulb syringe is used to remove secretions from an infant’s nose or mouth. Care needs to be taken to avoid stimulating the gag reflex. CHILDREN A catheter is used to remove secretions from an older child’s mouth or nose.

OLDER ADULTS Older adults often have cardiac and/or pulmonary disease, thus increasing their susceptibility to hypoxemia related to suctioning. Watch closely for signs of hypoxemia. If noted, stop suctioning and hyperoxygenate.

Home Care Considerations Suctioning Teach clients and families that the most important aspect of infection control is frequent hand washing. • Airway suctioning in the home is considered a clean procedure. • The catheter or Yankauer should be flushed by suctioning recently boiled or distilled water to rinse away mucus, followed by the suctioning of air through the device to dry the internal surface and, thus, discourage bacterial growth. The outer surface •

Following endotracheal intubation or a tracheostomy, the trachea and surrounding respiratory tissues are irritated and react by producing excessive secretions. Sterile suctioning is necessary to remove these secretions from the trachea and bronchi to maintain a patent airway. The frequency of suctioning depends on the client’s health and how recently the intubation was done. Additionally,

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PATIENT-CENTERED CARE of the device may be wiped with alcohol or hydrogen peroxide. The suction catheter or Yankauer should be allowed to dry and then be stored in a clean, dry area. • Suction catheters treated in the manner described above may be reused. It is recommended that catheters be discarded after 24 hours. Yankauer suction tubes may be cleaned, boiled, and reused.

suctioning may be necessary in clients who have increased secretions because of pneumonia or inability to clear secretions because of altered level of consciousness. Suctioning is associated with several complications: hypoxemia, trauma to the airway, nosocomial or health care–associated infection, and cardiac dysrhythmia, which is related to the hypoxemia.

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The following techniques are used to minimize or decrease these complications: •

•

•

•

•

•

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Suction only as needed. Because suctioning the client with an ETT or tracheostomy is uncomfortable for the client and potentially hazardous because of hypoxemia, it should be performed only when indicated and not on a fixed schedule. Sterile technique. Infection of the lower respiratory tract can occur during tracheal suctioning. The nurse using sterile technique during the suctioning process can prevent this complication. No saline instillation. Instilling normal saline into the airway has been a common practice and a routine part of the suctioning procedure. It was thought that the saline would facilitate removal of secretions and improve the client’s oxygenation status. Research, however, has shown that saline instillation does not facilitate removal of secretions and causes adverse effects such as hypoxemia and increased risk of pneumonia (Ntoumenopoulos, 2013; ­Pierson, 2013). Hyperinflation. This involves giving the client breaths that are greater than the tidal volume set on the ventilator through the ventilator circuit or via a manual resuscitation bag. Three to five breaths are delivered before and after each pass of the suction catheter. Hyperventilation. This involves increasing the number of breaths the client is receiving. This can be done through the ventilator or using a manual resuscitation bag. Both hyperinflation and hyperventilation help prevent suction hypoxemia; however, they should be used with caution because they can cause injury as a result of overdistention of the lungs (Hess, MacIntyre, Mishoe, Galvin, & Adams, 2012). Hyperoxygenation. This can be done with a manual resuscitation bag or through the ventilator and is performed by increasing

the oxygen flow (usually to 100%) before suctioning and between suction attempts. This is the best technique to avoid suction-­ related hypoxemia. To prevent hypoxia when tracheostomy and endotracheal suctioning are administered, the outer diameter of the suction catheter should not exceed one half the internal diameter of the tracheostomy or ETT (Nance-Floyd, 2011). A rule of thumb to determine suction catheter size is to double the millimeter size of the artificial airway. For example, an artificial airway (e.g., ­tracheostomy) diameter of 8 mm × 2 = 16. A size 16 French ­suction catheter would be the largest size catheter that would be safe to use. The nurse uses sterile techniques to prevent infection of the respiratory tract (Skill 50–3). The traditional method of suctioning an ETT or tracheostomy is sometimes referred to as the open method. If a client is connected to a ventilator, the nurse disconnects the client from the ventilator, suctions the airway, reconnects the client to the ventilator, and discards the suction catheter. Drawbacks to the open airway suction system include the nurse needing to wear personal protective equipment (e.g., goggles or face shield, gown) to avoid exposure to the client’s sputum and the potential cost of one-time catheter use, especially if the client requires frequent suctioning. With the closed airway/tracheal suction system (in-line suctioning) (Figure 50–30 •), the suction catheter attaches to the ventilator tubing and the client does not need to be disconnected from the ventilator. The nurse is not exposed to any secretions because the suction catheter is enclosed in a plastic sheath. The catheter can be reused as many times as necessary until the system is changed. The nurse needs to inquire about the agency’s policy for changing the closed suction system.

Client connection

Ventilator connection

T piece

Irrigation port

Labels

0.9% sodium chloride vials

Suction catheter and sleeve

Suction connection Control valve

Figure 50–30 • A closed airway suction (in-line) system.

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To prevent pneumonia that may result from accumulated ­secretions

ASSESSMENT Assess the client for the presence of adventitious (abnormal) breath sounds. Assess the client’s cough reflex and note the client’s ability or ­inability to remove the secretions through coughing. PLANNING

DELEGATION Suctioning a tracheostomy or endotracheal tube is a sterile, invasive technique requiring application of scientific knowledge and problem solving. This skill is performed by a nurse or respiratory therapist and is not delegated to UAP.

SKILL 50–3

PURPOSES • To maintain a patent airway and prevent airway obstructions • To promote respiratory function (optimal exchange of oxygen and carbon dioxide into and out of the lungs)

Equipment • Resuscitation bag (bag valve mask) connected to 100% oxygen • Sterile towel (optional) • Equipment for suctioning (see Skill 50–2) • Goggles and mask if necessary • Gown (if necessary) • Sterile gloves • Moisture-resistant bag

INTERPROFESSIONAL PRACTICE Suctioning a client with a tracheostomy or endotracheal tube may be within the scope of practice for specific health care providers. For example, in addition to nurses, respiratory therapists may suction a client with a tracheostomy or endotracheal tube. Although the respiratory therapist may verbally communicate their findings and plan to the health care team members, the nurse must also know where to locate their documentation in the client’s medical record.

IMPLEMENTATION Preparation Determine if the client has been suctioned previously and, if so, review the documentation of the procedure. This information can be very helpful in preparing the nurse for both the physiological and psychological impact of suctioning on the client. Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Inform the client that suctioning usually causes some intermittent coughing and that this assists in removing the secretions. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Provide for client privacy. 4. Prepare the client. • If not contraindicated, place the client in the semi-Fowler’s position to promote deep breathing, maximum lung expansion, and productive coughing. Rationale: Deep breathing oxygenates the lungs, counteracts the hypoxic effects of suctioning, and may induce coughing. Coughing helps to loosen and move secretions. 5. Prepare the equipment for an open suction system—see ­Variation section for a closed suction system. • Attach the resuscitation apparatus to the oxygen source. ❶ Adjust the oxygen flow to 100%. • Open the sterile supplies: a. Suction kit or catheter b. Sterile basin/container. • Pour sterile normal saline or water into sterile basin. • Place the sterile towel, if used, across the client’s chest below the tracheostomy. • Turn on the suction, and set the pressure in accordance with agency policy. The suction pressure should be set at

❶ Attaching the resuscitation apparatus to the oxygen source.

what is needed to adequately remove secretions. Hess et al. (2012) state that the suction pressure “should not exceed 100 mm Hg in infants, 125 mm Hg in children, and 150 mm Hg in adults” (p. 413). Nance-Floyd (2011) recommends using suction pressure of up to 120 mmHg for open system suctioning and up to 160 mmHg for closed system ­suctioning (p. 15). • Apply goggles, mask, and gown if necessary. Continued on page 1300

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Suctioning a Tracheostomy or Endotracheal Tube—continued Apply sterile gloves. Some agencies recommend putting a sterile glove on the dominant hand and an unsterile glove on the nondominant hand to protect the nurse. • Holding the catheter in the dominant hand and the connector in the nondominant hand, attach the suction catheter to the suction tubing (see Figure ❶ in Skill 50-2). 6. Flush and lubricate the catheter. • Using the dominant hand, place the catheter tip in the sterile saline solution. • Using the thumb of the nondominant hand, occlude the thumb control and suction a small amount of the sterile solution through the catheter. Rationale: This determines that the suction equipment is working properly and lubricates the outside and the lumen of the catheter. Lubrication eases insertion and reduces tissue trauma during insertion. Lubricating the lumen also helps prevent secretions from sticking to the inside of the catheter. 7. If the client does not have copious secretions, hyperventilate the lungs with a resuscitation bag before suctioning. • Summon an assistant, if one is available, for this step. • Using your nondominant hand, turn on the oxygen to 12 to 15 L/min. • If the client is receiving oxygen, disconnect the o ­ xygen source from the tracheostomy tube using your ­nondominant hand. • Attach the resuscitator to the tracheostomy or ETT. ❷ • Compress the Ambu bag three to five times, as the client inhales. This is best done by a second person who can use both hands to compress the bag. • Observe the rise and fall of the client’s chest to assess the adequacy of each ventilation. • Remove the resuscitation device and place it on the bed or the client’s chest with the connector facing up. Variation: Using a Ventilator to Provide Hyperventilation If the client is on a ventilator, use the ventilator for hyperventilation and hyperoxygenation. Newer models have a mode that provides 100% oxygen for 2 minutes and then switches back to the previous oxygen setting as well as a manual breath or sigh button. Rationale: The use of ventilator settings provides more consistent delivery of oxygenation and hyperinflation than a resuscitation device. 8. If the client has copious secretions, do not hyperventilate with a resuscitator. Instead: • Keep the regular oxygen delivery device on and increase the liter flow or adjust the FiO2 to 100% for several breaths before suctioning. Rationale: Hyperventilating a client who has copious secretions can force the secretions deeper into the respiratory tract.

SKILL 50–3

•

❷ Attaching the resuscitator to the tracheostomy tube.

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❸ Inserting the catheter into the trachea through the tracheostomy tube. Note: Suction is not applied while inserting the catheter.

9. Quickly but gently insert the catheter without applying any suction. • With your nondominant thumb off the suction port, quickly but gently insert the catheter into the trachea through the tracheostomy tube. ❸ Rationale: To prevent tissue trauma and oxygen loss, suction is not applied during insertion of the catheter. • Insert the catheter about 0.5 to 1 cm past the distal end of the tube for an open system, and 1 to 2 cm past the distal end for a closed system (Nance-Floyd, 2011) or until the client coughs. If you feel resistance, withdraw the catheter about 1 to 2 cm (0.4 to 0.8 in.) before applying suction. Rationale: Resistance usually means that the catheter tip has reached the bifurcation of the trachea. Withdrawing the catheter will prevent damaging the mucous membranes at the bifurcation. 10. Perform suctioning. • Apply suction for 5 to 10 seconds by placing the nondominant thumb over the thumb port. Rationale: Suction time is restricted to 10 seconds or less to minimize oxygen loss. • Rotate the catheter by rolling it between your thumb and forefinger while slowly withdrawing it. Rationale: This ­prevents tissue trauma by minimizing the suction time against any part of the trachea. • Withdraw the catheter completely, and release the suction. • Hyperventilate the client. • Suction again, if needed. 11. Reassess the client’s oxygenation status and repeat suctioning. • Observe the client’s respirations and skin color. Check the client’s pulse if necessary, using your nondominant hand. If the client is on a cardiac monitor, assess the rate and rhythm. • Encourage the client to breathe deeply and to cough between suctions. • Allow 2 to 3 minutes with oxygen, as appropriate between suctions when possible. Rationale: This provides an ­opportunity for reoxygenation of the lungs. • Flush the catheter and repeat suctioning until the air ­passage is clear and the breathing is relatively effortless and quiet. • After each suction, pick up the resuscitation bag with your nondominant hand and ventilate the client with no more than three breaths.

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SAMPLE DOCUMENTATION 12/13/2015 1000 Coarse crackles in RLL and LLL. Requires suctioning about every 1–2 hrs. Obtained large amount of pinkish-tinged, white thin mucus via ETT. Breath sounds clearer after suctioning. SpO2 increased from 90% before suctioning to 95% after suctioning. Client signals when he wants to be suctioned. ––––––– C. Holmes, RN

EVALUATION • Perform a follow-up examination of the client to determine the effectiveness of the suctioning (e.g., respiratory rate, depth, and character; breath sounds; color of skin and nail beds; character and amount of secretions suctioned; changes in vital signs [e.g., heart rate, oxygen saturation]).

Variation: Closed Airway/Tracheal Suction System (In-Line Catheter) • If a catheter is not already attached, apply clean gloves, aseptically open a new closed catheter set, and attach the ventilator connection on the T piece to the ventilator tubing. Attach the ­client connection to the ETT or tracheostomy. • Attach one end of the suction connecting tubing to the suction connection port of the closed system and the other end of the connecting tubing to the suction device. • Turn suction on, occlude or kink tubing, and depress the suction control valve (on the closed catheter system) to set suction to the appropriate level. Release the suction control valve. • Use the ventilator to hyperoxygenate and hyperinflate the client’s lungs. • Unlock the suction control mechanism if required by the ­manufacturer. • Advance the suction catheter enclosed in its plastic sheath with the dominant hand. Steady the T piece with the nondominant hand. • Depress the suction control valve and apply continuous suction for no more than 10 seconds and gently withdraw the catheter. • Repeat as needed remembering to provide hyperoxygenation and hyperinflation as needed. • When completed suctioning, withdraw the catheter into its sleeve and close the access valve, if appropriate. Rationale: If the system does not have an access valve on the client ­connector, the nurse needs to observe for the potential of the catheter migrating into the airway and partially obstructing the artificial airway. • Flush the catheter by instilling normal saline into the irrigation port and applying suction. Repeat until the catheter is clear. • Close the irrigation port and close the suction valve. • Remove and discard gloves. • Perform hand hygiene.

• •

SKILL 50–3

12. Dispose of equipment and ensure availability for the next suction. • Flush the catheter and suction tubing. • Turn off the suction and disconnect the catheter from the suction tubing. • Wrap the catheter around your sterile hand and peel the glove off so that it turns inside out over the catheter. Remove the other glove. • Discard the gloves and the catheter in the moistureresistant bag. • Perform hand hygiene. • Replenish the sterile fluid and supplies so that the suction is ready for use again. Rationale: Clients who require suctioning often require it quickly, so it is essential to leave the equipment at the bedside ready for use. • Be sure that the ventilator and oxygen settings are returned to presuctioning settings. Rationale: On some ventilators this is automatic, but always check. It is very dangerous for clients to be left on 100% oxygen. 13. Provide for client comfort and safety. • Assist the client to a comfortable, safe position that aids breathing. If the person is conscious, a semi-Fowler’s position is frequently indicated. If the person is unconscious, Sims’ position aids in the drainage of secretions from the mouth. 14. Document relevant data. • Record the suctioning, including the amount and description of suction returns and any other relevant assessments.

Relate findings to previous assessment data if available. Report significant deviations from normal to the primary care provider.

LIFESPAN CONSIDERATIONS Suctioning a Tracheostomy or Endotracheal Tube INFANTS AND CHILDREN Have an assistant gently restrain the child to keep the child’s hands out of the way. The assistant should maintain the child’s head in the midline position. OLDER ADULTS • Health care–associated pneumonia and ventilator-associated pneumonia (VAP) can occur because of infected secretions

in the upper airway. Oral antiseptic rinses (e.g., chlorhexidine ­gluconate) reduce the rate of nosocomial pneumonia in critically ill clients (Booker, Murff, Kitko, & Jablonski, 2013). • Do a thorough lung assessment before and after suctioning to determine effectiveness of suctioning and to be aware of any special problems.

Home Care Considerations  Suctioning a Tracheostomy or Endotracheal Tube Whenever possible, the client should be encouraged to clear the airway by coughing. • Clients may need to learn to suction their secretions if they ­cannot cough effectively. • Clean gloves should be used when endotracheal suctioning is performed in the home environment. •

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The nurse needs to instruct the caregiver on how to determine the need for suctioning and the correct process and rationale underlying the practice of suctioning to avoid potential complications of suctioning. • Stress the importance of adequate hydration as it thins secretions, which can aid in the removal of secretions by coughing or suctioning. •

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SKILL 50–4

Providing Tracheostomy Care PURPOSES • To maintain airway patency • To maintain cleanliness and prevent infection at the ­tracheostomy site ASSESSMENT Assess • Respiratory status including ease of breathing, rate, rhythm, depth, lung sounds, and oxygen saturation level • Pulse rate PLANNING

DELEGATION Tracheostomy care involves application of scientific knowledge, ­sterile technique, and problem solving, and therefore needs to be performed by a nurse or respiratory therapist.

INTERPROFESSIONAL PRACTICE Providing tracheostomy care may be within the scope of practice for specific health care providers. For example, in addition to nurses, respiratory therapists may help provide tracheostomy care for a ­client. Although the respiratory therapist may verbally communicate their findings and plan to the health care members, the nurse must also know where to locate their documentation in the client’s medical record. IMPLEMENTATION Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Provide for a means of communication, such as eye blinking or raising a finger, to indicate pain or distress. Follow through by carefully observing the client throughout the procedure, offering periodic eye contact, caring touch, and verbal reassurance. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Provide for client privacy. 4. Prepare the client and the equipment. • Assist the client to a semi-Fowler’s or Fowler’s position to promote lung expansion. • Suction the tracheostomy tube, if needed. (See Skill 50–3.) • If suctioning was required, allow the client to rest and restore oxygenation. • Open the tracheostomy kit or sterile basins. • Establish a sterile field. • Open other sterile supplies as needed including sterile applicators, suction kit, tracheostomy dressing, and disposable inner cannula, if applicable. • Pour the soaking solution and sterile normal saline into separate containers. • Apply clean gloves. • Remove the oxygen source. • Unlock the inner cannula (if present) and remove it by gently pulling it out toward you in line with its curvature. Place the inner cannula in the soaking solution, if not a disposable inner cannula. Rationale: This moistens and loosens dried secretions. • Based on the client’s respiratory assessments, place oxygen source over or near the outer cannula. Rationale: This prevents oxygen desaturation by maintaining oxygen to the client.

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To facilitate healing and prevent skin excoriation around the ­tracheostomy incision • To promote comfort •

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Character and amount of secretions from tracheostomy site Presence of drainage on tracheostomy dressing or ties Appearance of incision (note any redness, swelling, purulent ­discharge, or odor)

Equipment Sterile disposable tracheostomy cleaning kit or supplies ­including sterile containers, sterile nylon brush and/or pipe cleaners, sterile applicators, gauze squares • Disposable inner cannula if applicable • Towel or drape to protect bed linens • Sterile suction catheter kit (suction catheter and sterile container for solution) • Sterile normal saline (Some agencies may use a mixture of hydrogen peroxide and sterile normal saline. Check agency ­protocol for soaking solution.) • Sterile gloves (two pairs—one pair is for suctioning if needed.) • Clean gloves • Moisture-proof bag • Commercially prepared sterile tracheostomy dressing or sterile 4×4 gauze dressing • Cotton twill ties or Velcro collar • Clean scissors •

❶ Cleaning the inner cannula with a brush. Remove the soiled tracheostomy dressing. Place the soiled dressing in your gloved hand and peel the glove off so that it turns inside out over the dressing. Remove and discard the gloves and the dressing. • Perform hand hygiene. • Apply sterile gloves. Keep your dominant hand sterile during the procedure. 5. Clean the inner cannula. (See the Variation section for using a disposable inner cannula.) • Remove the inner cannula from the soaking solution. • Clean the lumen and entire inner cannula thoroughly using the brush or pipe cleaners moistened with sterile normal saline. ❶ Inspect the cannula for cleanliness by holding it at eye level and looking through it into the light. • Rinse the inner cannula thoroughly in the sterile normal saline. •

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SKILL 50–4

❷ Using an applicator stick to clean the tracheostomy site. After rinsing, gently tap the cannula against the inside edge of the sterile saline container. Use a pipe cleaner folded in half to dry only the inside of the cannula; do not dry the outside. Rationale: This removes excess liquid from the cannula and prevents possible aspiration by the client, while leaving a film of moisture on the outer surface to lubricate the cannula for reinsertion. 6. Replace the inner cannula, securing it in place. • Insert the inner cannula by grasping the outer flange and inserting the cannula in the direction of its curvature. • Lock the cannula in place by turning the lock (if present) into position to secure the flange of the inner cannula to the outer cannula. 7. Clean the incision site and tube flange. • Using sterile applicators or gauze dressings moistened with normal saline, clean the incision site. ❷ Handle the sterile supplies with your dominant hand. Use each applicator or gauze dressing only once and then discard. Rationale: This avoids contaminating a clean area with a soiled gauze dressing or applicator. • Hydrogen peroxide may be used (usually in a half-strength solution mixed with sterile normal saline; use a separate sterile container if this is necessary) to remove crusty secretions around the tracheostomy site. Do not use directly on the site. Check agency policy. Thoroughly rinse the cleaned area using gauze squares moistened with sterile normal saline. Rationale: Hydrogen peroxide can be irritating to the skin and inhibit healing if not thoroughly removed. • Clean the flange of the tube in the same manner. • Thoroughly dry the client’s skin and tube flanges with dry gauze squares. 8. Apply a sterile dressing. • Use a commercially prepared split-gauze tracheostomy dressing of nonraveling material. ❸ Never use cotton-filled gauze squares or cut the 4×4 gauze. Rationale: Cotton lint or gauze fibers can be aspirated by the client, potentially creating a tracheal abscess. Newer products include a nonadhesive hydrocellular dressing, which is a cushioned pad that absorbs large amounts of secretions. ❹ • Place the dressing under the flange of the tracheostomy tube. • While applying the dressing, ensure that the tracheostomy tube is securely supported. Rationale: Excessive movement of the tracheostomy tube irritates the trachea. 9. Change the tracheostomy ties or Velcro collar. • Change as needed to keep the skin clean and dry. •

❸ A commercially prepared tracheostomy dressing of nonraveling material.

❹ A nonadhesive hydrocellular tracheostomy dressing. Courtesy Covidien

•

Twill tape and specially manufactured Velcro ties are available. Twill tape is inexpensive and readily available; however, it is easily soiled and can trap moisture, which leads to irritation of the skin of the neck. Velcro ties are becoming more commonly used. ❺ They are wider, more comfortable, and cause less skin abrasion. Continued on page 1304

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SKILL 50–4

Providing Tracheostomy Care—continued

❺ A Velcro tracheostomy tie. For client safety, the literature recommends a two-person technique when changing the securing device to prevent tube dislodgement. This involves one person holding the tracheostomy tube in place while the other changes the securing device. Two-Strip Method (Twill Tape) • Cut two unequal strips of twill tape, one approximately 25 cm (10 in.) long and the other about 50 cm (20 in.) long. Rationale: Cutting one tape longer than the other allows them to be fastened at the side of the neck for easy access and to avoid the pressure of a knot on the skin at the back of the neck. • Cut a 1-cm (0.5-in.) lengthwise slit approximately 2.5 cm (1 in.) from one end of each strip. To do this, fold the end of the tape back onto itself about 2.5 cm (1 in.), then cut a slit in the middle of the tape from its folded edge. • Leaving the old ties in place, thread the slit end of one clean tape through the eye of the tracheostomy flange from the bottom side; then thread the long end of the tape through the slit, pulling it tight until it is securely fastened to the flange. Rationale: Leaving the old ties in place while securing the clean ties prevents inadvertent dislodging of the tracheostomy tube. Securing tapes in this manner avoids the use of knots, which can come untied or cause pressure and irritation. • If old ties are very soiled or it is difficult to thread new ties onto the tracheostomy flange with old ties in place, have an assistant apply a sterile glove and hold the tracheostomy in place while you replace the ties. Rationale: This is very important because movement of the tube during this procedure may cause irritation and stimulate coughing. Coughing can dislodge the tube if the ties are undone. • Repeat the process for the second tie. • Ask the client to flex the neck. Slip the longer tape under the client’s neck, place a finger between the tape and the client’s neck, ❻ and tie the tapes together at the side of the neck. Rationale: Flexing the neck increases its circumference the way coughing does. Placing a finger under the tie prevents making the tie too tight, which could interfere with coughing or place pressure on the jugular veins. • Tie the ends of the tapes using square knots. Cut off any long ends, leaving approximately 1 to 2 cm (0.5 in.). Rationale: Square knots prevent slippage and loosening. Adequate ends beyond the knot prevent the knot from inadvertently untying. • Once the clean ties are secured, remove the soiled ties and discard. •

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❻ Placing a finger underneath the tie tape before tying it.

One-Strip Method (Twill Tape) • Cut a length of twill tape 2.5 times the length needed to go around the client’s neck from one tube flange to the other. • Thread one end of the tape into the slot on one side of the flange. • Bring both ends of the tape together. Take them around the client’s neck, keeping them flat and untwisted. • Thread the end of the tape next to the client’s neck through the slot from the back to the front. • Have the client flex the neck. Tie the loose ends with a square knot at the side of the client’s neck, allowing for slack by placing one finger under the ties as with the two-strip method. Cut off long ends. • Tape and pad the tie knot. • Place a folded 4×4 gauze square under the tie knot, and apply tape over the knot. Rationale: This reduces skin ­irritation from the knot and prevents confusing the knot with the client’s gown ties. • Check the tightness of the ties. • Frequently check the tightness of the tracheostomy ties and position of the tracheostomy tube. Rationale: Swelling of the neck may cause the ties to become too tight, interfering with coughing and circulation. Ties can loosen in restless clients, allowing the tracheostomy tube to extrude from the stoma. Velcro Collar Method • Thread one piece of the collar with the Velcro end into the slot on one side of the flange. • Take the collar around the back of the client’s neck, ­keeping it flat. • Thread the other piece of the collar with the Velcro end into the slot on the other side of the flange. • Take the second piece of the collar around the back of the client’s neck, keeping it flat. • Have the client flex the neck and secure the two pieces of the collar together with the Velcro, allowing space for one to two fingers between the collar and the client’s neck. • Check the tightness of the collar as with the tie method. 10. Remove and discard sterile gloves. • Perform hand hygiene. 11. Document all relevant information. • Record suctioning, tracheostomy care, and the dressing change, noting your assessments.

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Providing Tracheostomy Care—continued SAMPLE DOCUMENTATION

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Variation: Using a Disposable Inner Cannula • Check policy for frequency of changing inner cannula because standards vary among institutions. • Open a new cannula package. EVALUATION • Perform appropriate follow-up such as determining character and amount of secretions, drainage from the tracheostomy, appearance of the tracheostomy incision, pulse rate and respiratory status compared to baseline data, and complaints of pain or discomfort at the tracheostomy site.

• •

Using a gloved hand, unlock the current inner cannula (if ­present) and remove it by gently pulling it out toward you in line with its curvature. Check the cannula for amount and type of secretions and ­discard properly. Pick up the new inner cannula touching only the outer locking portion. Insert the new inner cannula into the tracheostomy. Lock the cannula in place by turning the lock (if present) or ­clipping in place.

SKILL 50–4

12/11/2015 0900 Respirations 18–20/min. Lung sounds clear. Able to cough up secretions requiring little suctioning. Inner cannula changed. Trach dressing changed. Minimal amount of serosanguineous drainage present. Trach incision area pink to reddish in color 0.2 cm around entire opening. No broken skin noted in the reddened area. ––––––––––––––––––––––––––––––––––––––––– J. Garcia, RN

Relate findings to previous assessment data if available. Report significant deviations from normal to the primary care provider.

LIFESPAN CONSIDERATIONS Tracheostomy Care INFANTS AND CHILDREN • An assistant should always be present while tracheostomy care is performed. • Always keep a sterile, packaged tracheostomy tube taped to the child’s bed so that if the tube dislodges, a new one is ­available for immediate reintubation.

OLDER ADULTS Older adult skin is fragile and prone to breakdown. Care of the skin at the tracheostomy stoma is very important.

Home Care Considerations  Tracheostomy Care For tracheostomies older than 1 month, clean technique (rather than sterile technique) is used for tracheostomy care. • Stress the importance of good hand hygiene to the caregiver. • Tap water may be used for rinsing the inner cannula. • Teach the caregiver the tracheostomy care procedure and ­observe a return demonstration. Periodically reassess caregiver knowledge and/or tracheostomy care technique. •

Chest Tubes and Drainage Systems If the thin, double-layered pleural membrane is disrupted by lung disease, surgery, or trauma, the negative pressure between the pleural layers may be lost. The lung then collapses because it is no longer drawn outward as the diaphragm and intercostal muscles contract during inhalation. When air collects in the pleural space, it is known as a pneumothorax. A hemothorax is the accumulation of blood in the pleural space, and a pleural effusion exists when there is excessive fluid in the pleural space. The air, blood, or fluid in the pleural space places pressure on lung tissue and interferes with lung expansion. Chest tubes may be inserted into the pleural cavity to restore negative pressure and drain collected fluid or blood. Because air rises, chest tubes for pneumothorax often are placed in the upper anterior thorax, whereas chest tubes used to drain blood and fluid generally are placed in the lower lateral chest wall. When chest tubes are inserted, they must be connected to a sealed drainage system or a one-way valve that allows air and fluid to be

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PATIENT-CENTERED CARE Inform the caregiver of the signs and symptoms that may ­indicate an infection of the stoma site or lower airway. • Names and telephone numbers of health care personnel who can be reached for emergencies or advice must be available to the client and/or caregiver. • If the tracheostomy is permanent, provide contact information for available support groups. •

removed from the chest cavity but prevents air from entering from the outside. Sterile disposable drainage systems are used to prevent outside air from entering the chest tube. These systems typically have a suction control chamber, a water-seal chamber, and a closed collection chamber, for drainage (Figure 50–31 •). With the water-seal system, when the client inhales, the water prevents air from entering the system from the atmosphere. During exhalation, however, air can exit the chest cavity, bubbling up through the water. Suction can be added to the system to facilitate removing air and secretions from the chest cavity. The drainage system should always be kept below the level of the client’s chest to prevent fluid and drainage from being drawn back into the chest cavity. A Heimlich valve may be used for ambulatory clients (­Figure  50–32 •). The Heimlich valve is a one-way flutter valve that allows air to escape from the chest cavity, but prevents air from ­reentering. The arrow on the housing of the valve should always point away from the client. At each assessment, observe the inner valve carefully for movement during exhalation, indicating airflow

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Figure 50–31 • A disposable chest drainage system. Figure 50–33 • The Pneumostat is an example of a device often used for clients with a pneumothorax. It has a one-way valve and a small collection chamber.

• •

•

Figure 50–32 • Heimlich chest drain valve.

through the device. The Heimlich valve is not designed to collect fluid. Another device, attached to the chest tube and called the Pneumostat, also has a one-way valve and, unlike the Heimlich valve, a small builtin collection chamber. It is used exclusively for clients with a pneumothorax who usually have small amounts of fluid (Figure 50–33 •). Nursing responsibilities regarding drainage systems include the following: • Monitor and maintain the patency and integrity of the drainage

system.

• • • •

•

• Assess the client’s vital signs, oxygen saturation, cardiovascular

status, and respiratory status. Check the breath sounds bilaterally and check for symmetry of breath sounds. • Observe the dressing site at least every 4 hours. Inspect the dressing for excessive and abnormal drainage, such as bleeding or foulsmelling discharge. Palpate around the dressing site, and listen for a crackling sound indicative of subcutaneous emphysema.

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Subcutaneous emphysema, which is air in the subcutaneous tissues, can result from a poor seal at the chest tube insertion site. Determine level of discomfort with and without activity and medicate the client for pain if indicated. Encourage deep-breathing exercises and coughing every 2 hours (this may be contraindicated in clients who have had a lung removed). Have the client sit upright to perform the exercises, and splint the chest around the tube insertion site with a pillow or with a hand to minimize discomfort. Reposition the client every 2 hours. When the client is lying on the affected side, place rolled towels beside the tubing. Frequent position changes promote drainage, prevent complications, and provide comfort. Rolled towels prevent occlusion of the chest tube by the client’s weight. Assist the client with range-of-motion exercises of the affected shoulder three times per day to maintain joint mobility. Ensure that the connections are securely taped and that the chest tube is secured to the client’s chest wall. Keep the collection device below the client’s chest level. Frequently check the water-seal and suction control chambers. The water can evaporate and water may need to be added to the chamber. The water-seal level should fluctuate with respiratory effort. Assess the drainage in the tubing and collection chamber. The drainage is measured at regularly scheduled times (check agency policy). Mark the date and time at the fluid level on the drainage chamber. The unit is not replaced until almost full. Avoid aggressive chest tube manipulation (e.g., milking or stripping the tube). Milking can create excessive negative pressure that can harm the pleural membranes and/or surrounding tissues and cause the client pain (Durai, Hoque, & Davies, 2010).

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Chapter 50  •  Oxygenation • Avoid clamping the chest tube because this increases the risk of a

tension pneumothorax. You can clamp the tube for a moment to replace the drainage unit or to locate the source of an air leak, but never when transporting a client or for any extended period of time. • If the tube becomes disconnected from the collecting system, submerge the end in 2.5 cm (1 in.) of sterile saline or water to maintain the seal. If the chest tube is inadvertently pulled out, the wound should be immediately covered with a dry sterile dressing. If you can hear air leaking out of the site, ensure that the dressing is not occlusive. If the air cannot escape, this would lead to a tension pneumothorax. A tension pneumothorax occurs when there is buildup of air in the pleural space and it cannot escape, causing increased pressure. This pressure can eventually compromise cardiovascular function. • When transporting and ambulating the client: a. Keep the water-seal unit below chest level and upright. b. Disconnect the drainage system from the suction apparatus before moving the client and make sure the air vent is open. • Use standard precautions and personal protective equipment while manipulating the system and assisting with insertion or removal. Chest tube insertion and removal require sterile technique and must be done without introducing air or microorganisms into the pleural cavity. Removal of a chest tube is a brief but quite painful procedure. Medicate the client before the removal. Remove the dressing around the tube and prepare the dressing that will cover the insertion site. This will be an occlusive dressing if there is no purse-string suture around the insertion site to prevent air from entering the chest. Generally, the primary care provider performs the removal but, in some areas, specially trained nurses may be permitted to do so.

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Evaluating Using the goals and desired outcomes identified in the planning stage of the nursing process, the nurse collects data to evaluate the effectiveness of interventions. If outcomes are not achieved, the nurse, client, and support person if appropriate need to explore the reasons before modifying the care plan. For example, if the outcome “Respirations unlabored and rate is within expected range” is not met, examples of questions that need to be considered include the following: • What is the client’s perception of the problem? • Is the client complaining of shortness of breath or difficulty

breathing?

• Is the client taking medications or performing treatments such as

percussion, vibration, and postural drainage as prescribed?

• Has the client been exposed to an upper respiratory infection that

is affecting breathing?

• Do other factors need to be considered, such as the client’s psycho-

logical stress level?

Examples of questions to consider if the outcome “Able to complete ADLs without fatigue” is not met include the following: • What other factors may be affecting the client’s ability to complete

ADLs?

• Is the client getting adequate sleep? If not, what is interfering with

the client’s rest?

• Are there assistive devices (e.g., a shower chair, clothing that is

easy to put on) that could help the client achieve this goal?

• Does the client need help with housework and other ADLs? • Is the client’s diet adequate to meet nutritional needs?

NURSING CARE PLAN  Ineffective Airway Clearance Assessment Data

Nursing Diagnosis

Desired Outcomes*

Nursing Assessment Johti Singh is a 39-year-old secretary who was admitted to the hospital with an elevated temperature, fatigue, rapid, labored respirations; and mild dehydration. The nursing history reveals that Ms. Singh has had a “bad cold” for several weeks that just wouldn’t go away. She has been dieting for several months and skipping meals. Ms. Singh mentions that in addition to her full-time job as a secretary she is attending college classes two evenings a week. She has smoked one package of cigarettes per day since she was 18 years old. Chest x-ray confirms pneumonia.

Ineffective Airway Clearance ­related to thick sputum, secondary to pneumonia (as evidenced by rapid respirations, diminished and adventitious breath sounds, thick yellow sputum)

Respiratory Status: Airway ­Patency [0410] as evidenced by: • No deviation from normal range for respiratory rate • No accumulation of sputum • No adventitious breath sounds

Physical Examination

Diagnostic Data

Height: 167.6 cm (5960) Weight: 54.4 kg (120 lb) Temperature: 39.4°C (103°F) Pulse: 68 beats/min Respirations: 24/min Blood pressure: 118/70 mmHg Skin pale; cheeks flushed Chills; use of accessory ­muscles; inspiratory crackles with ­diminished breath sounds right base; expectorating thick, yellow sputum

Chest x-ray: right lobar infiltration WBC: 14,000 pH: 7.49 PaCO2: 33 mmHg HCO3–: 20 mEq/L PaO2: 80 mmHg O2 SAT: 88%

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NURSING CARE PLAN Ineffective Airway Clearance—continued Nursing Interventions*/Selected Activities

Rationale

Cough Enhancement [3250] Assist Ms. Singh to a sitting position with head slightly flexed, shoulders relaxed, and knees flexed.

Lying flat causes the abdominal organs to shift toward the chest, ­crowding the lungs and making it more difficult to breathe.

Encourage her to take several deep breaths.

Deep breathing promotes oxygenation before controlled coughing.

Encourage her to take a deep breath, hold for 2 seconds, and cough two or three times in succession.

Controlled coughing is accomplished by closure of the glottis and the explosive expulsion of air from the lungs by the work of abdominal and chest muscles.

Encourage use of incentive spirometry, as appropriate.

Breathing exercises help maximize ventilation.

Promote systemic fluid hydration, as appropriate.

Adequate fluid intake enhances liquefaction of pulmonary secretions and facilitates expectoration of mucus.

Respiratory Monitoring [3350] Monitor rate, rhythm, depth, and effort of respirations.

Provides a basis for evaluating adequacy of ventilation.

Note chest movement, watching for symmetry, use of accessory muscles, and supraclavicular and intercostal muscle retractions.

Presence of nasal flaring and use of accessory muscles during respirations may occur in response to ineffective ventilation.

Auscultate breath sounds, noting areas of decreased or ­absent ventilation and presence of adventitious sounds.

As fluid and mucus accumulate, abnormal breath sounds can be heard including crackles and diminished breath sounds resulting from ­fluid-filled air spaces and diminished lung volume.

Auscultate lung sounds after treatments to note results.

Assists in evaluating prescribed treatments and client outcomes.

Monitor client’s ability to cough effectively.

Respiratory tract infections alter the amount and character of ­secretions. An ineffective cough compromises airway clearance and prevents ­mucus from being expelled.

Monitor client’s respiratory secretions.

People with pneumonia commonly produce rust-colored, purulent sputum.

Institute respiratory therapy treatments (e.g., nebulizer) as needed.

A variety of respiratory therapy treatments may be used to open ­constricted airways and liquefy secretions.

Monitor for increased restlessness, anxiety, and air hunger.

These clinical manifestations would be early indicators of hypoxia.

Note changes in SpO2, tidal volume, and arterial blood gas values, as appropriate.

Evaluates the status of oxygenation, ventilation, and acid–base balance.

Evaluation Outcome partially met. Ms. Singh coughs and deep breathes purposefully q1–2h during the day. Her fluid intake is approximately 1,500 mL each day. Cough continues to be productive of moderately thick, rusty-colored sputum. Inspiratory crackles remain present in right lower lobe. *The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention. Outcomes, interventions and activities selected are only a sample of those by NOC and NIC and should be further individualized for each client.

Applying Critical Thinking 1. What factors may have led the medical staff to suspect that Ms. Singh had more than a very bad cold? Would you have come to the same conclusion? 2. The care plan appropriately focuses on the acute care of this client. Once she is significantly improved, the nurse will perform ­discharge teaching. What areas should be included? 3. The client already has some signs of respiratory distress. What signs might indicate that her condition was deteriorating into a more emergency situation? How would you handle this? 4. It appears that the client’s sputum has not been cultured. In caring for this client, what infection control guidelines would be needed? 5. Ms. Singh’s oxygen order is for a face mask at 6 L/min. She repeatedly pulls it off and you find it lying in the sheets. How might you intervene? See Critical Thinking Possibilities on student resource website.

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CONCEPT MAP Ineffective Airway Clearance

JS 39 y.o. female Pneumonia

• Increased temperature; fatigue; rapid, labored respirations; mild dehydration. “Bad cold” X several weeks. Dieting for several months and skipping meals. Works full-time job as secretary, college classes 2x/week. Smokes, 21 pack/years.

assess

• • • • •

Height: 167.6 cm (5' 6") Weight: 54.4 kg (120 lbs) TPR: 39.4°C (103°F), 68, 24 BP: 118/70 Skin pale; cheeks flushed; chills; use of accessory muscles, inspiratory crackles with diminished breath sounds at right base; expectorating thick, yellow sputum

• Chest x-ray: right lobar infiltrate • WBC: 14,000 • pH: 7.49 • PaCO2: 33 mmHg – • HCO3: 20 mEq/L • PaO2: 80 mmHg

generate nursing diagnosis Ineffective Airway Clearance r/t thick sputum, secondary to pneumonia (aeb rapid respirations, diminished and adventitious breath sounds, thick, yellow sputum) outcome

Respiratory Status: Airway Patency aeb no deviation from normal for respiratory rate and no • Accumulation of sputum • Adventitious breath sounds nursing intervention

nursing intervention

Cough Enhancement

Respiratory Monitoring

activity

activity

Assist to a sitting position with head slightly flexed, shoulders relaxed, and knees flexed

evaluation

activity activity

Promote systemic fluid hydration, as appropriate activity activity activity

Encourage her to take several deep breaths

Encourage her to take a deep breath, hold for 2 seconds, and cough two or three times in succession

Monitor rate, rhythm, depth, and effort of respirations

activity

activity activity

Note chest movement, watching for symmetry, use of accessory muscles, and supraclavicular and intercostal muscle retractions

Encourage use of incentive spirometry, as appropriate

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Outcomes partially met: • Coughs and deep breaths purposefully q 1–2 hr during the day • Fluid intake approximately 1,500 mL/day • Cough productive of moderately thick, rusty-colored sputum • Inspiratory crackles remain present in RLL

Monitor respiratory secretions

Monitor ability to cough effectively

Note changes in SpO2, and changes in ABG values, as appropriate activity

Auscultate breath sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds

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Chapter 50 Review CHAPTER HIGHLIGHTS • Respiration is the process of gas exchange between the individual •

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•

• • • •

•

•

and the environment. The respiratory system contributes to effective respiration through pulmonary ventilation (the movement of air between the atmosphere and the lungs), the diffusion of oxygen and carbon dioxide across the pulmonary membrane, transport of oxygen from the tissues to the lungs and carbon dioxide from the tissues to the lungs, and transport of oxygen and carbon dioxide between the systemic capillaries and the tissues. Alveoli and the capillaries that surround them form the respiratory membrane, where gas exchange between the lungs and the blood occurs. Effective pulmonary ventilation, or breathing, requires clear airways, an intact central nervous system and respiratory center, an intact thoracic cavity and musculature, and adequate pulmonary compliance (stretch) and recoil. Gas exchange occurs by diffusion, as gas molecules move from an area of higher concentration to an area of lower concentration. At the respiratory membrane, oxygen moves from the alveolus into the blood, while carbon dioxide moves from the blood into the alveolus. Most oxygen (97%) is carried to the tissues loosely combined with hemoglobin in red blood cells (RBCs). Anemia, which is too few RBCs or low hemoglobin levels, impairs oxygen transportation. Respiratory regulation includes both neural and chemical controls to maintain the correct concentrations of oxygen, carbon dioxide, and hydrogen ions in body fluids. The body’s “respiratory center” is located in the medulla oblongata and pons of the brain. Respiratory rates normally are highest in neonates and infants, gradually slowing to adult ranges. Aging affects the respiratory system: The chest wall becomes more rigid and lungs less elastic. Other factors affecting oxygenation include the environment, lifestyle, health status, medications, and stress. Respiratory function can be altered by conditions that affect the patency of the airway, movement of air into or out of the lungs, diffusion of oxygen and carbon dioxide between the alveoli and the pulmonary capillaries, and the transport of oxygen and carbon dioxide via the blood to and from the tissue cells. Hypoxia, insufficient oxygen in the tissues, can result from impaired ventilation (hypoventilation) or impaired diffusion, or from impaired oxygen transportation to the tissues because of anemia or decreased cardiac output. Airway obstruction interferes with ventilation. A low-pitched snoring sound, stridor, and abnormal breath sounds may accompany

•

•

•

•

•

•

•

•

partial airway obstruction. Extreme inspiratory effort with no chest movement indicates complete upper airway obstruction. Normal respirations are quiet and unlabored; altered respiratory patterns include tachypnea, bradypnea, hyperventilation, hypoventilation, and dyspnea. Shortness of breath is a subjective sensation of not getting enough air. The nursing history includes questions about current or past respiratory problems and about lifestyle, presence of symptoms such as cough or shortness of breath, smoking and other risk factors, and medications. Diagnostic tests that may be performed to assess oxygenation include sputum and throat culture specimens; blood tests such as arterial blood gases; pulmonary function tests; and visualization procedures such as x-rays, lung scans, laryngoscopy, and bronchoscopy. Nursing diagnoses for the client with problems of oxygenation include Ineffective Airway Clearance, Ineffective Breathing Pattern, Impaired Gas Exchange, and Activity Intolerance. These p ­ roblems also may be the etiology for several other nursing diagnoses, ­including Anxiety, Fatigue, Fear, Powerlessness, Insomnia, and ­Social Isolation. In discharge and home care planning, the nurse assesses the client’s self-care abilities and need for assistive devices, home environment, compliance with medical regimen, and knowledge level. The ability of the family or support people to provide assistance and financial support and to cope with the changes is also assessed, as are community factors such as the environment and resources. The nurse teaches the client about home care activities to maintain a patent airway and gas exchange and to promote healthy breathing. Dietary modifications, prescribed medications, and specific procedures also are taught, and the nurse makes referrals to community agencies as needed. Nursing interventions to promote oxygenation include promoting healthy breathing, deep breathing and coughing, and hydration; administering medications; implementing measures to clear secretions (e.g., incentive spirometry, percussion, vibration, postural drainage, and mucus clearing devices); initiating and monitoring oxygen therapy; initiating or assisting with procedures to maintain the airway (e.g., artificial airways and suctioning); providing tracheostomy care; and monitoring chest drainage systems. The effectiveness of nursing interventions is evaluated by using the goals and desired outcomes identified in the planning stage of the nursing process. If a goal is not met, the nurse asks pertinent questions to assess the reason for not meeting the goal.

TEST YOUR KNOWLEDGE 1. When planning care, for which client would the nurse include close observation for a decreased or absent cough reflex? 1. The client with a nasal fracture 2. The client with impairment of vagus nerve conduction 3. The client with a sinus infection 4. The client with reduction in respiratory membrane conduction

2. A client, diagnosed with chronic obstructive lung disease receiving oxygen at 1.5 liters per minute via nasal cannula, is complaining of shortness of breath. What action should the nurse take? 1. Increase the oxygen to 3 liters per minute via nasal cannula. 2. Lower the head of the client’s bed to semi-Fowler’s position. 3. Have the client breathe through pursed lips. 4. Encourage the client to breathe more rapidly.

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Chapter 50  •  Oxygenation 3. The nurse is preparing to perform tracheostomy care. Prior to beginning the procedure the nurse performs which action? 1. Tells the client to raise two fingers to indicate pain or distress. 2. Changes the twill tape holding the tracheostomy in place. 3. Cleans the incision site. 4. Checks the tightness of the ties and knot. 4. The nurse has placed an oropharyngeal airway in a client. What action should the nurse take at this time? 1. Tape the airway in place. 2. Suction the client. 3. Turn the client’s head to the side. 4. Insert a nasal trumpet. 5. Which client statement informs the nurse that his teaching about the proper use of an incentive spirometer was effective? 1. “I should breathe out as fast and hard as possible into the device.” 2. “I should inhale slowly and steadily to keep the balls up.” 3. “I should use the device three times a day, after meals.” 4. “The entire device should be washed thoroughly in sudsy water once a week.” 6. While a client with chest tubes is ambulating, the connection between the tube and the water seal dislodges. Which action by the nurse is most appropriate? 1. Assist the client to ambulate back to bed. 2. Reconnect the tube to the water seal. 3. Assess the client’s lung sounds with a stethoscope. 4. Have the client cough forcibly several times. 7. The nurse makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has 1. Anemia. 2. An infection. 3. A fractured rib. 4. A tumor of the medulla.

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8. Which term does the nurse document to best describe a client experiencing shortness of breath when lying down who must assume an upright or sitting position to breathe more comfortably and effectively? 1. Dyspnea 2. Hyperpnea 3. Orthopnea 4. Acapnea 9. A client with emphysema is prescribed corticosteroid therapy on a short-term basis for acute bronchitis. The client asks the nurse how the steroids will help him. The nurse responds by saying that the corticosteroids will do which of the following? 1. Promote bronchodilation. 2. Help the client to cough. 3. Prevent respiratory infection. 4. Decrease inflammation in the airways. 10. The nurse is planning to perform percussion and postural drainage. Which is an important aspect of planning the client’s care? 1. Percussion and postural drainage should be done before lunch. 2. The order should be coughing, percussion, positioning, and then suctioning. 3. A good time to perform percussion and postural drainage is in the morning after breakfast when the client is well rested. 4. Percussion and postural drainage should always be preceded by 3 minutes of 100% oxygen. See Answers to Test Your Knowledge in Appendix A.

READINGS AND REFERENCES Suggested Readings Burt, L., & Corbridge, S. (2013). COPD exacerbations: ­Evidence-based guidelines for identification, assessment, and management. American Journal of Nursing, 113(2), 34–43. doi:10.1097/01.NAJ.0000426688.96330.60 This is a follow-up to the article below by Corbrige et al. that outlines guidelines and evidence-based recommendations for identifying, assessing, and managing COPD exacerbations. Corbrige, S., Wilken, L., Kapella, M. C., & Gronkiewicz, C. (2012). An evidence-based approach to COPD: Part 1. American Journal of Nursing, 112 (3), 46–57. doi:10.1097/01.NAJ.0000412639.08764.21 The authors outline guidelines and other evidence-based recommendations on diagnosing and managing stable COPD in the outpatient setting.

Related Research Eastwood, G. M., Reade, M. C., Peck, L., Baldwin, I., ­Considine, J., & Bellomo, R. (2012). Critical care nurses’ opinion and self-reported practice of oxygen therapy: A survey. Australian Critical Care, 25, 23–30. doi:10.1016/ j.aucc.2011.05.001 McClean, E. B. (2012). Tracheal suctioning in children with chronic tracheostomies: A pilot study applying suction both while inserting and removing the catheter.

Journal of Pediatric Nursing, 27(1), 50–54. doi:10.1016/ j.pedn.2010.11.007 Özden, D., & Görgülü, S. R. (2012). Development of standard practice guidelines for open and closed system suctioning. Journal of Clinical Nursing, 21, 1327–1338. doi:10.1111/j.1365-2702.2011.03997.x

References Barnett, M. (2012). Back to basics: Caring for people with a tracheostomy. Nursing & Residential Care, 14, 390. Blakeman, T. C. (2013). Evidence for oxygen use in the hospitalized patient: Is more really the enemy of good? Respiratory Care, 58(10), 1679–1693. doi:10.4187/ respcare.02677 Booker, S., Murff, S., Kitko, L., & Jablonski, R. (2013). Mouth care to reduce ventilator-associated pneumonia. American Journal of Nursing, 113(10), 24–30. doi:10.1097/01 .NAJ.0000435343.38287.3a Bulechek, G. M., Butcher, H. K., Dochterman, J. M., & Wagner, C. M. (Eds.). (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Mosby Elsevier. Durai, R., Hoque, H., & Davies, T. (2010). Managing a chest tube and drainage system. AORN Journal, 91, 275–283. doi:10.1016/j.aorn.2009.09.026 Facchiano, L., Snyder, C., & Núñez, D. E. (2011). A literature review on breathing retraining as a self-management strategy operationalized through Rosswurm and

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Larrabee’s evidence-based practice model. Journal of the American Academy of Nurse Practitioners, 23, 421–426. doi:10.1111/j.1745-7599.2011.00623.x Herdman, T. H., & Kamitsuru, S. (Ed.). (2014). NANDA International nursing diagnoses: Definitions & classification, 2015–2017. Oxford, United Kingdom: Wiley-Blackwell. Hess, D. R., MacIntyre, N. R., Mishoe, S. C., Galvin, W. R., & Adams, A. B. (2012). Respiratory care principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett. Holland, A. E., Hill, C. J., Jones, A. Y., & McDonald, C. F. (2012). Breathing exercises for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, Issue 10. Art. No.: CD008250. doi:10.1002/14651858 .CD008250.pub2 Kallet, R. H. (2012). Is pulmonary oxygen toxicity still a clinically relevant issue? Critical Care Alert, 20(6), 41–43. Makic, M. B. F., Martin, S. A., Burns, S., Philbrick, D., & Rauen, C. (2013). Putting evidence into nursing practice: Four traditional practices not supported by the evidence. Critical Care Nurse, 33(2), 28–42. doi:10.4037/ ccn2013787 Martin, D. S., & Grocott, M. P. W. (2013). Oxygen therapy in critical illness. Critical Care Medicine, 41, 423–432. Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Mosby Elsevier.

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Morris, L. L., Whitmer, A., & McIntosh, E. (2013). Tracheostomy care and complications in the intensive care unit. ­Critical Care Nurse, 33(5), 18–31. doi:10.4037/ ccn2013518 Nance-Floyd, B. (2011). Tracheostomy care: An evidencebased guide to suctioning and dressing changes. American Nurse Today, 6(7), 14–16. Ntoumenopoulos, G. (2013). Endotracheal suctioning may or may not have an impact, but it does depend on what you measure! Respiratory Care, 58, 1707–1710. doi:10.4187/ respcare.02745 Patton, K. T., & Tibodeau, G. A. (2010). Anatomy and physiology (7th ed.). St. Louis, MO: Mosby Elsevier. Pierson, D. J. (2013). Effects of standardizing procedures on adverse effects of endotracheal suctioning. Critical Care Alert, 21(7), 54–55.

Rice, J. (2012). Medical terminology: A word-building approach (7th ed.). Upper Saddle River, NJ: Pearson Education. Wang, Q., Zhang, X., & Li, Q. (2010). Effects of a flutter mucus-clearance device on pulmonary function test results in healthy people 85 years and older in China. Respiratory Care, 55, 1449–1452.

Selected Bibliography Cataletto, M. (2011). Fundamentals of oxygen therapy. Nursing Made Incredibly Easy!, 9(2), 22–24. doi:10.1097/01 .NME.0000394045.03830.3d Frace, M. (2010). Tracheostomy care on the medical–surgical unit. MEDSURG Nursing, 19(1), 58–61. Freeman, S. (2011). Care of adult patients with a temporary tracheostomy. Nursing Standard, 26(2), 49–56. doi:10.7748/ns2011.09.26.2.49.c8706

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Heffner, J. E. (2013). The story of oxygen. Respiratory Care, 58(1), 18–31. doi:10.4187/respcare.01831 Jenabzadeh, N. E., & Chlan, L. (2011). A nurse’s experience being intubated and receiving mechanical ventilation. Critical Care Nurse, 31(6), 51–54. doi:10.4037/ccn2011182 Lynes, D., & Kelly, C. (2013). Acute oxygen therapy for patients in the community. Nursing Standard, 27(21), 63–68. doi:10.7748/ns2013.01.27.21.63.e7058 Morris, L. L., & Grossbach, I. (2012). Capping a cuffed tracheostomy tube . . . Promoting effective communication for patients receiving mechanical ventilation. Critical Care Nurse, 32(2), 12–13. doi:10.4037/ccn2012391 Preston, W. (2013). The increasing use of non-invasive ventilation. Practice Nursing, 24(3), 114–119. Siela, D. (2010). Evaluation standards for management of artificial airways. Critical Care Nurse, 30(4), 76–78. doi:10.4037/ccn2010306

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Circulation

LEARNING OUTCOMES After completing this chapter, you will be able to: 1. Outline the structure and physiology of the cardiovascular system. 2. Identify major risk factors for the development of cardiovascular disease and related health promotion objectives from Healthy People 2020. 3. Describe three major alterations in cardiovascular function. 4. Outline the nursing management of a client with cardiovascular disease.

5. Describe the critical nature of cardiopulmonary resuscitation. 6. Verbalize the steps used in: a. Applying a sequential compression device. 7. Recognize when it is appropriate to delegate aspects of applying a sequential compression device to unlicensed ­ ­assistive personnel. 8. Demonstrate appropriate documentation and reporting when applying a sequential compression device.

KEY TERMS afterload, 1317 atherosclerosis, 1319 atria, 1313 atrioventricular (AV) node, 1316 atrioventricular (AV) valves, 1313 automaticity, 1316 blood pressure (BP), 1318 bundle of His, 1316 cardiac output (CO), 1316

contractility, 1317 coronary arteries, 1314 C-reactive protein (CRP), 1322 creatine kinase (CK), 1326 diastole, 1314 endocardium, 1313 epicardium, 1313 heart failure, 1323 hemoglobin, 1319

INTRODUCTION

The circulatory, or cardiovascular, system is responsible for the transport of oxygen, fluids, electrolytes, and products of metabolism via the blood to and from tissues.

PHYSIOLOGY OF THE CARDIOVASCULAR SYSTEM

The respiratory and cardiovascular systems are closely linked and dependent on one another to deliver oxygen to the tissues of the body. Alterations in function of either system can affect the other and lead to tissue hypoxia (lack of oxygen). The heart and the blood vessels make up the cardiovascular system. Together with blood, it is the major transport system of the body, bringing oxygen and nutrients to the cells and removing wastes for disposal. The heart serves as the system’s pump, moving blood through the vessels to the tissues.

The Heart

The heart is a hollow, cone-shaped organ about the size of a fist. It is located in the mediastinum, between the lungs and underlying the sternum. It is enclosed by a double layer of fibroserous membrane known as the pericardium. The parietal, or outermost, pericardium serves to protect the heart and anchor it to surrounding structures. The visceral pericardium adheres to the surface of the heart, forming the heart’s

homocysteine, 1322 ischemia, 1324 metabolic syndrome (Met-S), 1322 myocardial infarction (MI), 1323 myocardium, 1313 pericardium, 1313 peripheral vascular resistance (PVR), 1318

preload, 1317 Purkinje fibers, 1316 semilunar valves, 1313 septum, 1313 sinoatrial (SA or sinus) node, 1316 stroke volume (SV), 1316 systole, 1314 troponin, 1326 ventricles, 1313

outermost layer, the epicardium. The heart wall contains two additional layers: the myocardium, cardiac muscle cells that form the bulk of the heart and contract with each beat, and the endocardium, which lines the inside of the heart’s chambers and great vessels (Figure 51–1 •). Four hollow chambers within the heart, two upper atria and two lower ventricles, are separated longitudinally by the interventricular septum, forming two parallel pumps. The atria and ventricles are separated from one another by the atrioventricular (AV) valves, the tricuspid valve on the right and the bicuspid or mitral valve on the left. The valves are named for the number of cusps (or leaflets) present on the valve. The ventricles, in turn, are separated from the great vessels (the pulmonary arteries and aorta) by the semilunar valves (named for their crescent moon shape): the pulmonary (also called the pulmonic) valve on the right and the aortic valve on the left. The valves serve to direct the flow of blood, allowing it to move from the atria to the ventricles, and the ventricles to the great vessels, but preventing backflow (Figure 51–2 •). Deoxygenated blood from the veins enters the right side of the heart through the superior and inferior venae cavae (singular is vena cava). From there, it flows into the right ventricle, which pumps it through the pulmonary artery into the lungs for gas exchange across the alveolar–capillary membrane. Freshly oxygenated blood returns to the left atrium via the pulmonary veins. From here, the blood enters the left ventricle to be pumped out for systemic circulation through the aorta (Figure 51–3 •). 1313

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Pericardium (external covering) Interior of chamber

Myocardium (muscle) Endocardium (internal lining)

Figure 51–1  •  The layers of the heart: the epicardium, the myocardium, and the endocardium. From Medical Terminology: A Word-Building Approach, 7th ed. (p. 263), by J. Rice, 2012. Reproduced by permission of Pearson Education, Inc., Upper Saddle River, New Jersey.

Tricuspid valve (right atrioventricular valve)

Aortic valve (left semilunar valve)

Mitral valve (left atrioventricular valve)

Pulmonary valve (right semilunar valve)

Figure 51–2  •  Heart valves in closed position viewed from the top. From Medical Terminology: A Word-Building Approach, 7th ed. (p. 266), by J. Rice, 2012. Reproduced by permission of Pearson Education, Inc., Upper Saddle River, New Jersey.

CORONARY CIRCULATION The heart muscle moves blood to the lungs and peripheral tissues but does not receive oxygen or nourishment from the blood within its chambers. Instead, it is supplied by a network of vessels known as coronary circulation or more commonly as the coronary arteries. The coronary arteries originate at the base of the aorta, branching out to encircle and penetrate the myocardium. These arteries fill during ventricular relaxation, bringing oxygen-rich blood to the myocardium (Figure 51–4 •). If these arteries become clogged with atherosclerotic plaques or are obstructed by a blood clot, the myocardium is deprived of oxygen, and the client may develop chest pain (angina) or

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experience a myocardial infarction (heart attack). The cardiac veins drain the deoxygenated blood from the myocardium into the coronary sinus, which empties into the right atrium.

CARDIAC CYCLE With each heartbeat, the myocardium goes through a cycle of contraction (systole) and relaxation (diastole). Systole is when the heart ejects (propels) the blood into pulmonary and systemic circulation. Diastole is when the ventricles fill with blood. The diastolic phase of the cardiac cycle is twice as long as the systolic phase. This is important because diastole (or ventricular filling) is largely a passive

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Aorta Superior vena cava

Right atrium

1 Sinoatrial node (pacemaker)

Left atrium

2 Internodal pathway

Purkinje fibers

3 Atrioventricular node 4 Atrioventricular bundle (Bundle of His)

Interventricular septum

Bundle branches

5 Purkinje fibers

1. The sinoatrial (SA) node fires a stimulus across the walls of both left and right atria causing them to contract. 2. The stimulus arrives at the atrioventricular (AV) node. 3. The stimulus is directed to follow the AV bundle (Bundle of His). 4. The stimulus now travels through the apex of the heart through the bundle branches. 5. The Purkinje fibers distribute the stimulus across both ventricles causing ventricular contraction.

Figure 51–3  •  The functioning of the heart valves and blood flow through the heart. From Medical Terminology: A Word-Building Approach, 7th ed. (p. 264), by J. Rice, 2012. Reproduced by permission of Pearson Education, Inc., Upper Saddle River, New Jersey.

TABLE 51–1   Cardiac Cycle and Heart Sounds Left main coronary artery Left atrial appendage Circumflex branch of left main coronary artery

Right coronary artery Right atrial appendage Posterior descending (interventricular) branch of right coronary artery

Left anterior descending branch of left coronary artery

Figure 51–4  •  The coronary arteries supply the heart muscle with oxygenated blood.

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Sound S1—first sound

Phase of Cardiac Cycle Beginning of ventricular systole; the sound is caused by closure of the atrioventricular valves—the tricuspid and the mitral.

S2—second sound Beginning of ventricular diastole; the sound is caused by closure of the semilunar valves—the aortic and pulmonic.

process. The longer diastolic phase allows this filling to occur. At the end of the diastolic phase, the atria contract, adding additional volume to the ventricles. This volume is sometimes called atrial kick. The relationship between the phases of the cardiac cycle and normal heart sounds is described in Table 51–1.

CARDIAC CONDUCTION SYSTEM Cardiac muscle contraction is a mechanical event that occurs in response to electrical stimulation. Cardiac muscle is unique in

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Right atrium

1 Sinoatrial node (pacemaker)

Left atrium

2 Internodal pathway

Purkinje fibers

3 Atrioventricular node 4 Atrioventricular bundle (Bundle of His)

Interventricular septum

Bundle branches

5 Purkinje fibers

1. The sinoatrial (SA) node fires a stimulus across the walls of both left and right atria causing them to contract. 2. The stimulus arrives at the atrioventricular (AV) node. 3. The stimulus is directed to follow the AV bundle (Bundle of His). 4. The stimulus now travels through the apex of the heart through the bundle branches. 5. The Purkinje fibers distribute the stimulus across both ventricles causing ventricular contraction.

Figure 51–5  •  The conduction system of the heart. The impulse is initiated by the SA node, then travels to the AV node, the bundle of His, bundle branches, and finally to the Purkinje fibers. From Medical Terminology: A Word-Building Approach, 7th ed. (p. 268), by J. Rice, 2012. Reproduced by permission of Pearson Education, Inc., Upper Saddle River, New Jersey.

that, unlike skeletal muscle, it can generate electrical impulses and contractions independently of the nervous system. This unique property of heart muscle is called automaticity. A network of specialized cells and pathways known as the cardiac conduction system normally controls the electrical activity and contractions of the heart. The primary pacemaker of the heart is the sinoatrial (SA or sinus) node, located where the superior vena cava enters the right atrium. The SA node normally initiates electrical impulses that are conducted throughout the heart and result in ventricular contraction. In adults, it usually discharges impulses at a regular rate of 60 to 100 times per minute, the “normal” heart rate. The impulse then spreads throughout the atria via the interatrial pathways. These conduction pathways converge and narrow through the ­atrioventricular (AV) node, slightly delaying transmission of the impulse to the ventricles. This delay allows the atria to contract slightly before ventricular contraction occurs. From the AV node, the impulse then progresses down through the intraventricular septum to the ventricular conduction pathways: the bundle of His, the right and left bundle branches, and the Purkinje fibers. These fibers terminate in ventricular muscle, stimulating contraction (Figure 51–5 •).

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CARDIAC OUTPUT As the ventricles contract during systole, blood flows out of the ventricles through the aorta and pulmonary artery into systemic and pulmonary circulation. The heart muscle then relaxes (the diastolic phase), allowing the ventricles to refill and cardiac muscle to be perfused. This repeated contraction and relaxation of the heart is known as the cardiac cycle. The cycle is repeated 60 to 100 times a minute in an adult, stimulated by impulses generated by the SA node. With each contraction, a certain amount of blood, known as the stroke volume, is ejected from the ventricles into circulation. In adults, the average stroke volume is about 70 mL per beat. ­ ardiac output (CO) is the amount of blood pumped by the C ventricles in 1 minute. Cardiac output is calculated by multiplying the stroke volume (SV), the amount of blood ejected with each contraction, times the heart rate (HR). Thus, SV × HR = CO. Normal cardiac output is 4 to 8 L/min. Cardiac output is an important indicator of how well the heart is functioning as a pump. If CO is poor, oxygen and nutrients do not reach cells as needed, impairing tissue perfusion. Cardiac output is affected by several factors, as discussed next.

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Chapter 51  •  Circulation HEART RATE  An increased heart rate increases CO, even if the

stroke volume does not change. Conversely, CO decreases when the heart rate falls if stroke volume remains constant. There are physiological limits to the increase in CO that occurs with increased heart rate. Very rapid heart rates, more than 150 beats per minute in an adult, may not allow adequate time for the ventricles to fill, causing CO to fall. Heart rate is influenced by many factors including the autonomic nervous system, blood pressure, hormones such as thyroid hormone, and some medications.

PRELOAD  Preload is the degree to which muscle fibers in the ventricle are stretched at the end of the relaxation period (diastole). Preload largely depends on the amount of blood returning to the heart from venous circulation; increased volume causes increased stretch, leading to more forceful contraction of cardiac muscle fibers. This physiological relationship is referred to as the Frank-Starling law of the heart, which states that the length of ventricular muscle fibers (stretch) at the end of diastole directly affects the strength (force) of contraction. For example, exercise increases venous return and therefore increases preload; in response, the heart contracts more forcefully, causing stroke volume and cardiac output to increase during exercise. CONTRACTILITY  Contractility is the natural ability of cardiac

muscle fibers to shorten or contract. Stroke volume decreases if contractility is poor, reducing cardiac output. Contractility is affected by the autonomic nervous system and certain drugs. Drugs that affect contractility are called inotropic drugs; positive inotropic drugs increase contractility, and negative inotropic drugs decrease contractility. See the Drug Capsule on digoxin in Chapter 29 to learn more about this positive inotropic medication. AFTERLOAD   Afterload is the resistance that the ventricle must

overcome during systole to eject blood into circulation. The right ventricle ejects blood into the pulmonary circulation, and the left ventricle ejects blood through the aortic valve to the systemic circulation. Blood flows from an area of higher pressure to an area of lower pressure. To move blood into the circulatory system, the ventricles must generate sufficient pressure to overcome vascular resistance or the pressure within the arteries, known as afterload. The right ventricle pumps blood into the low-pressure, lowresistance pulmonary vascular system; therefore, the pressures generated by the right ventricle are fairly low. The left ventricle, by contrast, pumps blood into the higher pressure systemic arterial system, generating much higher pressures and requiring more work. The higher the afterload, the harder the heart has to work to eject its contents, resulting in increased myocardial oxygen demand. For example, systemic vasoconstriction increases the arterial blood pressure and afterload, increasing the cardiac workload; vasodilation, on the other hand, reduces arterial pressure and the workload of the heart. Table 51–2 summarizes the factors related to cardiac function.

Blood Vessels

With each cardiac contraction, blood is ejected into a closed system of blood vessels that transport blood to the tissues and return it to the heart. The heart supports two circulatory systems: the low-pressure pulmonary system and the higher pressure systemic system.

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TABLE 51–2   Factors Related to Cardiac Function Indicator Cardiac output (CO)

Definition Amount of blood ejected from the heart each minute; CO = SV × HR

Stroke volume (SV)

Amount of blood ejected from the heart with each beat

Heart rate (HR)

Number of beats each minute

Contractility

Inotropic state of the myocardium, strength of contraction

Preload

Left ventricular end diastolic volume, stretch of the myocardium

Afterload

Resistance against which the heart must pump

Deoxygenated blood from the right ventricle enters the pulmonary system through the pulmonary arteries. The pulmonary arteries subdivide into lobar arteries. These lobar arteries follow the main bronchi into the lungs, then branch out to form arterioles and the dense capillary networks that encompass the alveoli. Oxygen diffuses into the blood from the alveoli, and carbon dioxide diffuses into the alveoli from the blood. This diffusion occurs across the alveolar–capillary membrane. The blood then returns to the left side of the heart via venules and the pulmonary veins. Note that the pulmonary vascular system is the only part of the circulatory system in which arteries (which transport blood away from the heart) carry deoxygenated blood, and veins (which transport blood toward the heart) contain oxygenated blood. The muscular left ventricle of the heart pumps oxygenated blood into the aorta. The blood then moves into major arteries that branch from the aorta and into successively smaller arteries, arterioles, and finally into the thin-walled capillary beds of organs and tissues. It is in the capillary beds that oxygen and nutrients are exchanged for metabolic waste products. The deoxygenated blood then returns to the heart through a series of venules and veins that become progressively larger until they empty into the superior and inferior venae cavae. With the exception of capillaries, blood vessel walls have three distinct layers, or tunics. The innermost layer, the tunica intima, is smooth endothelium that facilitates blood flow. The tunica media is made up of elastic fibers and smooth muscle cells innervated by the autonomic nervous system. This allows vessels to constrict or dilate, depending on the needs of the body. The tunica media of arteries is thicker and more muscular than that of veins, a feature that helps maintain blood pressure and continuous circulation to the tissues. The outermost layer of blood vessels is the tunica adventitia, a layer of connective tissue that supports, protects, and anchors the vessel to surrounding tissues. Capillaries contain only one thin layer of tunica intima, allowing gases and molecules to diffuse between the blood and the tissues.

ARTERIAL CIRCULATION Arterial circulation moves blood from the heart to the tissues, maintaining a constant flow to the capillary beds despite the intermittent pumping action of the heart. Blood flow, the volume of blood flowing through a given vessel, organ, or the entire circulatory system over a specific period, is determined by pressure differences and resistance. Blood always moves

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ANATOMY & PHYSIOLOGY REVIEW Preload and Afterload

Aorta Pulmonary artery

Superior vena cava

Left atrium Mitral valve Aortic valve Chordae tendinae Left ventricle

Pulmonary valve Right atrium Tricuspid valve

Interventricular septum

Inferior vena cava Right ventricle

Apex of the heart

From Medical Language, 3rd ed., by S. M.Turley, © 2014. Reproduced with permission of Pearson Education, Inc. Upper Saddle River, New Jersey.

QUESTIONS Preload is affected by the amount of blood returning to the heart from the venous circulation. Review the figure. 1. Which side of the heart is primarily affected by preload? 2. What could cause an increase of venous blood return to the heart? 3. When would an increase in preload have a positive effect/ outcome for the client? 4. When does an increase in preload have a negative effect/ outcome for the client? 5. What medication classification decreases preload? (Hint: Think about what could cause a decrease in venous return of volume to the heart.)

Afterload is the resistance against which the heart must pump. Review the figure. 6. Which side of the heart is primarily affected by afterload? 7. What can cause an increase in afterload (e.g., what can cause the left side of the heart to work harder)? 8. Based on the physiology, afterload can be decreased by medications that would have what physiological result/ outcome?

from an area of higher pressure to an area of lower pressure. The greater the difference between pressures, the greater the blood flow. Blood pressure (BP) is the force exerted on arterial walls by the blood flowing within the vessel. See Chapter 29 for a further explanation of blood pressure. Mean arterial pressure (MAP) maintains blood flow to the tissues throughout the cardiac cycle. It is a product of cardiac output times peripheral vascular resistance (PVR), or CO × PVR = MAP. Resistance is opposition to flow; peripheral vascular resistance impedes or opposes blood flow to the tissues. PVR is determined by:

with breathing draws blood upward toward the heart, an adaptation known as the respiratory pump. Skeletal muscle activity contributes to the muscular pump, as muscle contractions move blood toward the heart. Venous valves are vital in making these pumps work; once blood passes a valve, it cannot flow backward away from the heart. Figure 51–6 • depicts the relationship between arteries and veins and the entire circulatory system.

• • •

The viscosity, or thickness, of the blood Blood vessel length Blood vessel diameter.

VENOUS RETURN In contrast to the high-pressure arterial system, venous pressure is too low to adequately return blood from peripheral tissues to the heart without assistance. The fall in intrathoracic pressure that occurs

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See student resource website for answers.

Blood

Blood serves as the transport medium within the cardiovascular system, bringing oxygen and nutrients from the environment (via the lungs and gastrointestinal system) to the cells. Blood is a complex mixture of living elements (the blood cells) suspended in fluid (the plasma). Its primary functions are: • • •

Transporting oxygen, nutrients, and hormones to the cells, and metabolic wastes from the cells for elimination Regulating body temperature, pH, and fluid volume Preventing infection and blood loss.

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Capillary beds of lungs where gas exchange occurs

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in oxygen transportation, anemia (too few red blood cells [RBCs] that contain too little or abnormal hemoglobin) interferes with oxygen delivery to the tissues, leading to fatigue and activity intolerance.

LIFESPAN CONSIDERATIONS

Pulmonary Circulation Pulmonary arteries

Pulmonary veins

Aorta and branches Venae cavae

Left atrium

Left ventricle

Right atrium Right ventricle

Systemic Circulation

Capillary beds of all body tissues where gas exchange occurs Oxygen-poor, CO2-rich blood

Oxygen-rich, CO2-poor blood

Figure 51–6  •  The heart and blood vessels. The left side of the heart pumps oxygenated blood into the arteries. Deoxygenated blood returns via the venous system into the right side of the heart.

As previously noted in Chapter 50 , most oxygen is transported bound to hemoglobin. Hemoglobin is a major component of red blood cells (erythrocytes), the predominant cell present in blood. Hemoglobin binds easily with oxygen, releasing it to body tissues. When all four heme groups of the hemoglobin molecule are bound to oxygen, it is said to be fully saturated. Oxygen binding is affected by several factors, including PO2, temperature, pH, and PCO2. Up to a certain point (about 70 mmHg), the higher the PO2, the greater the affinity of hemoglobin for oxygen and the more saturated the hemoglobin molecules. The relationships between oxygen binding and temperature, pH, and PCO2 are the opposite: At higher temperatures, greater hydrogen ion concentrations (lower pH), and higher PCO2 levels, the affinity of hemoglobin for oxygen decreases, and hemoglobin releases its oxygen molecules. Because of hemoglobin’s importance

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At birth, profound changes occur in the cardiovascular system. As the lungs expand, pressure in the pulmonary vascular system falls, changing pressure relationships within the heart. The foramen ovale (an opening between the two atria of the fetal heart) closes as pressure on the right side of the heart falls and pressure on the left side increases. Arterial PO2 rises and arterial PCO2 falls, prompting closure of the ductus arteriosus (a short vessel between the pulmonary artery and aorta of the fetus). Pulse rates are highest and most variable in newborns. The resting heart rate for a neonate ranges from 100 to 170 beats/min immediately after birth and then the average heart rate is 120 beats/min (Ball, Bindler, & Cowen, 2014, p. 195). The heart rate decreases to 80 to 130 in infants up to 2 years of age, and continues to decrease throughout early childhood until reaching the adult rate of 60 to 100 by about age 10 years. Irregular heart rates are common in infants and young children, often increasing and decreasing with each breath. This pattern of irregularity is known as sinus arrhythmia, a normal variation in heart rate. As the conversion from fetal circulation occurs, and pressure in the left side of the heart rises, arterial blood pressure increases. Immediately after birth (1 to 3 days of age) BP averages about 60/40 to 80/45 mmHg. By 1 month BP is about 90/55, and it rises gradually to 110/65 by approximately 16 years of age (Ball, Bindler, & Cowen, 2010, p. 256). With aging, BP may again rise as arteriosclerosis affects the blood vessels, narrowing their lumen and decreasing their ability to dilate. Congenital heart disease occurs in approximately 1% of all live births. Death, however, from congenital heart disease has significantly decreased due to diagnostic advances and new surgical techniques. Nearly 1 million adults with congenital heart defects are living today in the United States (Ball et al., 2014, p. 804). Acquired heart diseases, though rare in childhood, include rheumatic fever, an inflammatory disorder that may occur following streptococcal infection (e.g., strep throat) and lead to heart valve damage. For most people, however, the heart continues to function effectively well into older adulthood unless the blood supply to the heart muscle is impaired by blood vessel disease. Atherosclerosis, the buildup of fatty plaques within the arteries, is the primary contributor to cardiovascular disease (CVD), which is the leading cause of death in North America. Children are rarely affected by diseases of the blood vessels, although the increase in childhood obesity has increased the incidence in this age group. Hypertension or elevated BP may be associated with obesity, sedentary lifestyle, and stress in children and adolescents. During middle adulthood, the incidence of hypertension increases significantly. Hypertension, known as the silent killer because of its lack of symptoms, is a major risk factor for sudden cardiac death in middle adulthood.

FACTORS AFFECTING CARDIOVASCULAR FUNCTION

Many factors affect cardiovascular function. Some of these factors are called risk factors, because, if present, they increase the risk of CVD. Risk factors have been identified for CVD, hypertension, and

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LIFESPAN CONSIDERATIONS Circulation CHILDREN • Blood pressure should be taken routinely on children after age 3 years, but is not typically evaluated before that age. • Heart murmurs, extra sounds detected when listening to the heart, are common in children, especially in the preschool years. The vast majority are not associated with a pathology, but are due to normal blood flow or transitional physiological processes that increase cardiac output (e.g., anemia, fever, exercise). OLDER ADULTS Normal changes of aging may contribute to problems of circulation in older adults, even when there is no actual pathology: • Blood vessels become less elastic and have an increase in calcification. This results in restricted blood flow and a decrease of oxygen and nutrients delivered to tissues (heart, peripheral, and cerebral). • Impaired valve function in the heart is often the result of increased stiffness and calcification and results in a decrease in cardiac output. • A decrease of muscle tone in the heart results in a decrease in cardiac output.

peripheral vascular disease, and the majority of these factors are the same for all three disorders.

Risk Factors

Major traditional risk factors for CVD in general are classified as either nonmodifiable (cannot be reduced) or modifiable (can be reduced). Newer, nontraditional cardiovascular risk factors have also been identified (Box 51–1). It is important to remember that most CVD is preventable. Research has shown that individuals with low cardiovascular risk factors have a substantially reduced risk of developing CVD. Unfortunately, the processes that lead to CVD begin early in life. For example, epidemiologic studies provide evidence that “risk factors associated with CVD in adulthood have their origins in childhood and adolescence” (Berra, Fletcher, Hayman, & Miller, 2013, p. 505).

NONMODIFIABLE RISK FACTORS The first nonmodifiable risk factor is heredity. There is a genetic influence on the development of CVD. That is, if a client has a parent BOX 51–1   Risk Factors for Cardiovascular Disease TRADITIONAL RISK FACTORS • Nonmodifiable • Heredity • Age • Gender • Modifiable • Elevated serum lipid level • Hypertension • Cigarette smoking • Diabetes • Obesity • Sedentary lifestyle NONTRADITIONAL RISK FACTORS • Metabolic syndrome (Met-S) • C-reactive protein (CRP) • Elevated homocysteine level

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There is a decrease in baroreceptor response to blood pressure changes, making the heart and blood vessels less responsive to exercise and stress. This often results in dizziness, falls, orthostatic hypotension, and mental changes. • A decrease in conduction ability in the heart also makes the heart less responsive to changes and stresses. This can also result in dizziness, falls, orthostatic hypotension, and mental changes. All of these factors become important if the person is challenged by stressors, such as exercise, stress, fever, surgery, or other changes. If challenged, the circulatory system of older adults is not as effective or as quick to return to normal. Individuals living with normal changes of aging and/or pathologic conditions of the circulatory system need to learn to balance diet, medications, and exercise. Nurses have a large role in working with these clients to develop appropriate interventions and provide teaching to help them maintain optimal functioning. Teaching clients to recognize any changes or worsening of their condition is very important. They need to know when to contact their primary care provider to make any needed changes. Changing lifestyles and fine-tuning medications can be critical, and nurses can be a part of this in every phase of the nursing process. •

with heart disease, he or she is at higher risk. In addition, members of certain racial and ethnic groups, such as African Americans, have a higher risk of developing CVD. The second is age. Cardiovascular disorders used to primarily affect people over age 60. Research, however, has shown that the major lifestyle behaviors associated with CVD (e.g., patterns of diet, physical activity, and tobacco use) are established early in childhood and do influence the development of CVD risk factors in childhood, adolescence, and adulthood. Jaquith, Harris, and Penprase (2013) report that CVD risk is a growing reality for very young children based on their study, which determined that children often change from “no risk to being at risk for CVD before preschool” (p. 264). The third nonmodifiable risk factor is gender. Until menopause, estrogen has a protective effect in women, slowing the progression of atherosclerosis and reducing the risk of CVD. This effect is lost at menopause, and postmenopausal women have the same risk for CVD as men. Caboral (2013) and Kuznar (2010) note, however, that gender-specific trends in heart disease reveal that cardiovascular risk factors for women are increasing. One possible explanation for this narrowing gap is that young women may believe that they are more at risk for other diseases (e.g., cancer). Another reason for increasing CVD in American women is the increase in average body weight (Sherrod, Sherrod, Spitzer, & Cheek, 2013, p. 62). Nurses need to assess and teach both men and women about cardiovascular risk factors.

MODIFIABLE RISK FACTORS Modifiable risk factors include elevated serum lipid levels, hypertension, cigarette smoking, diabetes, obesity, and sedentary lifestyle. Many of the Healthy People 2020 objectives relate to these modifiable risk factors. ELEVATED SERUM LIPID LEVELS  A strong link exists between elevated serum lipid levels and the development of CVD. Lipid disorders, also called dyslipidemias, are abnormalities of lipoprotein metabolism and include elevations of total cholesterol, LDL cholesterol, or triglycerides; or deficiencies of HDL cholesterol. A high dietary intake of saturated fats increases the total LDL levels, and intake

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of polyunsaturated fatty acids decreases total LDL in most individuals. Studies have also shown that trans-fatty acids (e.g., stick margarine, deep-fried foods) raise LDL levels and lower HDL levels, resulting in an increase in total cholesterol. The American Heart Association (AHA) (2014) recommends that between 25% and 35% of total calories come from fats. The fats should come from polyunsaturated and monounsaturated fatty acids, such as fish, nuts, and vegetable oils. The AHA also provides recommendations on its website for calories based on age, gender, and activity level. Among adults 75 years and older, 31% of men and almost 58% of women have a total cholesterol level of 240 mg/dL or higher, which is considered high risk (Holm, 2010, p. 252). Older adults, just like all other age groups, have become more obese, which leads to high cholesterol levels. It is this kind of data that accounts for Healthy People 2020 (U.S. Department of Health and Human Services [USDHHS], 2013b) promoting the following objectives: Increase the proportion of adults who have had their blood cholesterol checked within the preceding 5 years; reduce the proportion of adults with high total blood cholesterol levels; reduce the mean total blood cholesterol levels among adults; and increase the proportion of adults with elevated LDL cholesterol who adhere to the prescribed cholesterol-lowering diet, physical activity, weight control, and drug therapy. HYPERTENSION  Hypertension increases the risk of CVD in

several ways. First, it increases the workload of the heart, increasing oxygen demand and coronary blood flow. The increased workload also causes hypertrophy of the ventricles. Over time this can contribute to heart failure. Secondly, hypertension causes endothelial damage to the blood vessels, which stimulates the development of atherosclerosis. Atherosclerotic plaques in turn cause a worsening of hypertension by narrowing the vessel lumens and decreasing vessel elasticity. Therefore, there is a cyclical relationship between these two conditions that magnifies an affected person’s risk for CVD. High sodium intake can affect blood pressure and contribute to the development of hypertension. First, it may increase the release of natriuretic hormone, which indirectly contributes to hypertension. Additionally, sodium stimulates vasopressor mechanisms, which cause vasoconstriction. There is also evidence that other factors such as low potassium, calcium, and magnesium intake may contribute to vasoconstriction and the development of hypertension. Healthy People 2020 (USDHHS, 2013b) includes the following objectives relating to hypertension: Reduce the proportion of adults, children, and adolescents with hypertension; increase the proportion of adults with prehypertension and hypertension who meet the recommended guidelines for body mass index (BMI), saturated fat consumption, sodium intake, physical activity, and moderate alcohol consumption; increase the proportion of adults with hypertension who are taking the prescribed medications to lower their blood pressure; and increase the proportion of adults with hypertension whose blood pressure is under control.

CIGARETTE SMOKING  The cardiovascular system is affected

by cigarette smoking. Nicotine increases heart rate, blood pressure, and peripheral vascular resistance, increasing the heart’s workload. Smoking causes vasoconstriction, and in areas where vessels already are narrowed by atherosclerosis, tissue oxygenation can be impaired. Healthy People 2020 (USDHHS, 2013e) includes many objectives relating to tobacco use, including these: Reduce tobacco use by adolescents and adults; reduce the initiation of tobacco use among

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children, adolescents, and young adults; reduce the proportion of nonsmokers exposed to secondhand smoke; increase tobacco-free environments in schools, including all school facilities, property, vehicles, and school events; and increase tobacco screening in health care settings. DIABETES  Diabetes mellitus increases the risk of CVD and myocardial infarction (MI). High blood glucose levels are associated with accelerated development of atherosclerosis as well as high levels of serum lipids and triglycerides. Closely monitoring blood glucose levels in clients with diabetes and checking blood glucose levels in all clients for the development of increased levels are important nursing functions. Control of blood glucose levels can greatly reduce risk and slow development of atherosclerosis. Examples of objectives in Healthy People 2020 (USDHHS, 2013a) that pertain to diabetes include the following: Reduce the annual number of new cases of diagnosed diabetes in the population; reduce the diabetes death rate; reduce the rate of lower extremity amputations in individuals with diagnosed diabetes; improve glycemic control among individuals with diabetes; and increase prevention behaviors in individuals with prediabetes who are at high risk for diabetes. OBESITY  Nearly two thirds of the adult population of the United States is overweight or obese (Burke & Wang, 2011). Obesity and diabetes are major health problems that are rapidly getting worse in the United States. In addition, people with obesity have an increased risk for the development of CVD because obesity is often accompanied by elevated serum lipid levels and is associated with hypertension. Thus, adults who are obese are at risk for diabetes and hypertension. Additionally, obesity places an increased workload on the heart, which increases oxygen demand. Research has shown that obese individuals have an increased risk for heart failure and death, and that risk increases in proportion to the degree of obesity. Examples of objectives in Healthy People 2020 (USDHHS, 2013c) that pertain to weight include the following: Increase the proportion of adults who are at a healthy weight; reduce the proportion of children and adolescents who are obese; increase the contribution of fruits and whole grains to the diets of the population ages 2 years and older; reduce consumption of calories from solid fats and added sugars in the population ages 2 years and older; and increase the percentage of schools that offer nutritious foods and beverages outside of school meals. SEDENTARY LIFESTYLE  Regular physical activity is associated

with a reduction in the risk of death due to CVD, whereas a sedentary lifestyle is associated with increased risk. Physical exercise or activity increases the heart rate and, hence, the supply of oxygen in the body. With regular vigorous exercise, the heart muscle becomes more powerful and efficient. Aerobic exercise slows the atherosclerotic process, directly reducing the risk of CVD, and decreases risk of obesity and diabetes mellitus, therefore indirectly reducing risk as well. A healthy lifestyle that includes a heart-healthy diet and physical activity promotes cardiovascular health. This is true throughout the life span. Physical activity recommendations for children and adolescents emphasize 60 minutes/day of moderate-to-vigorous physical activity (Berra et al., 2013). Because children and adolescents spend a great deal of time in school, one of the Healthy People 2020 (­USDHHS, 2013d) objectives is to increase the proportion of the nation’s public and private schools that require daily physical education for all

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Evidence-Based Practice How Do Racial, Ethnic, and Socioeconomic Disparities Affect Knowledge of Cardiovascular Disease Among Women with Metabolic Syndrome? It is well known that racial, ethnic, and socioeconomic disparities are risks for many health conditions. The literature reflects that the metabolic syndrome (Met-S) is a recognizable cluster of risk factors associated with an increased risk for cardiovascular disease (CVD). Current public health strategies focus on educating the public about the traditional factors of hypertension, smoking, and elevated LDL cholesterol. The researchers (Giardina et al., 2011) focused on documenting the extent of CVD knowledge and awareness among women with Met-S and if such women were aware of options for managing an acute CVD emergency. Their data were derived from the baseline information of a cross-sectional, interviewer-assisted, face-to-face questionnaire of study participants recruited in four women’s heart centers. This was part of the Improving, Enhancing and Evaluating Outcomes of Comprehensive Heart Care in HighRisk Women program, sponsored by the Office on Women’s Health, USDHHS. A total of 698 women were enrolled in the study. A number of measures were collected: clinical characteristics (age, current/ ever diagnosis of diabetes mellitus, hypertension, hyperlipidemia, smoking, overweight, and obesity), physical measures (BP, waist circumference, height, weight, laboratory data), race and ethnicity, education, residence (suburban or urban), type of insurance, Framingham Risk Score (FRS), and questions to assess awareness and knowledge of the leading cause of death among women, the early symptoms and signs of heart attack and stroke, and the action to take if experiencing a heart attack or stroke (i.e., to call 911). Sixtyfour percent of the participants were classified for the presence or absence of metabolic risk. They ranged in age from 20 to 86 years with the mean being 55 years of age. Almost 44% were minority women. Thirty-three percent had less than high school or were high

EVIDENCE-BASED PRACTICE

school graduates and 36% had some college. Participants were primarily urban (77%); 32% had Medicaid or Medicare; and 44% had HMO, private pay, or other commercial insurance. Thirty percent of the participants had an income of ≤$19,999, and 39% of the group had three or more components of Met-S with the frequency of Met-S greatest in Hispanics. The results showed the following: Education was significantly related to the Met-S and greater occurrence of Met-S occurred in those with less than a high school education (70%); the frequency of a high FRS was greater in both Hispanics (79%) and non-Hispanic Blacks (48%); and fewer women with high FRS or with the Met-S knew that the leading cause of death among women is heart disease or knew the signs and symptoms of a heart attack or the need to call 911. Other studies have documented an increase in overall knowledge of the leading cause of death among White women; however, this study demonstrates that Hispanic and African American women remain significantly less aware than White women about the leading cause of death. IMPLICATIONS This study showed that Met-S occurred with greater frequency among women who were Hispanic and those with less than or high school education. The researchers stress that women who are at high risk for CVD (racial, ethnic, socioeconomic, and educational disparities and Met-S) need to be targeted to learn important CVD facts and recognize how to manage steps in a cardiac emergency in order to reduce the potential for morbidity and mortality. Nurses working with women who have these characteristics should be aware of these clients’ increased need for education about CVD and what to do if they experience signs and symptoms of an acute cardiac emergency.

students. The AHA (2013a) recommends at least 150 minutes per week of moderate exercise or 75 minutes per week of vigorous exercise for adults. The AHA (2013b) also states that nearly 40% of people over the age of 55 report no leisure-time physical activity when in fact the older an individual becomes, the more they need regular exercise. The Healthy People 2020 objectives also include increasing the proportion of adults who meet current federal physical activity guidelines for aerobic physical activity and for muscle strength training.

this inflammatory marker as an independent risk factor for CVD (Butcher & Beckstrand, 2010). Evidence does not suggest that lowering CRP reduces cardiovascular risk. Instead, CRP is used more as an assessment or predictor of who may be at risk. Usually, CRP screening is completed along with cholesterol screening to determine cardiovascular risk assessment. If the results are high, smoking cessation, diet, and exercise are recommended guidelines to reduce the CRP and cholesterol levels.

NONTRADITIONAL RISK FACTORS Other emerging modifiable risk factors that may influence cardiovascular function include the presence of metabolic syndrome or ­C-reactive protein or an elevated homocysteine level.

ELEVATED HOMOCYSTEINE LEVEL  Homocysteine is an amino acid that has been shown to be increased in many people with atherosclerosis. Clients with elevated homocysteine levels may have an increased risk of MI, CVD, cerebrovascular accidents (stroke), and peripheral vascular disease. It is thought that individuals can reduce their homocysteine level by taking a multivitamin that provides folate, vitamin B6, vitamin B12, and riboflavin. However, clinical trials that attempted to lower homocysteine levels through B-vitamin treatment have varied in their results (Martí-Carvajal, Solà, Lathyris, Karakitsiou, & Simancas-Racines, 2013).

METABOLIC SYNDROME  Metabolic syndrome (Met-S)

is a cluster of cardiovascular risk factors that increase the incidence of CVD. Five risk factors are included in Met-S: central obesity (e.g., increased waist circumference), increased triglycerides, hypercholesterolemia, hypertension, and elevated fasting glucose (Harris & Smith, 2014). A person is considered to have metabolic syndrome when at least three of the five risk factors are present. Each risk factor is usually treated individually. Overall, lifestyle activities and behaviors, such as nutrition and physical activity, are the best preventions for the development of Met-S risk factors. C-REACTIVE PROTEIN  Many studies have shown that acute

myocardial infarction (AMI) involves an inflammatory process. A useful screening test for this inflammatory process is the C-reactive protein (CRP) assay. Recent research has focused on the use of

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ALTERATIONS IN CARDIOVASCULAR FUNCTION

Cardiovascular function can be altered by conditions that affect: 1. The function of the heart as a pump 2. Blood flow to organs and peripheral tissues 3. The composition of the blood and its ability to transport oxygen and carbon dioxide.

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Culturally Responsive Care

PATIENT-CENTERED CARE

Gender and Race Disparities in Clients with Cardiovascular Disease ACUTE MYOCARDIAL INFARCTION Coronary heart disease is the leading cause of death in American females, yet women are underrepresented in the majority of cardiovascular research studies. Women tend to have an acute myocardial infarction (AMI) at an older age than men and are more likely to have complications. The presence of chest pain varies between men and women. More women have pain-free AMIs than men. They also tend to have more mid-back, shoulder blade, and upper-back pain than men. Research reflects that women who have an AMI experience longer delays in treatment and less aggressive treatment than men. This results in increased mortality rates. HEART FAILURE Symptoms of heart failure (HF) occur earlier in African Americans, possibly because of the higher rate of uncontrolled hypertension. The rate of hypertension for both African Americans and ­Caucasians is greatest in the southeastern United States. Studies reveal the following information about other risk factors for HF and other CVD: • African Americans have a higher average BMI than ­Caucasians. African Americans do not hold the same body image values as Caucasians; a larger body size may be ­valued more positively. • African Americans have a higher incidence of diabetes than other populations. • The incidence of HF is increasing in African American women. However, few research studies include African American women. CEREBROVASCULAR ACCIDENT (STROKE) African Americans have a greater incidence, greater mortality, and greater severity of strokes than Caucasians. IMPLICATIONS Research on gender differences is gradually increasing. However, research focusing on differences by race and ethnicity remains limited and needs to be more thoroughly investigated. In the meantime, two important areas for client education include informing women that AMI does not occur only in men, and teaching the public about how to prevent risk factors that contribute to HF and cerebrovascular accidents.

Three major alterations in cardiovascular function are decreased cardiac output, impaired tissue perfusion, and disorders that affect the composition or amount of blood available for transport of gases.

Decreased Cardiac Output

Although the heart is normally able to increase its rate and force of contraction to increase cardiac output during exercise, fever, or other times of need, some conditions interfere with these mechanisms. The vessels that supply blood to the heart muscle may become occluded by atherosclerosis or a blood clot, shutting off the blood supply to a portion of the myocardium. When this happens, the tissue becomes necrotic and dies, a condition known as a myocardial infarction (MI) or heart attack. If a large portion of the heart muscle is affected, particularly in the left ventricle, cardiac output falls

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because the affected muscle no longer contracts. Signs and symptoms of MI are variable and may include the following: • • • •

Chest pain; substernal and/or radiating to the left arm, jaw Nausea Shortness of breath Diaphoresis.

Heart failure may develop if the heart is unable to keep up with the body’s need for oxygen and nutrients to the tissues. Heart failure usually occurs because of MI, but it may also result from chronic overwork of the heart, such as in clients with uncontrolled hypertension or extensive arteriosclerosis. In left-sided heart failure, the vessels of the pulmonary system become congested or engorged with blood. This may cause fluid to escape into the alveoli and interfere with gas exchange, a condition known as pulmonary edema. Signs of heart failure may include the following: • • • • • • • • •

Pulmonary congestion; adventitious lung sounds Shortness of breath Dyspnea on exertion (DOE) Increased heart rate S3 heart sound Increased respiratory rate Nocturia Orthopnea Distended neck veins.

Other diseases such as myocarditis and cardiomyopathy also can affect the heart muscle, impairing its ability to contract and pump. Box 51–2 gives examples of conditions that may precipitate heart failure. Very irregular or excessively rapid or slow heart rates can also decrease cardiac output. With irregular or very rapid heart rates, the ventricles may not fill adequately between beats, so stroke volume (amount pumped with each beat) falls. If the heart rate is too slow, the heart may not be able to increase its stroke volume enough to maintain the cardiac output. Abnormalities of heart rate and rhythm are known as dysrhythmias and can be identified on an electrocardiogram (ECG). Alterations in the structure of the heart can affect cardiac output. Congenital heart defects result in abnormal blood flow and may even allow venous and arterial blood to mix. Oxygen supply to body tissues is affected in this case. Acquired heart diseases such as bacterial endocarditis and rheumatic fever may damage the heart valves, Examples of Conditions That May

BOX 51–2  Precipitate Heart Failure

CONDITIONS THAT INCREASE PRELOAD • Hypervolemia • Valvular disorders such as mitral regurgitation • Congenital defects such as patent ductus arteriosus CONDITIONS THAT INCREASE AFTERLOAD • Hypertension • Atherosclerosis CONDITIONS THAT AFFECT MYOCARDIAL FUNCTION • Myocardial infarction • Cardiomyopathy • Coronary artery disease

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affecting the flow of blood within the heart and to the great vessels. For example, if the mitral (bicuspid) valve becomes scarred and stenotic (constricted), it may not open fully, impairing filling of the left ventricle. Or, if the mitral valve does not fully close (mitral insufficiency), blood may escape back or regurgitate into the left atrium instead of entering the aorta each time the ventricle contracts.

Open

Impaired Tissue Perfusion

Atherosclerosis is by far the most common cause of impaired blood flow to organs and tissues. As vessels narrow and become obstructed, distal tissues receive less blood, oxygen, and nutrients. Ischemia is a lack of blood supply due to obstructed circulation. Any artery in the body may be affected by atherosclerosis, although the effects are most often associated with coronary arteries, vessels supplying blood to the brain, and arteries in peripheral tissues. Partial obstruction of coronary arteries causes myocardial ischemia, often resulting in angina pectoris; if the obstruction is complete a heart attack (MI) occurs. Partial obstruction of cerebral vessels may cause a transient ischemic attack (TIA); if the obstruction is complete, a stroke (cerebrovascular accident) occurs. Peripheral vascular disease leads to ischemia of distal tissues such as the legs and feet. Gangrene and amputation may result. Signs of impaired peripheral arterial circulation in the legs and feet may include the following: • • • • •

Decreased peripheral pulses Pain or paresthesias Pale skin color Cool extremities Decreased hair distribution.

The risk factors for peripheral atherosclerosis are similar to those for CVD and include cigarette smoking, high fat intake, obesity, and a sedentary lifestyle. Hypertension and diabetes also increase the risk for atherosclerosis, particularly if the blood pressure or blood glucose levels are not maintained at near-normal levels. Although much less common, other disorders such as vessel inflammation, arterial spasm, and blood clots also can occlude blood vessels, leading to ischemia. Tissue edema can impair flow through vessels and can increase the distance oxygen and nutrients must diffuse across to reach cells. On the venous side, incompetent valves may allow blood to pool in veins, causing edema and decreasing venous return to the heart (Figure 51–7 •). Veins also can become inflamed, reducing blood flow and increasing the risk of thrombus (clot) formation. Thrombi may then break loose, becoming emboli. These emboli tend to travel as far as the pulmonary circulation where they become trapped in small vessels (pulmonary emboli), occluding blood supply to the capillary side of the alveolar–capillary membrane. Although alveolar ventilation to the affected area often remains adequate, no gas exchange occurs there because of impaired blood flow. Signs of acute pulmonary embolism (PE) can be nonspecific and variable but may include the following: • •

Sudden onset of shortness of breath Pleuritic chest pain.

Blood Alterations

Because most oxygen is transported to the tissues in combination with hemoglobin, the problems of inadequate RBCs, low hemoglobin levels, or abnormal hemoglobin structure can affect tissue

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Closed

Figure 51–7  •  Left: Vein with competent valve; right, vein with ­incompetent valve that allows blood to pool in the veins. From Medical Terminology: A Word-Building Approach, 7th ed. (p. 298), by J. Rice, 2012. ­Reproduced by permission of Pearson Education, Inc., Upper Saddle River, New Jersey.

oxygenation. Anemia has several different causes: RBCs are lost along with other components because of acute or chronic bleeding; if diet is deficient in iron or folic acid, hemoglobin and RBCs are not formed adequately; and some disorders cause RBCs to break down excessively. People with sickle cell disease produce an abnormal form of hemoglobin and may experience tissue ischemia during exacerbations of the disease. Signs of anemia may include the following: • • • •

Chronic fatigue Pallor Shortness of breath Hypotension.

Blood volume also affects tissue oxygenation. If the blood volume is inadequate, as in hemorrhage or severe dehydration, blood pressure and cardiac output fall, and tissues may become ischemic. Conversely, clients with hypervolemia (excess blood volume), which can result from fluid retention or kidney failure, may develop heart failure and peripheral edema, also leading to tissue ischemia. ●◯●

NURSING MANAGEMENT

Assessing Nursing assessment of the cardiovascular system status includes a history, physical examination, and a review of relevant diagnostic data, including cardiac monitoring.

Nursing History A comprehensive nursing history should include data regarding: • Current and past cardiovascular problems • Family history of cardiovascular problems such as high blood

pressure, increased cholesterol level, heart attack, and stroke

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ASSESSMENT INTERVIEW Circulation CURRENT OR PAST CARDIOVASCULAR PROBLEMS • Do you have high blood pressure? • Do you have any history of heart disease such as angina, heart attack, or heart failure? Have you ever had a cardiac ­catheterization, angiogram, or angioplasty? Have you ever been diagnosed with rheumatic fever, endocarditis, pericarditis, or other diseases of the heart? If so, when? Have you had cardiac surgery or stent placement? • Have you ever been told that you have peripheral vascular disease? Do you ever develop pain in the calves of your legs when walking? How far can you walk before it occurs? What do you do to relieve it? Have you had surgery on your blood vessels? • Do your feet and ankles ever swell or feel very cold, numb, or tingling? Do you experience pain in your feet? Is the pain changed by position?

• • • •

Other medical history including diabetes and respiratory disorders Exercise and activity level History of tobacco use Diet, including fat and salt intake, alcohol intake, caffeine intake including soft drinks and chocolate • Presence of any symptoms such as pain, shortness of breath, dizziness, fatigue, palpitations, cough, and fainting • Medications for heart, blood pressure, circulation, and cholesterol • Lifestyle, including social support, stressors, and methods of coping.

Physical Assessment To examine the cardiovascular system, a nurse first evaluates blood pressure in both arms (the results should be within 10 mmHg of each other) and palpates peripheral pulses for their strength and equality. The apical pulse is auscultated for rate, rhythm, and the quality of heart sounds. Apical pulse rate and peripheral pulse rates should not vary more than a few beats per minute from one another. Carotid arteries are auscultated for bruits (a sound of turbulence), which may indicate atherosclerosis and narrowing (see Chapter 30 ). Also important as an indicator of cardiac function is lung sounds. By auscultating the lungs for adventitious sounds, the nurse assesses for increased pulmonary vessel pressure secondary to decreased cardiac output. Much information about the cardiovascular system is obtained by assessing the skin for color, temperature, hair distribution, lesions, and edema. Clients with extensive peripheral vascular disease may have cool feet with weak pulses and shiny, nearly hairless shins and feet. Pitting edema of the feet and ankles may be noted in clients with heart failure. See Chapter 30 for specific techniques for assessing the respiratory and cardiovascular systems. One noninvasive measure used to assess for peripheral vascular disease is the ankle brachial index (ABI). This is the ratio of arterial pressure in the ankle compared with that in the arm. The ABI is a simple, reliable means for diagnosing peripheral arterial disease (PAD) (Vascular Disease Foundation, 2014). The ABI has been traditionally determined using a conventional sphygmomanometer and a Doppler instrument. Aneroid BP cuffs, however, are being replaced by automated blood pressure equipment. To perform an ABI, the client has to be supine for 5 to 10 minutes while the nurse gathers BP cuffs, a handheld Doppler instrument, and ultrasound gel. Place a BP cuff on the client’s right arm and right ankle. After applying the gel, use the Doppler to determine the client’s systolic pressure in the right

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Do you become extremely fatigued with activity? Have you ever been told that you are anemic?

MEDICATION HISTORY • Have you taken or do you take any over-the-counter or ­prescription medications for your heart or blood pressure or to increase blood flow? • Do you take any anticoagulants or other medications to “thin” your blood? LIFESTYLE • Do you use tobacco? If so, what kind? • Do you exercise? What kind of exercise and how often? • How often do you drink alcoholic beverages such as beer, wine, or liquor? How much do you usually drink at a time?

BOX 51–3 

Measurement of an Ankle Brachial Index (ABI)

The ABI measurement compares the systolic blood pressure of the lower extremity with the systolic blood pressure of the brachial artery. A ratio is calculated based on the results. systolic pressure of the ankle ABI = systolic pressure of the arm EXAMPLE ABI =

132 systolic pressure of ankle = 1.06 124 systolic pressure of arm

Interpretation of ABI: • 1.00–1.29: normal • 0.91–0.99: borderline • 0.41–0.90: mild to moderate disease • ≤0.40: severe disease. From “Understanding the Ankle-Brachial Index,” by M. Moye, 2011, Nursing, 41(1), p. 68.

arm and right ankle using the right dorsalis pedis and posterior tibial arteries. Repeat this procedure for the client’s left arm and ankle. Use the higher ankle pressure (dorsalis pedis or posterior tibial) for each lower extremity and the higher arm pressure. Box 51–3 explains how to measure the ABI.

Diagnostic Studies Many diagnostic studies are available that can help to identify the presence of CVD. Diagnostic studies may also be used as screening tools to identify increased risk so that modifications can be made to reduce the risk of development of CVD. An example of this is the serum lipid level. If a client has an elevated serum lipid level, he or she should be educated about the effects of diet and the importance of reducing lipids to reduce the risk of CVD. Cardiac Monitoring

Cardiac monitoring allows for continuous observation of the client’s cardiac rhythm. Cardiac monitoring is a recording of the heart’s electrical activity. It is used in many instances: for clients who have known or suspected CVD, during and after surgery, to monitor responses to drug therapy, and to monitor clients at risk for serious complications such as shock. Electrodes placed on the client’s chest are attached to

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into the blood during an MI, as a result of cell membrane damage. Elevated levels of these enzymes can help differentiate between an MI (when myocardial cells actually die) and chest pain from a different cause such as angina or pleuritic pain. Hemodynamic Studies

Figure 51–8  •  A client with cardiac monitoring.

a monitor cable and bedside monitor (Figure 51–8 •). The monitor is equipped with alarms used to warn of potential problems such as very fast, very slow, or irregular heart rates. The alarm limits are usually set for 20 beats higher and lower than the client’s baseline rate, often at 100 to 110 and 50 to 55, respectively, for adults. For ambulatory clients (in the hospital or at home), the electrodes connect to a transmitter unit (also called telemetry). This unit electronically sends the signal to a central monitor for display or may store the information to be retrieved later in the primary care provider’s office. Another name for this type of ambulatory monitoring is a Holter monitor. Electrodes are attached and the client wears the monitor for 24 hours. A continuous ECG is recorded and later analyzed for irregularities. Electrocardiography most commonly uses 12 “leads” or 12 different views of the heart. In contrast, cardiac monitoring uses 2 or 3 leads at any given time. See Chapter 34 for more information about ECGs. CLINICAL ALERT! It is important to remember that ECG monitoring is a recording of the electrical activity of the heart; it does not reflect mechanical contraction and cardiac output. Always remember to check the client to assess for cardiac function. Just looking at the ECG does not give an assessment of the client’s status. Blood Tests

Specimens of venous blood can be used for several tests that may reflect some aspect of cardiovascular functioning. Because hemoglobin is the molecule to which oxygen attaches, a person’s hemoglobin level gives an indication of the oxygen-carrying capacity of the blood. A decreased hemoglobin level increases the risk of oxygen deficit in body tissues, especially when CVD is present. Measurement of serum electrolytes is important for clients with cardiovascular problems because electrolyte abnormalities such as hyperkalemia (higher than normal potassium) and hypokalemia (lower than normal potassium) can have a critical effect on the heart. Serum levels of magnesium, calcium, sodium, and phosphorus are also important to assess. Measurement of certain enzyme levels in the blood is an important part of the diagnostic evaluation of clients with chest pain. Enzymes such as creatine kinase (CK) and troponin are released

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Hemodynamics is the study of the forces or pressures involved in blood circulation. Hemodynamic studies or monitoring procedures may be performed to evaluate fluid status and cardiovascular function. Parameters evaluated in hemodynamic studies include heart rate, arterial blood pressure, central venous pressure, pressures in the pulmonary vascular system, and CO. Some of these parameters—for example, heart rate, arterial blood pressure, and venous pressure—are measured directly using an arterial, central venous, or pulmonary artery catheter; others, such as stroke volume and cardiac output, are calculated. Hemodynamic studies are performed in a diagnostic cardiac laboratory and require informed consent. Clients in intensive and cardiac care units may undergo continuous hemodynamic monitoring to evaluate cardiovascular status and the effect of interventions. Nurses in these units are responsible for obtaining accurate readings and maintaining the integrity of the system.

Diagnosing NANDA International (Herdman & Kamitsuru, 2014) includes the following diagnostic labels for clients with circulation problems: • Decreased Cardiac Output: inadequate blood pumped by the

heart to meet metabolic (demands) of the body

• Risk for Peripheral Neurovascular Dysfunction: vulnerable to dis-

ruption in the circulation, sensation, and motion of an ­extremity, which may compromise health • Activity Intolerance: insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Planning When planning care the nurse identifies nursing interventions that will assist the client to achieve these broad goals: • Maintain or improve tissue perfusion. • Maintain or restore an adequate cardiac output.

Obviously, goals will vary according to the diagnosis and defining characteristics for each individual. Appropriate preventive and corrective nursing interventions that relate to these must be identified. Specific nursing activities can be selected to meet the client’s individual needs. Examples of NIC interventions related to decreased cardiac output and tissue perfusion include the following: • Circulatory Care: Arterial Insufficiency • Cardiac Care • Hemodynamic Regulation.

To promote the transport of oxygen and carbon dioxide, the nurse can optimize CO by reducing stress, planning appropriate activities, and positioning the client for improved vascular blood flow.

Implementing Promoting Circulation Most people in good health give little thought to their cardiovascular function. Changing position frequently, ambulating, and exercising

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CLIENT TEACHING

Home Care and Circulation MAINTAINING CARDIAC OUTPUT AND TISSUE PERFUSION Teach the symptoms of heart failure to the client and family and emphasize when to contact the primary care provider. • Teach the client about the importance of maintaining regular physical activity to promote circulation and vascular health. Emphasize the need to increase activity levels gradually with the goal of exercising (walking, swimming, weight training, or aerobic exercise as recommended by the care provider) for at least 30 minutes five times per week. • Instruct the client to avoid exposure to cold, wearing warm clothing as needed. • Teach cardiopulmonary resuscitation or refer for instruction. DIETARY ALTERATIONS Instruct the client and family about prescribed dietary restrictions such as a low-sodium diet. Refer to a dietitian as needed for further instruction. • Discuss dietary measures to reduce the risk of atherosclerosis, including reducing total and saturated fats in the diet, reducing weight if obese, and increasing the intake of dietary fiber. MEDICATIONS Instruct the client and family about prescribed medications, including effects, side effects, and administration instructions.

CLIENT TEACHING

Promoting a Healthy Heart Exercise regularly, participating in at least 30 minutes of moderateintensity aerobic exercise five times a week. • Do not smoke. • Maintain your ideal weight. • Eat a diet low in total fat, saturated fats, and cholesterol. • Drink alcohol in moderation, if at all, consuming no more than 1 cocktail or 1 to 1 1/2 glasses of wine or beer daily. • Reduce stress and manage anger. • Effectively manage diabetes and hypertension, maintaining blood glucose and blood pressure levels within normal limits. • If female, discuss with your health care provider the ­advantages and risks of hormone replacement therapy after menopause (or after a total hysterectomy). • Consult your primary care provider about the advisability of low-dose aspirin therapy to further reduce the risk of CVD.

usually maintain adequate cardiovascular functioning. See Client Teaching for other ways to promote a healthy heart. Immobility is harmful to cardiovascular function. Without activity of the calf and leg muscles, blood pools in the veins of the lower extremities. This stagnant (sluggish) blood flow may allow clots to develop (venous thrombosis). With time, these clots can break loose and become emboli, eventually lodging in the small vessels of the pulmonary vascular system. Blood flow and gas exchange in the lungs are then impaired. Many nursing interventions can help clients maintain cardiac and vascular function. They may be classified as vascular and cardiac. Vascular

• Position with the legs elevated to promote venous return to the

heart. This is particularly important for clients with venous

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dysfunction. Care should be taken, however, to avoid this position in clients with cardiac dysfunction because it will increase preload and may increase stress on the heart. • Avoid pillows under the knees or more than 15 degrees of knee flexion to improve blood flow to the lower extremities and reduce venous stagnation. • Encourage leg exercises (such as flexion and extension of the feet, active contraction and relaxation of calf muscles) for a client on bed rest, and promote ambulation as soon as possible. • Encourage or provide frequent position changes. Cardiac

• Position the client in a high-Fowler’s position to decrease preload

and reduce pulmonary congestion.

• Monitor intake and output. Fluid restriction is usually not re-

quired for clients with mild to moderate cardiac dysfunction. With severe heart failure, a fluid restriction may be ordered.

Medications Many classes of medications are administered to clients with cardiovascular disorders. Drugs such as nitrates, calcium channel blockers, and angiotensin-converting enzyme (ACE) inhibitors reduce the workload of the heart and prevent vasoconstriction. Various drugs are used to treat cardiac dysrhythmias. Positive inotropic drugs such as digoxin are used to increase the contractile strength of the heart. (See the Drug Capsule feature on digoxin in Chapter 29 .) Betaadrenergic blocking agents such as propranolol or metoprolol may be given to block the sympathetic nervous system action on the heart and decrease oxygen consumption. Direct vasodilators may be used for clients with peripheral vascular disease and sometimes hypertension. Often clients are on numerous medications, and it is an important role of the nurse to help the client understand the purposes, effects, and side effects of the different medications. Administering medications is an important nursing function. Nurses are responsible for assessing for the effects of medications and also for potential complications. Examples include: • When diuretics are administered, the nurse assesses intake, out-

put, and serum potassium level (because many diuretics can lower potassium level). • When positive inotropic medications are administered, the nurse should assess blood pressure, heart rate, peripheral pulses, and lung sounds as indicators of cardiac output. • When antihypertensive medications are administered, it is critical for the nurse to monitor blood pressure. Additionally, many antihypertensive medications can cause postural hypotension.

Preventing Venous Stasis When clients have limited mobility or are confined to bed, venous return to the heart is impaired and the risk of venous stasis increases. Immobility is a problem not only for ill or debilitated clients but also for some travelers who sit with legs dependent for long periods in a motor vehicle or an airplane. Venous stasis may allow clots (venous thrombosis) to develop in a deep vein, often in the thigh or calf. This is called deep venous thrombosis or deep vein thrombosis (DVT). If the thrombus breaks free, it can travel and become a PE where it blocks a pulmonary artery or one of its branches. Blood flow and gas exchange in the lungs are then impaired. If the clot is large enough,

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sudden death can occur. DVT is associated with the development of about 90% of all PEs (Larkin, Mitchell, & Petrie, 2012). The term venous thromboembolism (VTE) incorporates both DVT and PE. VTE is one of the most common preventable causes of hospital-related death, especially among older adults because advancing age is a major risk for VTE (McNamara, 2014; Pollak & McBane, 2014). Preventing venous stasis is an important nursing intervention to reduce the risk of complications following surgery, trauma, or major medical problems. Positioning and leg exercises are discussed in Chapter 50 and antiemboli stockings in Chapter 37 . Sequential compression devices are an additional mechanical measure to help prevent venous stasis. Sequential Compression Devices

Clients who are undergoing surgery or who are immobilized because of illness or injury or are in a critical care unit may benefit from sequential compression devices (SCDs) to promote venous return from the legs. Another term used in the literature is intermittent pneumatic compression devices (IPCDs) and because there are different types of IPCDs, they are often collectively referred to as SCDs. SCDs are useful in preventing thrombi and edema, which may result from venous stasis, but they are not used for clients who have arterial insufficiency, cellulitis, infection of the extremity, active DVT, or preexisting venous thrombosis. SCDs inflate and deflate plastic sleeves to promote venous flow. The plastic sleeves are attached by tubing to an air pump that alternately inflates and deflates portions of the sleeve to a specified pressure. SCDs are available in foot (sometimes called a foot pump), knee-length, or thigh-length sleeves. The foot pump artificially stimulates the venous plantar plexus (a large vein located in the foot) to increase blood circulation in the foot. The inflation and deflation of the pump simulate the blood flow that results from walking. For the knee-length or thigh-length SCDs, the ankle area inflates first, followed by the calf region, and then the thigh area. This sequential inflation and deflation process assists the leg muscles in moving blood toward the heart (Figure 51–9 •). Larkin, Mitchell, and Petrie (2012) indicate that “another benefit of mechanical compression devices is that they contribute to increasing the fibrinolytic activity within the vasculature and thus to preventing fibrin clot formation” (p. 517).

Figure 51–9  •  Sequential venous compression devices enhance ­venous return. They are available in knee-high or thigh-length versions.

Both knee-high and thigh-high SCDs are equally effective against VTEs if they are worn 90% of the day or for more than 21 of each 24 hours (Stone & Chamberlin, 2011). Clients may not wear them because of discomfort, warmth, or soiling, particularly for the thigh-high SCDs. Stone and Chamberlin conducted a study and found that using only the knee-high SCDs as the standard for the intensive care units in their hospital resulted in increased client compliance with wearing SCDs and no newly diagnosed DVTs in the ICU a year after the change was implemented. The SCD is removed for ambulation and is usually discontinued when the client resumes normal activity. To avoid falls, remind the client that the SCD needs to be removed before ambulating, particularly when the client needs to use the bathroom during the night. Sequential compression therapy often complements other preventive measures. The client’s risk level for DVT or PE often determines the preventive measures used. For example, clients at low risk may require only antiemboli stockings. Clients at moderate risk may have both antiemboli stockings and sequential therapy as part of their treatment. The primary care provider may order antiemboli stockings, sequential therapy, and anticoagulation therapy for the high-risk client. Skill 51–1 outlines how to apply a sequential compression device.

SKILL 51–1

Applying Sequential Compression Devices PURPOSES • To promote venous return from the legs • To decrease risk of deep venous thrombosis and/or PE ASSESSMENT Assess for baseline data: • Cardiovascular status, including heart rate and rhythm, ­peripheral pulses, and capillary refill

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• •

Color and temperature of extremities Movement and sensation of feet and lower extremities and Homans’ sign

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Applying Sequential Compression Devices—continued Equipment • Measuring tape • SCD, including disposable sleeves, air pump, and tubing

SKILL 51–1

PLANNING Check the primary care provider’s order for type of SCD sleeve. ­Rationale: Foot, knee- and thigh-length sleeves are available. • Read the manufacturer’s directions for connecting and operating the compression controller.

DELEGATION Unlicensed assistive personnel (UAP) often remove and reapply the SCD when performing hygiene care. The nurse should check that the UAP knows the correct application process for the SCD. Remind the UAP that the client should not have the SCD removed for long periods of time because the purpose of the SCD is to promote circulation. Remind UAP to inspect the SCD sleeve and tubing each time prior to applying the sleeves.

IMPLEMENTATION Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and the procedure for applying the sequential compression device. Rationale: The ­client’s participation and comfort will be increased by understanding the rationale for applying the SCD. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Provide for client privacy and drape the client appropriately. 4. Prepare the client. • Place the client in a dorsal recumbent or semi-Fowler’s ­position. • Measure the client’s legs as recommended by the manufacturer if a thigh-length sleeve is required. Rationale: Foot- and knee-length sleeves come in just one size; the thigh circumference determines the size needed for a thigh-length sleeve. 5. Apply the sequential compression sleeves. • Place a sleeve under each leg with the opening at the knee. • Wrap the sleeve securely around the leg, securing the Velcro tabs. ❶ Allow two fingers to fit between the leg and the sleeve. Rationale: This amount of space ensures that the sleeve does not impair circulation when inflated. 6. Connect the sleeves to the control unit and adjust the pressure as needed. • Connect the tubing to the sleeves and control unit, ensuring that arrows on the plug and the connector are in alignment and that the tubing is not kinked or twisted. Rationale: Improper alignment or obstruction of the tubing by kinks or twists will interfere with operation of the SCD. • Turn on the control unit and adjust the alarms and pressures as needed. The sleeve cooling control and alarm should be on; ankle pressure is usually set at 35 to 55 mmHg. EVALUATION • Perform appropriate follow-up assessments, such as peripheral vascular status including pedal pulses, skin color and temperature, skin integrity, and neurovascular status, including movement and sensation.

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❶ Applying a sequential compression device to the leg.

Rationale: It is important to have the sleeve cooling control on for comfort and to reduce the risk of skin irritation from moisture under the sleeve. Proper pressure settings prevent injury to the client. Alarms warn of possible control unit ­malfunctions. 7. Document the procedure. • Record baseline assessment data and application of the SCD. Note control unit settings. • Assess and document skin integrity and neurovascular and peripheral vascular status per agency policy while the SCD is in place. Remove the unit and notify the primary care provider if the client complains of numbness and tingling or leg pain. These may be symptoms of nerve compression.

• •

Compare to the baseline data, if available. Report significant deviations from normal to the primary care provider.

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LIFESPAN CONSIDERATIONS Sequential Compression Devices CHILDREN • Because young children tend to be more active, the SCD is rarely necessary unless the child is immobile (e.g., comatose).

OLDER ADULTS • SCD sleeves may become loose as clients move around in bed. Check that the sleeves are secure and properly positioned.

Home Care Considerations  Sequential Compression Devices A sequential compression device may be used in the home. Inform the client or caregiver how to apply the device correctly

PATIENT-CENTERED CARE

and how to operate the system, including how to respond to the alarm.

DRUG CAPSULE

Low Molecular Weight Heparin  enoxaparin (Lovenox) PREVENTION OF DEEP VENOUS THROMBOSIS The low molecular weight heparins are anticoagulants used to prevent deep venous thrombosis after hip, knee, or abdominal surgery. They are also used for clients at risk for thromboembolus secondary to prolonged bed rest due to acute illness. These heparins are given subcutaneously either once a day or every 12 hours. They have a predictable dose response and do not require daily lab test monitoring. NURSING RESPONSIBILITIES • Administration: • Administer deep subcutaneous. Do not give IM. • Client should be lying down during administration. • Do not expel the air bubble from the prefilled syringe. This avoids loss of the drug. • The manufacturer recommends injection into the right or left anterior lateral or posterior lateral aspect of the abdominal wall for best absorption.

Cardiopulmonary Resuscitation Cardiopulmonary resuscitation (CPR) is a combination of oral resuscitation (mouth-to-mouth breathing or use of a mask), which supplies oxygen to the lungs, and external cardiac massage (chest compression), which is intended to reestablish cardiac function and blood circulation. CPR is also referred to as basic life support (BLS). The AHA issues revised standards for CPR every five years (e.g., 2010, 2015). It covers all aspects of emergency cardiac care and simplifies CPR procedures so more health care professionals and lay rescuers might learn them and perform them correctly. The complete guidelines are available online. A cardiac arrest is the cessation of cardiac function; the heart stops beating. Often a cardiac arrest is unexpected and sudden. When it occurs, the heart no longer pumps blood to any of the organs of the body. Breathing then stops, and the person becomes unconscious and limp. Within 20 to 40 seconds of a cardiac arrest, the victim is clinically dead. After 4 to 6 minutes, the lack of oxygen supply to the brain causes permanent and extensive damage. The three cardinal signs of a cardiac arrest are apnea, absence of a carotid or femoral pulse, and dilated pupils. The person’s skin appears pale or grayish and feels cool. Cyanosis is evident when respiratory function fails before heart failure. A respiratory arrest (pulmonary arrest) is the cessation of breathing. It often occurs because of a blocked airway, but it can occur following a cardiac arrest and for other reasons. A respiratory

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Alternate between right and left abdomen sites. Insert the entire length of the needle into a skinfold created by the thumb and forefinger; hold the skinfold until the needle is withdrawn. • Do not massage the injection site to minimize bruising. Do not mix with other injections. Lovenox and regular heparin cannot be used interchangeably. Assess baseline lab data (e.g., CBC, liver function, coagulation) and monitor periodically. Observe for early signs/symptoms of bleeding. • •

• • • •

CLIENT AND FAMILY TEACHING • Review how to administer (see above). • Administer at the same time each day. • Report any unusual bleeding or bruising. • Avoid aspirin or NSAIDs. Note: Prior to administering any medications, review all aspects with a current drug handbook or other reliable source.

arrest may occur abruptly or be preceded by short, shallow breathing that becomes increasingly labored. It is vital that all nurses be trained to perform CPR so resuscitation measures can be initiated immediately when a cardiac or respiratory arrest occurs. Nurses also can be instrumental in increasing community awareness of the need for CPR training and ensuring its availability. Each health care facility has policies and procedures for announcing cardiac/respiratory arrest and initiating interventions, as well as a name by which this emergency is referred; such emergencies are often referred to as a “code.” There may be a button at the head of each bed for calling a code, an extension dialed on the phone, or it may be a special phone used to announce the emergency. It is critical that each member of the client care team know the procedure for announcing this emergency. Calling the code summons the code team to the location of the emergency. The code team is made up of specially trained staff who can handle the emergency. Individuals are needed to perform rescue breathing, deliver chest compressions, administer medications, and make a record of the code activities. One person must be designated as the code leader—the person who directs the activities of the other team members. Some clients have requested via an advance directive that, should they arrest, they not be resuscitated. It is every person’s right to make an advance directive of their wishes, and a client’s code status should always be documented, per agency policy, in the medical

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record (e.g., do not resuscitate [DNR]). Under most circumstances, if there is no DNR order in the record, all clients who arrest will have resuscitation efforts begun. Both legally and ethically, there is no such thing as a “partial code,” “slow code,” or “mini code.” Throughout any emergency situation, the nurse must remember the person behind all of the technology. There is a client with spiritual and emotional needs who requires a personal connection. Holding a hand, making eye contact, talking directly to them—brief, seemingly small things make a huge difference to clients. To humanize health care is always a goal. Nursing therapeutic presence is the key. This should be extended to family members as well.

Evaluating Using the overall goals identified in the planning stage, the nurse collects data to evaluate the effectiveness of interventions.

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If desired outcomes are not achieved, the nurse, client, and support people if appropriate need to explore the reasons before modifying the care plan. For example, if the outcome “cardiac pump effectiveness” is not achieved, questions to be considered might include the following: • Have other outcome measures for the goal of maintaining ad-

equate cardiac output been met?

• Are prescribed medications being administered and/or taken as

ordered?

• Are any additional factors placing stress on the heart? • Is there a balance between factors that affect cardiac output, such

as preload and afterload?

• Are there signs of fluid overload such as weight gain?

Critical Thinking Checkpoint Mrs. Gloria Papadopolis reports that she is having increasing difficulty because she experiences severe pain in her calf muscles after walking for more than a city block. The pain subsides if she rests for a few minutes, but returns with activity. Her feet are cool and pale; pedal and posterior tibial pulses are not palpable, and femoral pulses are difficult to palpate. She lives in a downtown apartment and uses public transportation to travel across town to visit her husband’s grave weekly. 1. What are the circulatory causes of her leg pain? Which risk factors would you expect to find in her history to support this conclusion?

2. Name two nursing diagnoses appropriate for Mrs. Papadopolis. Which would have the highest priority and why? 3. The primary care provider suggests that Mrs. Papadopolis cease her visits to the cemetery since she has to walk a long way there to reach the grave site. Would you agree with this plan? Why or why not? What considerations or viewpoints influence your choice? 4. Mrs. Papadopolis says that she wears support stockings ­because her friend told her they help the circulation in her legs. How would you respond to this information? See Critical Thinking Possibilities on student resource website.

Chapter 51 Review CHAPTER HIGHLIGHTS • The cardiovascular system transports gases in the blood to and

•

•

• • •

• •

from the tissues and facilitates the diffusion of gases between the capillaries and body tissues. The heart and the blood vessels make up the cardiovascular system. Together with blood, it is the major system for transporting oxygen and nutrients to the cells and removing wastes for disposal. The right side of the heart receives deoxygenated blood from the body and pumps it to the lungs via the pulmonary arteries; the left side receives oxygenated blood from the lungs and pumps it out to the body via the aorta. Coronary arteries supply oxygen and nutrients to the heart muscle. The cardiac cycle is made up of systolic and diastolic periods. The cardiac conduction system controls the electrical activity of the heart and the cardiac cycle: systole, contraction of the heart muscle and ejection of blood, and diastole, the relaxation period during which the heart fills with blood. Cardiac output depends on stroke volume, or the amount of blood ejected during systole, and heart rate. Systemic blood vessels carry blood to the tissues through a system of arteries, arterioles, and capillaries and return it to the heart through the venules, veins, and the venae cavae.

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• Blood pressure rises gradually from birth to reach the adult range

during adolescence. • Atherosclerosis causes fatty plaque to develop within arteries. • Decreased cardiac output, impaired tissue perfusion, and disor-

•

• • •

•

ders affecting the blood are the major cardiovascular problems that affect oxygenation. Cardiac output may fall with a myocardial infarction (MI), heart failure, dysrhythmias, and structural alterations of the heart (e.g., valve deformities). The most common cause of impaired blood flow to organs and tissues is atherosclerosis; this can lead to tissue ischemia and pain. Cardiac monitoring is used for continuous observation of the heart rate and rhythm. Nursing interventions to promote circulation include using sequential compression devices to promote venous return from the legs, which prevents venous stasis. Cardiopulmonary resuscitation (CPR) is used during cardiopulmonary arrest. Each nurse needs to be aware of the hospital’s policies and procedures regarding emergencies.

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TEST YOUR KNOWLEDGE 1. The post-myocardial infarction client asks the nurse about return to exercise. What information should the nurse give this client? 1. It is better to exercise when it is cold. 2. Environmental temperatures have little impact on cardiac function. 3. Avoid exercise when the weather is hot or cold. 4. Hot temperatures increase peripheral blood vessel contraction. 2. The client’s electrocardiogram (ECG) monitor reflects normal electrical activity through the heart’s conduction system. The nurse knows that the electrical impulse travels in which sequence? 1. Atrioventricular node 2. Bundle branches 3. Sinoatrial node 4. Bundle of His 5. Purkinje fibers Place the numbers in the correct sequence: ____________ 3. Which would most likely be included in the evaluation of the ­client goal of “Demonstrate adequate tissue perfusion”? 1. Symmetrical chest expansion 2. Use of pursed-lip breathing 3. Brisk capillary refill 4. Activity intolerance 4. The client has complaints of being tired, listless, and unable to tolerate activity at usual levels. Which laboratory value would the nurse review first while assessing this complaint? 1. Blood urea nitrogen 2. Hemoglobin and hematocrit 3. Blood sugar 4. Serum potassium 5. A client has a heart rate of 170 beats per minute. For what will the nurse assess next in this client? 1. Increased cardiac output 2. Increased preload 3. Decreased afterload 4. Decreased cardiac output 6. The nurse is assigned to three clients with the following diagnoses: myocardial infarction (MI), heart failure (HF), and anemia. In planning for their nursing care, the nurse knows that all three clients will have which sign/symptom? 1. Pain 2. Distended neck veins 3. Shortness of breath 4. Nausea

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7. Which set of assessment data best validates that the nurse should initiate cardiopulmonary resuscitation on a comatose client? 1. Cool, pale skin; unconsciousness; absence of radial pulse 2. Cyanosis, slow pulse, dilated pupils 3. Absent pulses, flushed skin, pinpoint pupils 4. Apnea, absence of carotid or femoral pulses, dilated pupils 8. Which diagnoses would be most appropriate for clients with cardiovascular disease? Select all that apply. 1. Ineffective Peripheral Tissue Perfusion 2. Acute Confusion 3. Decreased Cardiac Output 4. Sleep Pattern Disturbance 5. Activity Intolerance 9. The surgeon ordered sequential compression devices (SCDs) to be applied postoperatively. The client asks why the SCDs are needed. Which is the best response by the nurse when teaching the client about the purpose of SCDs? 1. They promote arterial circulation. 2. They promote venous return from the legs. 3. They decrease afterload. 4. They decrease postoperative pain. 10. A client with severe mitral stenosis is having surgery tomorrow. While teaching the client, the nurse shows the client a diagram of the heart. Identify with an “X” which valve the client will have replaced.

See Answers to Test Your Knowledge in Appendix A.

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READINGS AND REFERENCES Suggested Readings Drumright, K., Julkenbeck, S., & Judd, C. (2013). The ABCs of acute PE. Nursing made Incredibly Easy!, 11(2), 45–49. Pulmonary embolism (PE) is the most common preventable cause of death in the hospital setting. The most common risk factor for PE is DVT and VTE (which includes both PE and DVT). The authors review Virchow’s triad, signs and symptoms, diagnosis, treatments, and prevention. Elpern, E., Killeen, K., Patel, G., & Senecal, P. A. (2013). The application of intermittent pneumatic compression devices for thromboprophylaxis. American Journal of Nursing, 113(4), 30–36. doi:10.1097/01 .NAJ.0000428736.48428.10 The authors note that “thromboprophylaxis, using either chemical or mechanical strategies or both, can reduce the incidence of VTE in the critically ill, and VTE prophylaxis is recommended for all critically ill patients” (p. 30). Mechanical prophylactic devices (i.e., SCDs) are widely used and are applied, maintained, and monitored exclusively by nursing personnel. The authors conducted an observational study, and this article reports the frequent errors found in the application of SCDs. This is important to know because applying SCDs incorrectly increases the client’s risk of thrombosis. Herman, A. (2013). Coronary artery disease: The plaque plague. Nursing made Incredibly Easy!, 11(2), 34–43. doi:10.1097/01.NME.0000426303.65238.4e The author provides a comprehensive overview of CAD including the pathophysiology of atherosclerotic plaque, the different types of plaque (along with pictures for the visual learner), information on MI, interventions for MI, treatment, teaching, and prevention strategies for CAD.

Related Research Duff, J., Walkeer, K., Omari, A., Middleton,S., & McInnes, E. (2013). Educational outreach visits to improve nurses’ use of mechanical venous thromboembolism prevention in hospitalized medical patients. Journal of Vascular Nursing, 31, 139–149. doi:10.1016/j.jvn.2013.04.002 Schultz, A. B., Chen, C. Y., Burton, W. N., & Edington, D. W. (2012). The burden and management of dyslipidemia: Practical issues. Population Health Management, 15, 302–308. doi:10.1089/pop.2011.0081

References American Heart Association. (2013a). American Heart Association recommendations for physical activity in adults. Retrieved from http://www.heart.org/HEARTORG/ GettingHealthy/PhysicalActivity/FitnessBasics/AmericanHeart-Association-Recommendations-for-Physical-Activityin-Adults_UCM_307976_Article.jsp American Heart Association. (2013b). Physical activity in older Americans. Retrieved from http://www.heart.org/ HEARTORG/GettingHealthy/PhysicalActivity/FitnessBasics/ Physical-Activity-in-Older-Americans_UCM_308039_ Article.jsp American Heart Association. (2014). Know your fats. Retrieved from http://www.heart.org/HEARTORG/Conditions/ Cholesterol/PreventionTreatmentofHighCholesterol/KnowYour-Fats_UCM_305628_Article.jsp Ball, J. W., Bindler, R. C., & Cowen, K. J. (2010). Child health nursing: Partnering with children & families (2nd ed.). Upper Saddle River, NJ: Prentice Hall.

Ball, J. W., Bindler, R. C., & Cowen, K. J. (2014). Child health nursing: Partnering with children & families (3rd ed.). Upper Saddle River, NJ: Prentice Hall. Berra, K., Fletcher, B., Hayman, L. L., & Miller, N. H. (2013). Global cardiovascular disease prevention: A call to action for nursing executive summary. Journal of Cardiovascular Nursing, 28, 505–513. doi:10.1097/ JCN.0b013e31826b6822 Burke, L. E., & Wang, J. (2011). Treatment strategies for overweight and obesity. Journal of Nursing Scholarship, 43, 368–375. doi:10.1111/j.1547-5069.2011.01424.x Butcher, J., & Beckstrand, R. (2010). Fiber’s impact on highsensitivity C-reactive protein levels in cardiovascular disease. Journal of the American Academy of Nurse Practitioners, 22, 566–572. doi:10.1111/j.1745-7599.2010.00555.x Caboral, M. F. (2013). Update on cardiovascular disease prevention in women. American Journal of Nursing, 133(3), 26–33. doi:10.1097/01.NAJ.0000427876.02924.dd Giardina, E. V., Sciacca, R. R., Foody, J. M., D’Onofrio, G., Villablanca, A. C., Leatherwood, S., . . . Haynes, S. G. (2011). The DHHS Office on Women’s Health initiative to improve women’s heart health: Focus on knowledge and awareness among women with cardiometabolic risk factors. Journal of Women’s Health, 20, 893–900. doi:10.1089/jwh.2010.2448 Harris, H., & Smith, C. J. (2014). Caring for patients with metabolic syndrome. American Nurse Today, 9(4). Retrieved from http://www.americannursetoday.com/ Article.aspx?id=11412&fid=11360 Herdman, T. H., & Kamitsuru, S. (2014) (Eds.). NANDA International nursing diagnoses: Definitions and classification, 2015–2017. Oxford, United Kingdom: Wiley-Blackwell. Holm, K. (2010). Promoting cardiovascular health. Special considerations for the elderly. Journal of Cardiovascular Nursing, 25, 252–253. doi:10.1097/JCN.0b013e3181cec829 Jaquith, B. C., Harris, M. A., & Penprase, B. (2013). Cardiovascular disease risk in children and adolescents. Journal of Pediatric Nursing, 28, 258–266. doi:10.1016/ j.pedn.2012.11.003 Kuznar, W. (2010). Sex differences in heart disease trends. American Journal of Nursing, 110(2), 18–19. doi:10.1097/01.NAJ.0000368039.17578.f1 Larkin, B., Mitchell, K., & Petrie, K. (2012). Translating evidence to practice for mechanical venous thromboembolism prophylaxis. AORN Journal, 96, 513–527. doi:10.1016/ j.aorn.2012.07.011 Martí-Carvajal, A. J., Solà, I., Lathyris, D., Karakitsiou, D. E., & Simancas-Racines, D. (2013). Homocysteine-lowering interventions for preventing cardiovascular events. Cochrane Database of Systematic Reviews, Issue 1, Art. No.: CD006612. doi:10.1002/14651858.CD006612.pub3 McNamara, S. A. (2014). Prevention of venous thromboembolism. AORN Journal, 99, 642–647. doi:10.1016/ j.aorn.2014.02.001 Moye, M. (2011). Understanding the ankle-brachial index. Nursing, 41(1), 68. doi:10.1097/01 .NURSE.0000391353.07304.9c Pollak, A. W., & McBane, R. D. (2014). Succinct review of the new VTE prevention and management guidelines. Mayo Clinic Proceedings, 89(3), 394–408. doi:10.1016/ j.mayocp.2013.11.015

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Rice, J. (2012). Medical terminology: A word-building approach (7th ed.). Upper Saddle River, NJ: Pearson Education. Sherrod, M. M., Sherrod, N. M., Spitzer, M. T., & Cheek, D. J. (2013). AHA recommendations for preventing heart disease in women. Nursing, 43(5), 61–65. doi:10.1097/01 .NURSE.0000427992.69682.40 Stone, A., & Chamberlin, L. (2011). Out with the thigh-high, in with the knee-high sequential compression devices. Critical Care Nurse, 31(2), e37. U.S. Department of Health and Human Services. (2013a). Healthy people 2020: Diabetes objectives. Retrieved from http://healthypeople.gov/2020/topicsobjectives2020/ objectiveslist.aspx?topicId=8 U.S. Department of Health and Human Services. (2013b). Healthy people 2020: Heart disease and stroke objectives. Retrieved from http://healthypeople.gov/2020/ topicsobjectives2020/objectiveslist.aspx?topicId=21 U.S. Department of Health and Human Services. (2013c). Healthy people 2020: Nutrition and weight status objectives. Retrieved from http://healthypeople.gov/2020/ topicsobjectives2020/objectiveslist.aspx?topicId=29 U.S. Department of Health and Human Services. (2013d). Healthy people 2020: Physical activity objectives. Retrieved from http://healthypeople.gov/2020/topicsobjectives2020/ objectiveslist.aspx?topicId=33 U.S. Department of Health and Human Services. (2013e). Healthy people 2020: Tobacco use objectives. Retrieved from http://healthypeople.gov/2020/topicsobjectives2020/ objectiveslist.aspx?topicId=41 Vascular Disease Foundation. (2014). Ankle-brachial index. Retrieved from http://vasculardisease.org/peripheralartery-disease/pad-diagnosis/ankle-brachial-index

Selected Bibliography Blakemore, S. (2012). Drive to screen all adult inpatients for risk of blood clots will save lives. Nursing Older People, 24(9), 7. doi:10.7748/nop2012.11.24.9.7.p9734 Braun, L. T. (2010). How inflammatory markers refine CV risk status. American Nurse Today, 5(5), 30–31. Choi, M., & Hector, M. (2012). Management of venous thromboembolism for older adults in long-term care facilities. Journal of the American Academy of Nurse Practitioners, 24(6), 335–344. doi:10.1111/j.1745-7599.2012.00733.x Fenimore, G. S. (2010). Evaluating CAD with a pharmacologic stress test. Nursing, 40(5), 51–52. Giancoli, A. N. (2014). Cutting through cholesterol confusion. Environmental Nutrition, 37(1), 7. McEvoy, M. (2014). 6 surprising best resuscitation practices. American Nurse Today, 9(3), 20–24. Meetoo, D. (2013). Understanding and managing deep vein thrombosis. Nurse Prescribing, 11, 390–395. Sadler, C. (2011). Calculating risk. Nursing Standard, 26(9), 24–25. Tadej, M. (2013). A service pathway for patients at risk of peripheral arterial disease. British Journal of Community Nursing, 18, 168–172. Walker, J. (2013). Reducing cardiovascular disease risk: Cholesterol and diet. Nursing Standard, 28(2), 48–55. Warren, E. (2013). Ten things the practice nurse can do about peripheral arterial disease. Practice Nurse, 43(12), 14–18.

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Fluid, Electrolyte, and Acid–Base Balance

LEARNING OUTCOMES After completing this chapter, you will be able to: 1. Discuss the function, distribution, composition, movement, and regulation of fluids and electrolytes in the body. 2. Describe the regulation of acid–base balance in the body, ­including the roles of buffers, the lungs, and the kidneys. 3. Identify factors affecting normal body fluid, electrolyte, and acid–base balance. 4. Discuss risk factors for, and causes and effects of, fluid, electrolyte, and acid–base imbalances. 5. Collect assessment data related to clients’ fluid, electrolyte, and acid–base balances. 6. Identify examples of nursing diagnoses, outcomes, and interventions for clients with altered fluid, electrolyte, or acid–base balance. 7. Teach clients measures to maintain fluid and electrolyte balance. 8. Implement measures to correct imbalances of fluids, electrolytes, acids, and bases, such as enteral or parenteral replacements and blood transfusions.

9. Evaluate the effect of nursing and collaborative interventions on clients’ fluid, electrolyte, or acid–base balance. 10. Verbalize the steps used in: a. Starting an intravenous infusion. b. Monitoring an intravenous infusion. c. Changing an intravenous container and tubing d. Discontinuing an intravenous infusion. e. Changing an intravenous catheter to an intermittent infusion lock. f. Initiating, maintaining, and terminating a blood transfusion using a Y-set. 11. Recognize when it is appropriate to delegate aspects of fluid, electrolyte, and acid–base balance to unlicensed assistive personnel. 12. Demonstrate appropriate documentation and reporting of fluid, electrolyte, and acid–base balance activities.

KEY TERMS acid, 1342 acidosis, 1342 active transport, 1337 agglutinins, 1384 agglutinogens, 1384 alkalosis, 1342 anions, 1335 antibodies, 1384 antigens, 1384 arterial blood gases (ABGs), 1357 bases, 1342 buffers, 1342 cations, 1335 central venous access device (CVAD), 1365 colloid osmotic pressure, 1337 colloids, 1336 compensation, 1350 crystalloids, 1336 dehydration, 1346 diffusion, 1337

drop factor, 1374 electrolytes, 1335 extracellular fluid (ECF), 1335 extravasation, 1378 filtration, 1337 filtration pressure, 1337 fluid volume deficit (FVD), 1344 fluid volume excess (FVE), 1345 hematocrit (Hct), 1357 hemolytic transfusion reaction, 1384 homeostasis, 1334 hydrostatic pressure, 1337 hypercalcemia, 1347 hyperchloremia, 1350 hyperkalemia, 1347 hypermagnesemia, 1350 hypernatremia, 1346 hyperphosphatemia, 1350 hypertonic, 1336 hypervolemia, 1345

INTRODUCTION

In good health, a delicate balance of fluids, electrolytes, acids, and bases maintains the body. This balance, or homeostasis, depends on multiple physiological processes that regulate fluid intake and output, as well as the movement of water and the substances dissolved in it between body compartments.

hypocalcemia, 1347 hypochloremia, 1350 hypokalemia, 1347 hypomagnesemia, 1350 hyponatremia, 1346 hypophosphatemia, 1350 hypotonic, 1336 hypovolemia, 1344 infiltration, 1378 insensible fluid loss, 1339 interstitial fluid, 1335 intracellular fluid (ICF), 1335 intravascular fluid, 1335 ions, 1335 isotonic, 1336 metabolic acidosis, 1351 metabolic alkalosis, 1352 milliequivalent, 1335 obligatory losses, 1339 oncotic pressure, 1337 osmolality, 1336

osmosis, 1337 osmotic pressure, 1337 overhydration, 1346 peripherally inserted central venous catheter (PICC), 1365 pH, 1342 pitting edema, 1345 plasma, 1335 renin-angiotensin-aldosterone system, 1339 respiratory acidosis, 1351 respiratory alkalosis, 1351 selectively permeable, 1336 solutes, 1336 solvent, 1336 specific gravity, 1357 third space syndrome, 1344 transcellular fluid, 1335 vesicant, 1378 volume expanders, 1362

Almost every illness has the potential to threaten this balance. Even in daily living, factors such as excessive temperatures or vigorous activity can disturb homeostasis if adequate water and salt intake are not maintained. Therapeutic measures, such as the use of diuretics or nasogastric suction, can also disturb the body’s homeostasis unless water and electrolytes are replaced.

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BODY FLUIDS AND ELECTROLYTES

The proportion of the human body composed of fluid is surprisingly large. Approximately 60% of the average healthy adult’s weight is water, the primary body fluid. In good health this volume remains relatively constant, and a person’s weight varies by less than 0.2 kg (0.5 lb) in 24 hours, regardless of the amount of fluid ingested. Water is vital to health and normal cellular function, serving as: • • • • •

A medium for metabolic reactions within cells A transporter for nutrients, waste products, and other substances A lubricant An insulator and shock absorber A means of regulating and maintaining body temperature.

Age, sex, and body fat affect total body water. Infants have the highest proportion of water, accounting for 70% to 80% of their body weight. The proportion of body water decreases with age. In people older than 60 years of age, it represents only about 50% of total body weight. Women generally have a lower percentage of body water than men. In both women and older adults, this is due to lower levels of muscle mass and a greater percentage of fat tissue. Fat tissue is essentially free of water, whereas lean tissue contains a significant amount of water. Therefore, water makes up a greater percentage of a lean individual’s body weight than of an individual who is obese.

Distribution of Body Fluids

The body’s fluid is divided into two major compartments, intracellular and extracellular. Intracellular fluid (ICF) is found within the cells of the body. It constitutes approximately two thirds of the total body fluid in adults. Extracellular fluid (ECF) is found outside the cells and accounts for about one third of total body fluid. ECF is further subdivided into compartments. The two main compartments of ECF are intravascular and interstitial. Intravascular fluid, or plasma, accounts for approximately 20% of ECF and is found within the vascular system. Interstitial fluid, accounting for approximately 75% of ECF, surrounds the cells. The other compartments of ECF include the lymph and transcellular fluids. Examples of transcellular fluid include cerebrospinal, pericardial, pancreatic, pleural, intraocular, biliary, peritoneal, and synovial fluids (Figure 52–1 •). Intracellular fluid is vital to normal cell functioning. It contains solutes such as oxygen, electrolytes, and glucose, and it provides a medium in which metabolic processes of the cell take place. Although ECF is in the smaller of the two compartments, it is the transport system that carries oxygen and nutrients to, and waste products from, body cells. For example, plasma carries oxygen from the lungs and glucose from the gastrointestinal tract to the capillaries of the vascular system. From there, the oxygen and glucose move across the capillary membranes into the interstitial spaces and then across the cellular membranes into the cells. The opposite route is taken for waste products, such as carbon dioxide going from the cells to the lungs, and metabolic waste going to the kidneys. Interstitial fluid transports wastes from cells by way of the lymph system, as well as directly into the blood plasma through capillaries.

Composition of Body Fluid

Extracellular and intracellular fluids contain oxygen from the lungs, dissolved nutrients from the gastrointestinal tract, excretory

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Cell fluid 25 liters Total body fluid 40 liters

Plasma 3 liters

Interstitial and transcellular fluid 12 liters

Extracellular fluid 15 liters

Figure 52–1  •  Total body fluid represents 40 L in an adult male weighing 70 kg (154 lb).

products of metabolism such as carbon dioxide, and charged particles called ions. Many salts dissociate in water; that is, they break up into electrically charged ions. The salt called sodium chloride breaks up into one ion of sodium (Na+) and one ion of chloride (Cl−). These charged particles are called electrolytes because they are capable of conducting electricity. The number of ions that carry a positive charge, called cations, and ions that carry a negative charge, called anions, should be equal. Examples of cations are sodium (Na+), potassium (K+), calcium (Ca2+), and magnesium (Mg2+). Examples of anions include chloride (Cl−), bicarbonate (HCO3−), phosphate (PO43–), and sulfate (SO42–). Electrolytes generally are measured in milliequivalents per liter (mEq/L) or milligrams per 100 milliliters (mg/100 mL). The term milliequivalent refers to the chemical combining power of the ion, or the capacity of cations to combine with anions to form molecules, whereas the term milligram refers to the weight of the ion. Therefore, 1 mEq of any anion equals 1 mEq of any cation in terms of their capacity to combine into molecules. For example, sodium and chloride combine equally, so 1 mEq of Na+ equals 1 mEq of Cl−; however, a molecule of sodium is not equal in weight to a molecule of chloride. Clinically, the milliequivalent system is most often used. However, nurses need to be aware that different systems of measurement may be found when interpreting laboratory results. For example, calcium levels frequently are reported in milligrams per deciliter (1 dL = 100 mL) instead of milliequivalents per liter. It also is important to remember that laboratory tests are usually performed using blood plasma, an extracellular fluid. These results reflect what is happening in ECF, more specifically within intravascular fluid,

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INTRACELLULAR FLUID Na+

PLASMA

INTERSTITIAL FLUID

KEY Cations

HCO3– –

Na+

Cl

+

K

Milliequivalents per liter (mEq/L)

150 HCO3–

Ca2+ –

HCO3 HPO42–

+

Mg2

K+ Anions

100

HCO3–

Cl–

Na+

Na+

SO42–

Cl–

–

Cl

–

HPO42

50

HPO42– Proteins + Mg2

0

Cations

Anions

SO42–

Org. acid K+ + Ca2

Proteins

Cations

Anions

K+ Cations

HPO42– SO42–

Organic acid Proteins

Anions

Figure 52–2  •  Electrolyte composition (cations and anions) of body fluid compartments. From Fundamentals of Anatomy and Physiology, 10th ed., by F. H. Martini, J. L. Nath, and E. F. Bartholomew, © 2015. Reproduced by permission of Pearson Education, Inc., Upper Saddle River, NJ.

but generally it is not possible to directly measure electrolyte concentrations within body cells. The composition of fluids varies from one body compartment to another. In ECF, the principal electrolytes are sodium, chloride, and bicarbonate. Other electrolytes such as potassium, calcium, and magnesium are present, but in much smaller quantities. Plasma and interstitial fluid, the two primary components of ECF, contain essentially the same electrolytes and solutes, with the exception of protein. Plasma is a protein-rich fluid, containing large amounts of albumin, but interstitial fluid contains little or no protein. The composition of ICF differs significantly from that of ECF. Potassium and magnesium are the primary cations present in ICF, and phosphate and sulfate are the major anions. As in ECF, other electrolytes are present within the cell, but in much smaller concentrations (Figure 52–2 •). Other body fluids such as gastric and intestinal secretions also contain electrolytes. This is of particular concern when these fluids are lost from the body (for example, in severe vomiting or diarrhea, or when gastric suction removes gastric secretions). Fluid and electrolyte imbalances can result from excessive losses through these routes.

Movement of Body Fluids and Electrolytes

The body fluid compartments are separated from one another by cell membranes and the capillary membrane. Although these membranes are completely permeable to water, they are considered to be selectively permeable to solutes, because substances other than

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water move across them with varying degrees of ease. Small particles such as ions, oxygen, and carbon dioxide move easily across these membranes, but larger molecules such as glucose and proteins have more difficulty moving between fluid compartments. Solutes are substances dissolved in a liquid. For example, when sugar is added to coffee, the sugar is the solute. Solutes may be ­crystalloids (salts that dissolve readily into true solutions) or ­colloids (substances such as large protein molecules that do not readily dissolve into true solutions). A solvent is the component of a solution that can dissolve a solute. In the previous example, coffee is the solvent for the sugar. In the body, water is the solvent; the solutes include electrolytes, gases such as oxygen and carbon dioxide, glucose, urea, amino acids, and proteins. The concentration of solutes in body fluids is usually expressed as the osmolality. Osmolality is determined by the total solute concentration within a fluid compartment and is measured as parts of solute per kilogram of water. Osmolality is reported as milliosmoles per kilogram (mOsm/kg). Sodium is by far the greatest determinant of the osmolality of plasma, or serum osmolality, although glucose and urea also contribute. ­Potassium, glucose, and urea are the primary determinants of the osmolality of intracellular fluid. The term tonicity may also be used to refer to the osmolality of one solution in relation to another solution. Solutions may be termed isotonic, hypertonic, or ­hypotonic. In relation to body fluids, an isotonic solution has the same osmolality as ECF. Normal saline, 0.9% sodium chloride, is an example of an isotonic solution. Hypertonic solutions, such as 3% sodium chloride, have a higher osmolality than ECF. Hypotonic solutions, such

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as 0.45% sodium chloride, have a lower osmolality than ECF. See Table 52–10 later in this chapter for additional information about intravenous (IV) solutions. Osmotic pressure is the power of a solution to pull water across a semipermeable membrane. When two solutions of different concentrations are separated by a semipermeable membrane, the solution with the higher solute concentration exerts a higher osmotic pressure, pulling water across the membrane to equalize the concentrations of the solutions. For example, infusing a hypertonic IV solution such as 3% sodium chloride will pull fluid out of red blood cells (RBCs) and into plasma, causing the cells to shrink. On the other hand, a hypotonic solution administered intravenously will cause the RBCs to swell as water is pulled into the cells by their higher osmotic pressure. In the body, plasma proteins also exert osmotic pressure called colloid osmotic pressure or oncotic pressure, holding water in plasma, and when necessary pulling water from the interstitial space into the vascular compartment. This is an important mechanism for maintaining vascular volume. The methods by which water and solutes move in the body are called diffusion, osmosis, filtration, and active transport.

DIFFUSION Diffusion occurs when two solutes of different concentrations are separated by a semipermeable membrane (Figure 52–3 •). The rate of diffusion of a solute varies according to the size of the molecules, the concentration of the solution, and the temperature of the solution. Larger molecules move less quickly than smaller ones, molecules move from a solution of higher concentration to a solution of lower concentration, and increases in temperature increase the rate of motion of molecules and therefore the rate of diffusion. OSMOSIS Osmosis is a specific kind of diffusion in which water moves across cell membranes, from the less concentrated solution (the solution with less solute and more water) to the more concentrated solution (the solution with more solute and less water) (Figure 52–4 •). In other words, water moves toward the higher concentration of solute in an attempt to equalize the concentrations of both water and solute. Osmosis occurs in the body when the concentration of solutes is higher on one side of a selectively permeable membrane, such as the capillary membrane, than on the other side. For example, a marathon runner loses a significant amount of body water through Higher concentration

Dissolved substance

Lower concentration

Semipermeable membrane

Figure 52–3  •  Diffusion: the movement of molecules through a s­ emipermeable membrane from an area of higher concentration to an area of lower concentration.

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Higher concentration

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Lower concentration H20

H20 H20

Dissolved substances

Semipermeable membrane

Water molecules

Figure 52–4  •  Osmosis: the movement of water molecules from a less concentrated area to a more concentrated area in an attempt to equalize the concentration of solutions on two sides of a membrane.

perspiration, increasing the concentration of solutes in the plasma. This higher solute concentration draws water from the interstitial space and cells into the vascular compartment to equalize the concentration of solutes in all fluid compartments. Osmosis is an important mechanism for maintaining homeostasis and fluid balance.

FILTRATION Filtration is a process whereby fluid and solutes move together across a membrane from an area of higher pressure to an area of lower pressure. An example of filtration is the movement of fluid and nutrients from the capillaries of the arterioles to the interstitial fluid around the cells. The pressure that results in the movement of the fluid and solutes out of a compartment is called filtration pressure. Hydrostatic pressure is the pressure exerted by a fluid within a closed system on the walls of the container in which it is contained. The hydrostatic pressure of blood is the force exerted by blood against blood vessel walls. Recall that the plasma proteins and other solutes in the blood exert osmotic pressure. Osmotic pressure opposes and balances the force of hydrostatic pressure, and holds fluid in the vascular compartment to maintain the vascular volume. However, when hydrostatic pressure is greater than osmotic pressure, fluid filters out of the blood vessels. Filtration pressure is the difference between the hydrostatic pressure and the osmotic pressure (Figure 52–5 •). ACTIVE TRANSPORT Active transport is the movement of solutes across cell membranes from a less concentrated solution to a more concentrated one (­Figure 52–6 •). This process differs from diffusion and osmosis, which are passive processes, in that metabolic energy is expended. In active transport, a substance combines with a carrier on the outside surface of the cell membrane, and they move to the inside surface of the cell membrane. Once inside, they separate, and the substance is released to the inside of the cell. A specific carrier is required for each substance. The process of active transport is of particular importance in maintaining the differences in sodium and potassium ion concentrations of ECF and ICF. Under normal conditions, sodium concentrations are higher in ECF, and potassium concentrations are higher in ICF. To maintain these proportions, an active transport mechanism (the sodium-potassium pump) is activated, moving sodium from cells into plasma and potassium from plasma into cells. Active

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Arterial side of capillary bed

Colloid osmotic pressure Hydrostatic pressure (constant throughout (venous blood pressure) capillary bed)

Hydrostatic pressure (arterial blood pressure)

Direction of filtration fluid and solutes

Direction of filtration fluid and solutes

Interstitial space

Figure 52–5  •  Schematic of filtration pressure changes within a capillary bed. On the arterial side, arterial blood pressure exceeds colloid osmotic pressure, so that water and dissolved substances move out of the capillary into the interstitial space. On the venous side, venous blood pressure is less than colloid osmotic pressure, so that water and dissolved substances move into the capillary.

Intracellular fluid

ATP

Na+

Na+

K+ K+

Na+

Na+

Na+

K+

Na+

Na+

Na+

K+

Extracellular fluid

Na+

ATP

K+

K+

K+

K+

ATP K+

K+

K+

Na+

K+

ATP

Na+

Na+

Na+

Na+

Na+ Na+

K+ K+

Na+ Na+

Na+ Na+

K+ K+

Cell membrane

Figure 52–6  •  An example of active transport. Energy (ATP) is used to move sodium and potassium molecules across a semipermeable membrane against sodium’s and potassium’s concentration gradients (i.e., from areas of lesser concentration to areas of greater concentration).

transport moves and holds sodium and potassium against their ­diffusion gradients.

Regulating Body Fluids

In a healthy person, the volumes and chemical composition of the fluid compartments stay within specific and narrow limits. Normally, fluid intake and fluid loss are balanced. Illness can upset this balance so that the body has too little or too much fluid.

FLUID INTAKE During periods of normal activity at moderate temperature, the ­average adult drinks about 1,500 mL/day, despite the fact that they need 2,500 mL/day for normal functioning. The additional 1,000-mL volume is acquired from foods and from the oxidation of these foods during metabolic processes. The water content of food is relatively large, contributing about 750 mL/day. Water as a by-product of food metabolism accounts for most of the remaining fluid volume required. This quantity is approximately 200 mL/day for the average adult (Table 52–1). The thirst mechanism is the primary regulator of fluid intake. The thirst center is located in the hypothalamus of the brain. A number of stimuli trigger the thirst center, including the osmotic pressure of body fluids, vascular volume, and angiotensin (a hormone released

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TABLE 52–1

Average Daily Fluid Intake for an Adult

Source Oral fluids

Amount (mL) 1,200–1,500

Water in foods

1,000

Water as by-product of food metabolism

200

Total

2,400–2,700

in response to decreased blood flow to the kidneys), causing the sensation of thirst and the desire to drink fluids. Thirst is normally relieved immediately after drinking a small amount of fluid, when the ingested fluid distends the upper gastrointestinal tract, but before the fluid is actually absorbed from the gastrointestinal tract. However, this relief is only temporary, and thirst returns in about 15 minutes. The thirst is again temporarily relieved by drinking a small amount of fluid. This mechanism protects the individual from drinking too much, because it takes between 30 minutes and 1 hour for fluid to be absorbed and distributed throughout the body.

FLUID OUTPUT Fluid losses from the body counterbalance the intake of fluid, as shown in Table 52–2. The routes of fluid output include: • • •

Urine Feces Insensible losses (through the skin as perspiration and through the lungs as water vapor in expired air). TABLE 52–2

Average Daily Fluid Output for an Adult

Route Urine

Amount (mL) 1,400–1,500

Insensible losses  Lungs

350–400

 Skin

350–400

Sweat

100

Feces

100–200

Total

2,300–2,600

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urinary bladder, and is the major route of fluid output. Normal urine output for an adult is 1,400 to 1,500 mL per 24 hours, or at least 0.5 mL per kilogram per hour. In healthy people, urine output may vary noticeably from day to day. Urine volume should automatically increase as fluid intake increases. If fluid losses through other routes are large, however, urine volume should decrease to maintain fluid balance.

FECES  The chyme that passes from the small intestine into the large intestine contains both water and electrolytes. The volume of chyme entering the large intestine in an adult is normally about 1,500 mL/day. Of this amount, all but about 100 mL is reabsorbed in the proximal half of the large intestine. The reabsorbed volume contains primarily water and electrolytes. INSENSIBLE LOSSES  Insensible fluid losses occur through

the skin and the lungs. They are called insensible because it is usually not noticeable and cannot be measured. Insensible fluid loss through the skin occurs in two ways, diffusion and perspiration. Water loss through diffusion is not noticeable but normally accounts for 300 to 400 mL/day. This loss can be significantly increased if the protective layer of the skin is damaged, as with burns or large abrasions. Perspiration, which may be noticeable but is not measurable, varies depending on factors such as environmental temperature, body temperature, and metabolic activity. Fever and exercise increase metabolic activity and heat production, thereby increasing fluid losses through the skin. Another type of insensible loss is the water in exhaled air. In an adult, this is normally 300 to 400 mL/day. When respiratory rate accelerates, for example, due to exercise or an elevated body temperature, this loss can increase. Certain fluid losses are required to maintain normal body function. These are known as obligatory losses. Approximately 500 mL of fluid must be excreted through the kidneys of an adult each day to eliminate metabolic waste products. Water lost through respirations, the skin, and in feces also are obligatory losses, necessary for temperature regulation and elimination of waste products. The total of all these losses is approximately 1,300 mL/day.

MAINTAINING HOMEOSTASIS The volume and composition of body fluids are regulated through several homeostatic mechanisms. A number of organs and systems contribute to this regulation, including the kidneys, lungs, and the cardiovascular and gastrointestinal systems. Hormones such as antidiuretic hormone (ADH; also known as arginine vasopressin or AVP), the renin-angiotensin-aldosterone system, and atrial natriuretic factor are also involved, as are mechanisms to monitor and maintain vascular volume. KIDNEYS  The kidneys are the primary regulator of body fluids

and electrolyte balance. They regulate the volume and osmolality of ECF by regulating water and electrolyte excretion. The kidneys control the reabsorption of water from plasma filtrate and ultimately the amount excreted as urine. Although 135 to 180 L of plasma per day is normally filtered in an adult, only about 1.5 L of urine is excreted. Electrolyte balance is maintained by selective retention and excretion by the kidneys. The kidneys also play a significant role in acid–base regulation, excreting hydrogen ion (H+) and retaining bicarbonate.

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HORMONES  Several neuroendocrine control mechanisms help control fluid and electrolyte balance. ANTIDIURETIC HORMONE  ADH, which regulates water excretion from the kidney, is synthesized in the anterior portion of the hypothalamus and acts on the collecting ducts of the nephrons. When serum osmolality rises, ADH is produced, causing the collecting ducts to become more permeable to water. This increased permeability allows more water to be reabsorbed into the blood. As more water is reabsorbed, urine output falls and serum osmolality decreases because the water dilutes body fluids. Conversely, if serum osmolality decreases, ADH is suppressed, the collecting ducts become less permeable to water, and urine output increases. Excess water is excreted, and serum osmolality returns to normal. Other factors also affect the production and release of ADH, including blood volume, temperature, pain, stress, and some drugs such as opiates, barbiturates, and nicotine (Figure 52–7 •). RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM  The reninangiotensin-aldosterone system is another neuroendocrine control mechanism that contributes to maintaining fluid balance. Specialized receptors in the kidneys respond to changes in renal perfusion, stimulating the renin-angiotensin-aldosterone system. If blood flow or pressure to the kidney decreases, renin is released. Renin causes the conversion of angiotensinogen to angiotensin I, which is then converted to angiotensin II by angiotensin-converting enzyme. Angiotensin II acts directly on the nephrons to promote sodium and water retention. In addition, it stimulates the release of aldosterone from the adrenal cortex. Aldosterone also promotes sodium retention in the distal nephron. The net effect of the renin-angiotensinaldosterone system is to increase blood volume (and renal perfusion) through sodium and water retention. ATRIAL NATRIURETIC FACTOR  Atrial natriuretic factor (ANF) is released from cells in the atrium of the heart in response to excess blood volume and stretching of the atrial walls. Acting on the nephrons, ANF promotes sodium wasting and acts as a potent diuretic, thus decreasing blood volume. ANF also inhibits thirst, reducing fluid intake.

Regulating Electrolytes

Electrolytes, charged ions capable of conducting electricity, are present in all body fluids and fluid compartments. Just as maintaining fluid balance is vital to normal body functioning, so is maintaining electrolyte balance. Although the concentration of specific electrolytes differs between fluid compartments, a balance of cations (positively charged ions) and anions (negatively charged ions) always exists. Electrolytes are important for: • • • •

Maintaining fluid balance Contributing to acid–base regulation Facilitating enzyme reactions Transmitting neuromuscular reactions.

Most electrolytes enter the body through dietary intake and are excreted in the urine. Some electrolytes, such as sodium chloride and potassium, are not stored by the body and must be consumed daily to maintain normal levels. Other electrolytes, such as calcium, are stored in the body; when serum levels drop, ions can shift out of storage into the blood to maintain adequate serum levels for normal functioning,

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↑ oo o o it

↓ oo o o it

ore eptor in pot u ti u te po terior pituit r to e rete

i uppre e

in re e i t tu u e per e i it

ue it tu u e to e o e e per e e to ter

↑ e orption o into oo

↓ e orption o into oo

Urine output ↓ Serum/blood osmolality ↓ as the water dilutes body fluids

Urine output ↑ Serum osmolality returns to normal

Figure 52–7  •  Antidiuretic hormone (ADH) regulates water excretion from the kidneys.

at least in the short term. The regulatory mechanisms and functions of the major electrolytes are summarized in Table 52–3.

SODIUM Sodium (Na+) is the most abundant cation in ECF and a major contributor to serum osmolality. Normal serum sodium levels are 135 to 145 mEq/L. Sodium functions largely in controlling and regulating water balance. When sodium is reabsorbed from the kidney tubules, chloride and water are reabsorbed with it, thus maintaining ECF volume. Sodium is found in many foods, and found in high levels in foods such as bacon, ham, processed cheese, and table salt. POTASSIUM Potassium (K+) is the major cation in ICF, with only a small amount found in the ECF. ICF levels of potassium are usually 125 to 140  mEq/L, while normal serum potassium levels are 3.5 to 5.0 mEq/L. The ratio of intracellular to extracellular potassium must be maintained for neuromuscular response to stimuli. Potassium is a

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vital electrolyte for skeletal, cardiac, and smooth muscle activity. It is also involved in maintaining acid–base balance, and it contributes to intracellular enzyme reactions. Potassium must be ingested daily because the body cannot conserve it. Many fruits and vegetables, meat, fish, and other foods contain potassium (Box 52–1).

CALCIUM The vast majority (99%) of calcium (Ca2+) in the body is stored in the skeletal system, with a relatively small amount in extracellular fluid. Although the calcium outside the bones and teeth amounts to only about 1% of the total calcium in the body, it is vital in regulating neuromuscular function, including muscle contraction and relaxation, as well as cardiac function. ECF calcium is regulated by a complex interaction of parathyroid hormone, calcitonin (a hormone produced by the thyroid), and calcitriol (a metabolite of vitamin D). When calcium levels in the ECF fall, parathyroid hormone and calcitriol cause calcium to be released from bones into ECF and increase the absorption of calcium in the intestines, thus raising serum calcium levels.

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TABLE 52–3   Regulation and Functions of Electrolytes Electrolyte

Regulation Renal reabsorption or excretion Aldosterone increases Na+ reabsorption in collecting duct of nephrons

Function Regulating ECF volume and distribution Maintaining blood volume Transmitting nerve impulses and contracting muscles

Sodium (Na+)

• •

Potassium (K+)

• • • •

Renal excretion Aldosterone increases K+ excretion Movement into and out of cells Insulin helps move K+ into cells; tissue damage and acidosis shift K+ out of cells into ECF

• • •

Calcium (Ca2+)

• •

Redistribution between bones and ECF Parathyroid hormone and calcitriol increase serum Ca2+ levels; calcitonin decreases serum levels

• • • • •

Forming bones and teeth Transmitting nerve impulses Regulating muscle contractions Maintaining cardiac pacemaker (automaticity) Blood clotting

Magnesium (Mg2+)

• •

Conservation and excretion by kidneys Intestinal absorption increased by vitamin D and parathyroid hormone

• • • • •

Intracellular metabolism Operating sodium-potassium pump Relaxing muscle contractions Transmitting nerve impulses Regulating cardiac function

Chloride (Cl−)

•

Excreted and reabsorbed along with sodium in the kidneys • Aldosterone increases chloride reabsorption with sodium

• • • •

HCl production Regulating ECF balance and vascular volume Regulating acid–base balance Buffer in oxygen–carbon dioxide exchange in RBCs

Phosphate (PO43–)

•

Excretion and reabsorption along with sodium in the kidneys • Parathyroid hormone decreases serum levels by increasing renal excretion • Reciprocal relationship with calcium: increasing serum calcium decreases phosphate levels; ­decreasing serum calcium increases phosphate

• • • • • •

Forming bones and teeth Metabolizing carbohydrate, protein, and fat Cellular metabolism; producing ATP and DNA Muscle, nerve, and RBC function Regulating acid–base balance Regulating calcium levels

Bicarbonate (HCO3−)

• •

•

Major body buffer involved in acid–base regulation

Excretion and reabsorption by the kidneys Regeneration by kidneys

BOX 52–1  Potassium-Rich Foods VEGETABLES Avocado Raw carrot Baked potato Raw tomato Spinach

FRUITS Dried fruits (e.g., raisins and dates) Banana Apricot Cantaloupe Orange

MEATS AND FISH Beef Cod Pork Veal

BEVERAGES Milk Orange juice Apricot nectar

Conversely, calcitonin stimulates the deposition of calcium in bone, reducing the concentration of calcium ions in the blood. With increasing age, the intestines absorb calcium less effectively, and more calcium is excreted by the kidneys. Calcium shifts out of the bone to replace these ECF losses, increasing the risk of osteoporosis and fractures of the wrists, vertebrae, and hips. Lack of weight-bearing exercise (which helps keep calcium in the bones) and a vitamin D deficiency contribute to this risk, as do genetics and lifestyle factors. Milk and milk products are the richest sources

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• • •

Maintaining ICF osmolality Transmitting nerve and other electrical impulses Regulating cardiac impulse transmission and muscle contraction • Skeletal and smooth muscle function • Regulating acid–base balance

of calcium, with other foods such as dark green leafy vegetables and canned salmon containing smaller amounts. Many clients benefit from calcium supplements. Serum calcium levels are often reported in two ways, based on the way it is circulating in the plasma. Approximately 50% of serum calcium circulates in a free, or unbound, form. The other 50% circulates bound to either plasma proteins or other nonprotein ions. The total serum calcium level (normal range: 8.5 to 10.5 mg/dL) represents both bound and unbound calcium. The ionized serum calcium level (normal range: 4.0 to 5.0 mg/dL) represents free, or unbound, calcium.

MAGNESIUM Magnesium (Mg2+) is found primarily in the skeleton and ICF, where it is the second most abundant intracellular cation. It is important for intracellular metabolism, particularly in the production and use of ATP. Magnesium also is necessary for protein and DNA synthesis within the cells. Only about 1% of the body’s magnesium is in ECF, and it has a normal serum level of 1.5 to 2.5 mEq/L. In ECF it is involved in regulating neuromuscular and cardiac function. Maintaining and ensuring adequate magnesium levels is an important part of the care of clients with cardiac disorders. Cereal grains, nuts, dried fruit, legumes, and green leafy vegetables are good sources of magnesium in the diet, as are dairy products, meat, and fish.

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CHLORIDE Chloride (Cl−) is the major anion of ECF, and normal serum levels are 95 to 108 mEq/L. Chloride functions with sodium to regulate serum osmolality and blood volume. The concentration of chloride in ECF is regulated secondarily to sodium; when sodium is reabsorbed in the kidney, chloride usually follows. Chloride is a major component of gastric juice as hydrochloric acid (HCl) and is involved in regulating acid–base balance. It also acts as a buffer in the exchange of oxygen and carbon dioxide in RBCs. Chloride is found in the same foods as sodium. PHOSPHATE Phosphate (PO43–) is the major anion of ICF. It also is found in ECF, bone, skeletal muscle, and nerve tissue. Normal serum levels of phospate in adults range from 2.5 to 4.5 mg/dL. Children have much higher phosphate levels than adults, with that of a newborn nearly twice that of an adult. Higher levels of growth hormone and a faster rate of skeletal growth probably account for this difference. Phosphate is involved in many chemical actions of cells, and is essential for functioning of muscles, nerves, and red blood cells. It is also involved in the metabolism of protein, fat, and carbohydrate. Phosphate is absorbed from the intestine and is found in many foods such as meat, fish, poultry, milk products, and legumes. BICARBONATE Bicarbonate (HCO3−) is present in both ICF and ECF. Its primary function is regulating acid–base balance as an essential component of the body’s buffering system. The kidneys regulate extracellular bicarbonate levels. Bicarbonate is excreted when too much is present; if more is needed, the kidneys both regenerate and reabsorb bicarbonate ions. Unlike electrolytes that must be consumed in the diet, adequate amounts of bicarbonate are produced through metabolic processes.

ACID–BASE BALANCE

An important part of regulating the homeostasis of body fluids is regulating their acidity and alkalinity. An acid is a substance that releases hydrogen ions (H+) in solution. Strong acids such as hydrochloric acid release all or nearly all their hydrogen ions; weak acids like carbonic acid release some hydrogen ions. Bases, or alkalis, have a low hydrogen ion concentration and can accept hydrogen ions in solution. The relative acidity or alkalinity of a solution is measured by its pH, which is an inverse reflection of the hydrogen ion concentration of the solution. The higher the hydrogen ion concentration, the lower the pH; the lower the hydrogen ion concentration, the higher the pH. Water has a pH of 7 and is neutral. Solutions with a pH lower than 7 are acidic; those with a pH higher than 7 are alkaline. The pH scale is logarithmic; a solution with a pH of 5 is 10 times more acidic than one with a pH of 6.

pH 6.8 Death

7.35

7.45

Acidosis

Normal

7.8 Alkalosis

Death

pH scale 1 Acidic solution (high H+)

7 Neutral

14 Alkaline solution (low H+)

Figure 52–8  •  Body fluids are normally slightly alkaline, between a pH of 7.35 and 7.45.

BUFFERS Buffers prevent excessive changes in pH by binding with or releasing hydrogen ions. If body fluids become too acidic, meaning excess hydrogen ions are present in body fluids, buffers bind with the hydrogen ions. If body fluids become too alkaline, meaning not enough hydrogen ions are present in body fluids, buffers can release hydrogen ions. The action of a buffer is immediate, but limited in its capacity to maintain or restore normal acid–base balance. The major buffer in ECF is the bicarbonate (HCO3−) and carbonic acid (H2CO3) system. The amounts of bicarbonate and carbonic acid in the body vary; however, as long as a ratio of 20 parts of bicarbonate to 1 part of carbonic acid is maintained, the pH remains within its normal range of 7.35 to 7.45 (Figure 52–9 •). However, adding a strong acid to ECF can change this ratio because bicarbonate is depleted in neutralizing the acid. When this happens, the pH drops, and the client has a condition called acidosis. The ratio can also be upset by adding a strong base to ECF, depleting carbonic acid as it combines with the base. In this case the pH rises and the client has alkalosis. In addition to the bicarbonate–carbonic acid buffer system, plasma proteins, hemoglobin, and phosphates also function as buffers in body fluids. RESPIRATORY REGULATION The lungs help regulate acid–base balance by eliminating or retaining carbon dioxide (CO2). When combined with water, carbon dioxide forms carbonic acid (CO2 + H2O = H2CO3). This chemical reaction is reversible; carbonic acid breaks down into carbon dioxide and water. The lungs help regulate acid–base balance by altering the rate 1 part carbonic acid or 1.2 mEq/L

20 parts bicarbonate or 24 mEq/L

Regulation of Acid–Base Balance

Body fluids are normally maintained within a narrow range that is slightly alkaline. The normal pH of arterial blood is between 7.35 and 7.45 (Figure 52–8 •). Acids are continually produced during metabolism. Several body systems, including the respiratory and renal systems, and buffers are actively involved in maintaining the narrow pH range necessary for optimal functioning. Buffers help maintain acid–base balance by neutralizing excess acids or bases. The lungs and the kidneys help maintain a normal pH by either excreting or retaining acids and bases as needed.

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Death 6.8

Figure

Acidosis

Normal 7.35

Alkalosis 7.45

Death

7.8

52–9  •  Carbonic acid–bicarbonate ratio and pH.

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and depth of respirations. The response of the respiratory system to changes in pH is rapid, occurring within minutes. Carbon dioxide is a powerful stimulator of the respiratory center in the brain. When blood levels of carbonic acid and carbon dioxide rise, the respiratory center is stimulated and the rate and depth of respiration increase. This causes an increased amount of carbon dioxide to be exhaled, and carbonic acid levels fall. By contrast, when blood levels of carbonic acid and carbon dioxide fall, the rate and depth of respiration decrease. This causes an increased level of carbon dioxide to be retained, and carbonic acid levels rise. Carbon dioxide levels in the blood are measured as PCO2, the partial pressure of the dissolved CO2 in venous blood, and PaCO2, the partial pressure of the dissolved CO2 in arterial blood. Normal PaCO2 is 35 to 45 mmHg.

RENAL REGULATION Although buffers and the respiratory system can compensate for changes in pH, the kidneys are the ultimate long-term regulator of acid–base balance. They are slower to respond to changes, requiring hours to days to correct imbalances, but their response is more permanent and selective than that of the other systems. The kidneys maintain acid–base balance by selectively excreting or conserving bicarbonate and hydrogen ions. When excess hydrogen ions are present and pH falls (acidosis), the kidneys reabsorb and regenerate bicarbonate and excrete hydrogen ions. When insufficient hydrogen ions are present and pH rises (alkalosis), excess bicarbonate is excreted and hydrogen ions are retained. The normal serum bicarbonate level is 22 to 26 mEq/L. The relationship between respiratory and renal regulation of acid–base balance is further explained in Box 52–2.

FACTORS AFFECTING BODY FLUID, ELECTROLYTES, AND ACID–BASE BALANCE

The ability of the body to adjust fluids, electrolytes, and acid–base balance is influenced by age, sex and body size, environmental temperature, and lifestyle.

BOX 52–2

1343

Physiological Regulation of Acid–Base Balance

Lungs CO2 + H2O Carbon dioxide + Water

Kidneys ↔

H2CO3

↔

Carbonic acid

H + HCO3 Hydrogen + bicarbonate

The lungs and kidneys are the two major systems that work on a continuous basis to help regulate the acid–base balance in the body. In the biochemical reactions above, the processes are all reversible and go back and forth as the body’s needs change. The lungs can work very quickly and do their part by either retaining or getting rid of carbon dioxide by changing the rate and depth of respirations. The kidneys work much more slowly; they may take hours to days to regulate the balance by either excreting or conserving hydrogen and bicarbonate ions. Under normal conditions, the two systems work together to maintain homeostasis.

Age

Infants and growing children have much greater fluid turnover than adults because their higher metabolic rate increases fluid loss. Infants lose more fluid through the kidneys because immature kidneys are less able to conserve water than adult kidneys. In addition, infants’ respiratory rate is much higher than that of adults, and their body surface area is proportionately greater than that of adults, both of which increases insensible fluid losses. This higher turnover of fluid, combined with the losses produced by disease, can create critical fluid imbalances in children much more rapidly than in adults. In older people, the normal aging process may affect fluid balance. The thirst response is often diminished. Antidiuretic hormone levels remain normal or may even be elevated, but the nephrons become less able to conserve water in response to ADH. Higher levels of atrial natriuretic factor in older adults may also contribute to this impaired ability to conserve water. These normal changes of aging increase the risk of dehydration. When combined with the increased

LIFESPAN CONSIDERATIONS Fluid and Electrolyte Imbalance INFANTS AND CHILDREN Infants are at high risk for fluid and electrolyte imbalance because: • Their immature kidneys cannot concentrate urine. • They have a rapid respiratory rate and proportionately larger body surface area than adults, leading to greater insensible losses through the skin and respirations. • They cannot express thirst, nor actively seek fluids. Vomiting and/or diarrhea in infants and young children can lead quickly to electrolyte imbalance. Oral rehydration therapy (ORT) with electrolyte solutions such as Pedialyte should be used to restore fluid and electrolyte balance in mild to moderate dehydration. Prompt treatment with ORT can prevent the need for IV therapy and hospitalization. Even if the child is vomiting, small sips of an ORT solution can be helpful. OLDER ADULTS Older adults are at high risk for fluid and electrolyte imbalance ­because of decreases in: • Thirst sensation • Ability of the kidneys to concentrate urine • Intracellular fluid and total body water

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Response to body hormones that help regulate fluid and electrolytes. Other factors that may influence fluid and electrolyte balance in older adults are: • Use of diuretics for hypertension and heart disease • Decreased intake of food and water, especially in older adults with dementia or who are dependent on others to feed them and offer them fluids • Preparations for diagnostic tests that include being NPO for long periods of time, laxatives, or contrast dyes • Impaired renal function, for example, in older adults with diabetes. All of these conditions increase older adults’ risk for fluid and electrolyte imbalance, particularly under conditions that tax the normal compensatory mechanisms, such as a fever, influenza, surgery, or heat exposure. The change can happen quickly and become serious in a short time. Astute observations and quick actions by the nurse can help prevent serious consequences. A change in mental status may be the first symptom of impairment and must be further evaluated to determine the cause. •

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likelihood of heart diseases, impaired renal function, and multiple drug regimens, the older adult’s risk for fluid and electrolyte imbalance is significant.

Sex and Body Size

Total body water also is affected by sex and body size. Fat cells contain little or no water, but lean muscle tissue has a high water content; therefore, people with a higher percentage of body fat have less body water than people with a higher percentage of lean muscle. Women generally have proportionately more body fat and, therefore, less body water than men. Water accounts for approximately 60% of an adult man’s weight, but approximately 52% of an adult woman’s weight. In someone who is obese this percentage may be even lower, with water accounting for only 30% to 40% of the person’s weight.

Environmental Temperature

People with an illness and those participating in strenuous activity are at increased risk for fluid and electrolyte imbalances when the environmental temperature is high. Fluid losses through sweating are increased in hot environments as the body attempts to dissipate heat. These losses are even greater in people who are not accustomed to a hot environment. Both electrolytes and water are lost through sweating. When only water is replaced, electrolyte depletion is a risk. A person who is electrolyte depleted may experience fatigue, weakness, headache, and gastrointestinal symptoms such as anorexia and nausea. The risk of adverse effects is even greater if lost water is not replaced. Body temperature rises, and the person is at risk for heat exhaustion or heatstroke; this happens when a person’s heat production exceeds the body’s ability to dissipate heat. Consuming adequate amounts of cool liquids, particularly during strenuous activity, reduces the risk of adverse effects from heat. Balanced electrolyte solutions and carbohydrate-electrolyte solutions such as sports drinks are recommended because they replace both water and electrolytes lost through perspiration.

Lifestyle

Lifestyle factors such as diet, exercise, stress, and alcohol consumption affect fluid, electrolyte, and acid–base balance. Intake of fluids and electrolytes is affected by diet. People with anorexia nervosa or bulimia are at risk for severe fluid and electrolyte imbalances because of inadequate intake or purging regimens (e.g., induced vomiting, use of diuretics and laxatives). Seriously malnourished people have decreased serum protein levels, and may develop edema because serum osmotic pressure is reduced. When calorie intake is not adequate to meet the body’s needs, fat stores are broken down and fatty acids are released, increasing the risk of acidosis. Regular weight-bearing exercise such as walking or running has a beneficial effect on calcium balance. The rate of bone loss that occurs in postmenopausal women and older men is slowed with weight-bearing exercise, reducing the risk of osteoporosis. Stress can increase cellular metabolism, blood glucose concentration, and catecholamine levels. In addition, stress can increase production of ADH and stimulate the renin-angiotensin-­aldosterone system, both of which decrease urine production. The overall response of the body to stress is to increase blood volume. Heavy alcohol consumption increases the risk of low calcium, magnesium, and phosphate levels. People who drink large amounts of alcohol are also at risk for acidosis associated with breakdown of fat tissue.

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DISTURBANCES IN FLUID VOLUME, ELECTROLYTE, AND ACID–BASE BALANCES

A number of factors such as illness, trauma, surgery, and medications can affect the body’s ability to maintain fluid, electrolyte, and acid– base balance. The kidneys play a major role in maintaining fluid, electrolyte, and acid–base balances, and renal disease is a significant cause of imbalances. In addition, decreased blood flow to the kidneys due to cardiovascular disease stimulates the renin-angiotensin-­aldosterone system, causing sodium and water retention. Diseases such as diabetes mellitus, cancer, and chronic obstructive lung disease may affect acid–base balance. Clients who are confused or unable to communicate their needs are at risk for inadequate fluid intake. Vomiting, diarrhea, or nasogastric suction can cause significant fluid losses. Tissue trauma, such as burns, causes fluid and electrolytes to be lost from damaged cells. Medications such as diuretics or corticosteroids can result in abnormal losses of electrolytes and fluid loss or retention.

Fluid Imbalances

Fluid imbalances are of two basic types: isotonic and osmolar. Isotonic imbalances occur when water and electrolytes are lost or gained in equal proportions, so that the osmolality of body fluids remains constant. Osmolar imbalances involve the loss or gain of only water, so that the osmolality of the serum is altered. Thus, four categories of fluid imbalances may occur: (1) an isotonic loss of water and electrolytes, (2) an isotonic gain of water and electrolytes, (3) a hyperosmolar loss of only water, and (4) a hypo-osmolar gain of only water. These are referred to, respectively, as fluid volume deficit, fluid volume excess, dehydration (hyperosmolar imbalance), and overhydration (hypo-osmolar imbalance).

FLUID VOLUME DEFICIT Isotonic fluid volume deficit (FVD) occurs when the body loses both water and electrolytes from the ECF in similar proportions. Thus, the decreased volume of fluid remains isotonic. In FVD, fluid is initially lost from the intravascular compartment, so it often is called hypovolemia. FVD generally occurs as a result of (a) abnormal losses through the skin, gastrointestinal tract, or kidney; (b) decreased intake of fluid; (c) bleeding; or (d) movement of fluid into a third space. See the section on third space syndrome that follows. For the risk factors and clinical signs related to fluid volume deficit, see Table 52–4. THIRD SPACE SYNDROME  In third space syndrome, fluid shifts from the vascular space into an area where it is not readily accessible as extracellular fluid. This fluid remains in the body but is essentially unavailable for use, causing an isotonic fluid volume deficit. Fluid may be isolated in the bowel, in injured tissue (e.g., severe burns), or in potential spaces such as the peritoneal or pleural cavities. Third spacing has two distinct phases: loss and reabsorption. The client with third space syndrome during the loss phase has an isotonic fluid deficit. During the reabsorption phase, tissues begin to heal and fluid moves back into the intravascular space. Careful nursing assessment is vital to effectively identify and intervene for clients experiencing third spacing. Because fluid shifts from the vascular compartment (loss phase) and then back into the vascular compartment after time (reabsorption phase), assessment for manifestations of fluid volume deficit and excess is vital.

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TABLE 52–4   Isotonic Fluid Volume Deficit Risk Factors Loss of water and electrolytes from: • Vomiting • Diarrhea • Excessive sweating • Polyuria • Fever • Nasogastric suction • Abnormal drainage or wound losses Insufficient intake due to: • Anorexia • Nausea • Inability to access fluids • Impaired swallowing • Confusion, depression

Clinical Manifestations Complaints of weakness and thirst Weight loss: • 2% loss = mild FVD • 5% loss = moderate • 8% loss = severe Fluid intake less than output Decreased tissue turgor Dry mucous membranes, sunken eyeballs, decreased tearing Subnormal temperature Weak pulse; tachycardia Decreased blood pressure Postural (orthostatic) hypotension (significant drop in BP when moving from lying to sitting or standing position) Decreased capillary refill Decreased central venous pressure Decreased urine volume (1.030) Increased hematocrit Increased blood urea nitrogen (BUN)

FLUID VOLUME EXCESS Fluid volume excess (FVE) occurs when the body retains both water and sodium in similar proportions to normal ECF. This is commonly referred to as hypervolemia (increased blood volume). FVE is always secondary to an increase in the total body sodium content, which leads to an increase in total body water. Because both water and sodium are retained, the serum sodium concentration remains essentially normal and the excess volume of fluid is isotonic. ­Specific causes of FVE include (a) excessive intake of sodium chloride; (b) administering sodium-containing infusions too rapidly, particularly to clients with impaired regulatory mechanisms; and (c) disease processes that alter regulatory mechanisms, such as heart failure, renal failure, cirrhosis of the liver, and Cushing’s syndrome. The risk factors and clinical manifestations for FVE are summarized in Table 52–5. EDEMA  In fluid volume excess, both intravascular and interstitial

spaces have an increased water and sodium content. Excess interstitial fluid is known as edema. Edema typically is most apparent in areas

Nursing Interventions Assess for clinical manifestations of FVD. Monitor weight and vital signs, including temperature. Assess tissue turgor. Monitor fluid intake and output. Monitor laboratory findings. Administer oral and IV fluids as indicated. Provide frequent mouth care. Implement measures to prevent skin breakdown. Provide for safety (e.g., provide assistance for a client rising from bed or chair).

where the tissue pressure is low, such as around the eyes, and in dependent tissues (known as dependent edema), where hydrostatic capillary pressure is high. Edema can be caused by several different mechanisms. The three main mechanisms are increased capillary hydrostatic pressure, decreased serum osmotic pressure, and increased capillary permeability. FVE increases capillary hydrostatic pressure, pushing fluid into the interstitial tissues. This type of edema is often seen in dependent tissues such as the feet, ankles, and sacrum because of the effects of gravity. Low levels of plasma proteins from malnutrition or liver or kidney diseases can reduce serum osmotic pressure, so that fluid cannot be held in the capillaries. This allows fluid to leak into interstitial spaces, causing edema. With tissue trauma and some disorders such as allergic reactions, capillaries become more permeable, allowing fluid to escape into interstitial tissues. Obstructed lymph flow also impairs the movement of fluid from interstitial tissues back into the vascular compartment, resulting in edema. Pitting edema is edema that leaves a small depression or pit after finger pressure is applied to the swollen area. The pit is caused by

TABLE 52–5   Isotonic Fluid Volume Excess Risk Factors Excess intake of sodium-containing IV fluids Excess ingestion of sodium in diet or medications (e.g., sodium bicarbonate antacids such as Alka-Seltzer or hypertonic enema solutions such as Fleet’s) Impaired fluid balance regulation related to: • Heart failure • Renal failure • Cirrhosis of the liver

Clinical Manifestations Weight gain: • 2% gain = mild FVE • 5% gain = moderate • 8% gain = severe Fluid intake greater than output Full, bounding pulse; tachycardia Increased blood pressure and central ­­venous pressure Distended neck veins Moist crackles (rales) in lungs; dyspnea, shortness of breath Mental confusion

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Nursing Interventions Assess for clinical manifestations of FVE. Monitor weight and vital signs. Assess for edema. Assess breath sounds. Monitor fluid intake and output. Monitor laboratory findings. Place in Fowler’s position. Administer diuretics as ordered. Restrict fluid intake as indicated. Restrict dietary sodium as ordered. Implement measures to prevent skin breakdown.

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2mm

1+ Barely detectable 4mm 2+ 2 to 4 mm 6mm 3+ 5 to 7 mm

12mm A

4+ More than 7 mm

B

Figure 52–10  •  Evaluation of edema. A, Palpate for edema over the tibia as shown here and behind the medial malleolus, and over the dorsum of each foot. B, Four-point scale for grading edema.

movement of fluid to adjacent tissue, away from the point of pressure (Figure 52–10 •). Within 10 to 30 seconds the pit normally disappears as fluid returns to the area.

DEHYDRATION Dehydration, or a hyperosmolar fluid imbalance, occurs when water is lost from the body, leaving the client with excess sodium. Because water is lost while electrolytes, particularly sodium, are retained, serum osmolality and serum sodium levels increase. Water is drawn into the vascular compartment from the interstitial space and cells, resulting in cellular dehydration. Older adults are at particular risk for dehydration because of decreased thirst sensation. Dehydration can also affect clients who are hyperventilating, have a prolonged fever, are in diabetic ketoacidosis, or are receiving enteral feedings with insufficient water intake. OVERHYDRATION Overhydration, or a hypo-osmolar fluid imbalance, occurs when water is gained in excess of electrolytes, resulting in low serum osmolality and low serum sodium levels. Water is drawn into the cells, causing them to swell. In the brain, this can lead to cerebral edema and impaired neurologic function. Overhydration, sometimes called water intoxication, often occurs when both fluid and electrolytes are lost, for example, through excessive sweating, but only water is replaced. It can also result from the syndrome of inappropriate antidiuretic hormone (SIADH), a disorder that can occur with some malignant tumors, AIDS, head injury, or administration of certain drugs such as barbiturates or anesthetics.

SODIUM Sodium (Na+), the most abundant cation in the extracellular fluid, not only moves into and out of the body but also moves in careful balance among the three fluid compartments. It is found in most body secretions, for example, saliva, gastric and intestinal secretions, bile, and pancreatic fluid. Therefore, continuous or excessive excretion of any of these fluids can result in a sodium deficit. Because of its role in regulating water balance, sodium imbalances usually are accompanied by water imbalances. Hyponatremia is a sodium deficit, or serum sodium level of less than 135 mEq/L, and is, in acute care settings, a common electrolyte imbalance. Because of sodium’s role in determining the osmolality of ECF, hyponatremia typically results in a low serum osmolality. Water is drawn out of the vascular compartment into interstitial ­tissues and the cells (Figure 52–11 A •), causing the clinical manifestations associated with this disorder. As sodium levels decrease, the brain and nervous system are affected by cellular edema. Severe hyponatremia, serum levels below 115 mEq/L, is a medical emergency and can lead to increasing intracranial pressure and coma (Crawford & Harris, 2011). Hypernatremia is excess sodium in ECF, or a serum sodium of greater than 145 mEq/L. Because the osmotic pressure of Cell swells as water is pulled in from ECF

Cell shrinks as water is pulled out into ECF

H2O H2O

H2O

H2O

Electrolyte Imbalances

The most common and clinically significant electrolyte imbalances involve sodium, potassium, calcium, magnesium, chloride, and phosphate.

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A

Hyponatremia: Na+less than 135 mEq/L

B

Hypernatremia: Na+greater than 145 mEq/L

Figure 52–11  •  The extracellular sodium level affects cell size. A, In hyponatremia, cells swell; B, in hypernatremia, cells shrink in size.

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DRUG CAPSULE

Diuretic Agent  furosemide (Lasix) THE CLIENT WITH FLUID VOLUME EXCESS Furosemide, which is a loop diuretic, inhibits sodium and chloride reabsorption in the loop of Henle and the distal renal tubule. This results in significant diuresis, with renal excretion of water, sodium chloride, potassium, magnesium, hydrogen, and calcium. Furosemide is commonly used for the clinical management of edema secondary to heart failure, treatment of hypertension, and treatment of hepatic or renal disease. Therapeutic effects include diuresis and lowering of blood pressure. NURSING RESPONSIBILITIES • Assess the client’s fluid status regularly. Assessment should include daily weight, close monitoring of intake and output, vital signs, skin turgor, edema, lung sounds, and mucous membranes. • Monitor the client’s potassium levels. Furosemide is a loop diuretic, which excretes potassium and may result in hypokalemia. • Administer in the morning to avoid increased urination during hours of sleep. • If the client is also taking digitalis glycosides, he or she should be assessed for anorexia, nausea, vomiting, muscle cramps,

extracellular fluid is increased, fluid moves out of the cells into the ECF (Figure 52–11 B). As a result, the cells become dehydrated. Like hyponatremia, the primary manifestations of hypernatremia are neurologic in nature. It is important to note that normally a person’s thirst mechanism protects against hypernatremia. When an individual becomes thirsty, the body is stimulated to drink water, which helps correct the hypernatremia. Clients at highest risk for hypernatremia are those who are unable to access water, such as clients who are unconscious, clients who are unable to request fluids such as infants or older adults with dementia, or ill clients with an impaired thirst mechanism. Table 52–6 lists risk factors and clinical signs for hyponatremia and hypernatremia.

POTASSIUM Although the amount of potassium (K+) in extracellular fluid is small, it is vital to normal neuromuscular and cardiac function. Normal renal function is important for maintenance of potassium balance, because 80% of potassium is excreted by the kidneys. Potassium must be replaced daily to maintain its balance, which normally happens through food intake. Hypokalemia is a potassium deficit, defined as a serum potassium level of less than 3.5 mEq/L. Gastrointestinal losses of potassium through vomiting and gastric suction are common causes of hypokalemia, as is the use of potassium-wasting diuretics, such as thiazide or loop diuretics. Symptoms of hypokalemia are usually mild until the level drops below 3 mEq/L, unless the decrease in potassium is rapid. When the decrease is gradual, the body compensates by shifting potassium from the intracellular environment into the serum. Hyperkalemia is a potassium excess, defined as a serum potassium level greater than 5.0 mEq/L. Hyperkalemia is less common than hypokalemia, and rarely occurs in clients with normal renal function. It is, however, more dangerous than hypokalemia and can lead to cardiac arrest. As with hypokalemia, symptoms are more

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paresthesia, and confusion. The potassium-depleting effect of furosemide places the client at increased risk for digitalis toxicity. CLIENT AND FAMILY TEACHING Medication should be taken exactly as directed. If a dose is missed, take it as soon as possible; however, if a day has been missed, do not double the dose the next day. • Weigh yourself daily, and report weight gain or loss of more than 3 pounds in 1 day to your primary care provider. • Contact your primary care provider immediately if you begin to experience muscle weakness, cramps, nausea, dizziness, numbness, or tingling of the extremities. • Some form of potassium supplementation may be needed. Your primary care provider may order oral potassium supplements for you; if not, you may need to consume a diet high in potassium. • Make position changes from lying to sitting and sitting to ­standing slowly in order to minimize dizziness. •

Note: Prior to administering any medication, review all aspects in a current drug handbook or other reliable source.

severe and occur at lower levels when the increase in potassium is rapid. Table 52–6 lists risk factors and clinical signs for hypokalemia and hyperkalemia. CLINICAL ALERT! Potassium may be given intravenously for severe hypokalemia. It must always be diluted appropriately and never be given IV push. Potassium that is to be given IV should be mixed in the pharmacy and double-checked prior to administration by two nurses. The usual concentration of IV potassium is 20 to 40 mEq/L.

CALCIUM Regulating the level of calcium (Ca2+) in the body is more complex than the other major electrolytes, so calcium balance can be affected by many factors. Imbalances of this electrolyte are relatively common. Hypocalcemia is a calcium deficit, defined as a total serum calcium level of less than 8.5 mg/dL or an ionized calcium level of less than 4.5 mEq/L. Severe depletion of calcium can cause tetany with muscle spasms and paresthesias (numbness and tingling around the mouth, hands, and feet), and can lead to seizures. Two signs indicate hypocalcemia: Chvostek’s sign is a contraction of the facial muscles in response to tapping the facial nerve in front of the ear (Figure 52–12 A •); Trousseau’s sign is a carpal spasm in response to inflating a blood pressure cuff on the upper arm to 20 mmHg greater than the systolic pressure for 2 to 5 minutes (Figure 52–12 B). Clients at greatest risk for hypocalcemia are those whose parathyroid glands have been removed. This is frequently associated with thyroidectomy or other neck surgery, which can result in unintentional removal or damage to the parathyroid glands. Low serum magnesium levels (hypomagnesemia) and chronic alcoholism also increase the risk of hypocalcemia. Hypercalcemia is a calcium excess, defined as a total serum calcium level greater than 10.5 mg/dL, or an ionized calcium level of greater than 5.5 mEq/L. It most often occurs when calcium is released

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TABLE 52–6   Electrolyte Imbalances Risk Factors HYPONATREMIA Loss of Sodium • Gastrointestinal fluid loss • Sweating • Use of diuretics Gain of Water • Hypotonic tube feedings • Excessive drinking of water • Excess IV D5W (dextrose in water) administration Syndrome of Inappropriate ADH (SIADH) • Head injury • AIDS • Malignant tumors HYPERNATREMIA Loss of Water • Insensible water loss (hyperventilation or fever) • Diarrhea • Water deprivation Gain of Sodium • Parenteral administration of saline solutions • Hypertonic tube feedings without ­adequate water • Excessive use of table salt (1 tsp ­contains 2,300 mg of sodium) Conditions such as: • Diabetes insipidus • Heat stroke HYPOKALEMIA Loss of Potassium • Vomiting and gastric suction • Diarrhea • Heavy perspiration • Use of potassium-wasting drugs (e.g., diuretics) • Poor intake of potassium (as with ­debilitated clients, alcoholics, anorexia nervosa) • Hyperaldosteronism

HYPERKALEMIA Decreased Potassium Excretion • Renal failure • Hypoaldosteronism • Potassium-conserving diuretics High Potassium Intake • Excessive use of K+ containing salt substitutes • Excessive or rapid IV infusion of potassium • Potassium shift out of the tissue cells into the plasma (e.g., infections, burns, acidosis)

Clinical Manifestations

Nursing Interventions

Lethargy, confusion, apprehension Muscle twitching Abdominal cramps Anorexia, nausea, vomiting Headache Seizures, coma Laboratory findings: Serum sodium < 135 mEq/L Serum osmolality < 280 mOsm/kg

Assess clinical manifestations. Monitor fluid intake and output. Monitor laboratory data (e.g., serum sodium). Assess client closely if administering hypertonic saline solutions. Encourage food and fluid high in sodium if ­permitted (e.g., table salt, bacon, ham, ­processed cheese). Limit water intake as indicated.

Thirst Dry, sticky mucous membranes Tongue red, dry, swollen Weakness Severe hypernatremia: • Fatigue, restlessness • Decreasing level of consciousness • Disorientation • Convulsions Laboratory findings: Serum sodium > 145 mEq/L Serum osmolality > 300 mOsm/kg

Monitor fluid intake and output. Monitor behavior changes (e.g., restlessness, disorientation). Monitor laboratory findings (e.g., serum sodium). Encourage fluids as ordered. Monitor diet as ordered (e.g., restrict intake of salt and foods high in sodium).

Muscle weakness, leg cramps Fatigue, lethargy Anorexia, nausea, vomiting Decreased bowel sounds, decreased bowel motility Cardiac dysrhythmias Depressed deep-tendon reflexes Weak, irregular pulses Laboratory findings: Serum potassium < 3.5 mEq/L Arterial blood gases (ABGs) may show alkalosis T-wave flattening and ST-segment ­depression on ECG

Monitor heart rate and rhythm. Monitor clients receiving digitalis (e.g., digoxin) closely, because hypokalemia increases risk of digitalis toxicity. Administer oral potassium as ordered with food or fluid to prevent gastric irritation. Administer IV potassium solutions at a rate no faster than 10–20 mEq/h; never administer undiluted potassium intravenously. For clients receiving IV potassium, monitor for pain and ­inflammation at the injection site. Teach client about potassium-rich foods. Teach clients how to prevent excessive loss of potassium (e.g., through abuse of diuretics and laxatives).

Gastrointestinal hyperactivity, diarrhea Irritability, apathy, confusion Cardiac dysrhythmias or arrest Muscle weakness, areflexia (absence of reflexes) Decreased heart rate Irregular pulse Paresthesias and numbness in extremities Laboratory findings: Serum potassium > 5.0 mEq/L Peaked T wave, widened QRS on ECG

Closely monitor cardiac status and ECG. Administer diuretics and other medications such as glucose and insulin as ordered. Hold potassium supplements and K+ conserving diuretics. Monitor serum K+ levels carefully; a rapid drop may occur as potassium shifts into the cells. Teach clients to avoid foods high in potassium and salt substitutes.

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TABLE 52–6  Electrolyte Imbalances—continued Risk Factors HYPOCALCEMIA Surgical Removal of the Parathyroid Glands Conditions such as: • Hypoparathyroidism • Acute pancreatitis • Hyperphosphatemia • Thyroid carcinoma Inadequate Vitamin D Intake • Malabsorption • Hypomagnesemia • Alkalosis • Sepsis • Alcohol abuse

HYPERCALCEMIA • Prolonged immobilization Conditions such as • Hyperparathyroidism • Malignancy of the bone • Paget’s disease

HYPOMAGNESEMIA • Excessive loss from the gastrointestinal tract (e.g., from nasogastric suction, diarrhea, fistula drainage) • Long-term use of certain drugs (e.g., diuretics, aminoglycoside antibiotics) Conditions such as: • Chronic alcoholism • Pancreatitis • Burns

HYPERMAGNESEMIA Abnormal retention of magnesium, as in: • Renal failure • Adrenal insufficiency • Treatment with magnesium salts

Clinical Manifestations

Nursing Interventions

Numbness, tingling of the extremities and around the mouth Muscle tremors, cramps; if severe can progress to tetany and convulsions Cardiac dysrhythmias; decreased cardiac output Positive Trousseau’s and Chvostek’s signs (see Table 52–8 and Figure 52–12) Confusion, anxiety, possible psychoses Hyperactive deep-tendon reflexes Laboratory findings: Serum calcium < 8.5 mg/dL (total) or 4.5 mEq/L (ionized) Lengthened QT intervals Prolonged ST segments

Closely monitor respiratory and cardiovascular status. Take precautions to protect a confused client. Administer oral or parenteral calcium ­supplements as ordered. When administering intravenously, closely monitor cardiac status and ECG during infusion. Teach clients at high risk for osteoporosis about: • Dietary sources rich in calcium. • Recommendation for 1,000–1,500 mg of ­calcium per day. • Calcium supplements. • Regular exercise. • Estrogen replacement therapy for ­postmenopausal women.

Lethargy, weakness Depressed deep-tendon reflexes Bone pain Anorexia, nausea, vomiting Constipation Polyuria, hypercalciuria Flank pain secondary to urinary calculi Dysrhythmias, possible heart block Laboratory findings: Serum calcium > 10.5 mg/dL (total) or 5.5 mEq/L (ionized) Shortened QT intervals Shortened ST segments

Increase client movement and exercise. Encourage oral fluids as permitted to maintain a dilute urine. Teach clients to limit intake of food and fluid high in calcium. Encourage ingestion of fiber to prevent constipation. Protect a confused client; monitor for pathologic fractures in clients with long-term hypercalcemia. Encourage intake of acid–ash fluids (e.g., prune or cranberry juice) to counteract deposits of ­calcium salts in the urine.

Neuromuscular irritability with tremors Increased reflexes, tremors, convulsions Positive Chvostek’s and Trousseau’s signs (see Table 52–8 and Figure 52–12) Tachycardia, elevated blood pressure, dysrhythmias Disorientation and confusion Vertigo Anorexia, dysphagia Respiratory difficulties Laboratory findings: Serum magnesium < 1.5 mEq/L Prolonged PR intervals, widened QRS complexes, prolonged QT intervals, ­depressed ST segments, broad flattened T waves, prominent U waves

Assess clients receiving digitalis for digitalis toxicity. Hypomagnesemia increases the risk of toxicity. Take protective measures when there is a ­possibility of seizures: • Assess the client’s ability to swallow water prior to initiating oral feeding. • Initiate safety measures to prevent injury during seizure activity. • Carefully administer magnesium salts as ordered. Encourage clients to eat magnesium-rich foods if permitted (e.g., whole grains, meat, seafood, and green leafy vegetables). Refer clients to alcohol treatment programs as indicated.

Peripheral vasodilation, flushing Nausea, vomiting Muscle weakness, paralysis Hypotension, bradycardia Depressed deep-tendon reflexes Lethargy, drowsiness Respiratory depression, coma Respiratory and cardiac arrest if hypermagnesemia is severe Laboratory findings: Serum magnesium > 2.5 mEq/L Electrocardiogram showing prolonged QT interval, prolonged PR interval, ­widened QRS complexes, tall T waves

Monitor vital signs and level of consciousness when clients are at risk. If patellar reflexes are absent, notify the primary care provider. Advise clients who have renal disease to contact their primary care provider before taking over-thecounter drugs.

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A. Positive Chvostek's Sign Figure

B. Positive Trousseau's Sign

52–12  •  A, Positive Chvostek’s sign; B, positive Trousseau’s sign.

From Medical Surgical Nursing: Critical Thinking in Client Care, 5th ed., by P. Lemone, K. Burke, and G. Bauldoff, 2011, Upper Saddle River, NJ: Pearson Education, Inc. Reproduced by permission.

in excess from the bony skeleton. This is usually due to malignancy or prolonged immobilization. The risk factors and clinical manifestations related to calcium imbalances are found in Table 52–6.

MAGNESIUM Magnesium (Mg2+) imbalances are relatively common in hospitalized clients, although they may be unrecognized. Hypomagnesemia is a magnesium deficiency, defined as a serum magnesium level of less than 1.5 mEq/L. It occurs more frequently than hypermagnesemia. Chronic alcoholism is the most common cause of hypomagnesemia. Magnesium deficiency also may aggravate the manifestations of alcohol withdrawal, such as delirium tremens (DTs). Hypermagnesemia is a magnesium excess, defined as a serum magnesium level above 2.5 mEq/L, due to increased intake or decreased excretion. It is often iatrogenic, meaning caused by medical treatment; usually the cause is oversupplementation with magnesium. Table 52–6 lists risk factors and manifestations for clients with altered magnesium balance. CHLORIDE Because of the relationship between sodium ions and chloride ions (Cl−), imbalances of chloride commonly occur in conjunction with sodium imbalances. Hypochloremia is a chloride deficit, defined as a serum chloride level below 95 mEq/L, and is usually related to excess loss of chloride through the GI tract, kidneys, or sweating. Hypochloremic clients are at risk for alkalosis, and may experience muscle twitching, tremors, or tetany. Hyperchloremia is a chloride excess, defined as a serum chloride level above 108 mEq/L. Excess replacement of sodium chloride or potassium chloride is a risk factor for high serum chloride levels, as are conditions that lead to hypernatremia. The manifestations of hyperchloremia include acidosis, weakness, and lethargy, with the risk of dysrhythmias or coma.

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PHOSPHATE Phosphate (PO43–) is found in both intracellular and extracellular fluid. Most of the phosphorus (P+) in the body exists as PO43–. Phosphate is critical for cellular metabolism because it is a major component of adenosine triphosphate (ATP). Phosphate imbalances frequently are related to therapeutic interventions for other disorders. Hypophosphatemia is a phosphate deficit, defined as a serum phosphate level of less than 2.5 mg/dL. Glucose and insulin administration and total parenteral nutrition can cause phosphate to shift into the cells from extracellular fluid compartments, leading to hypophosphatemia. Alcohol withdrawal, acid–base imbalances, and the use of antacids that bind with phosphate in the GI tract are other possible causes. Manifestations of hypophosphatemia include paresthesias, muscle weakness and pain, mental changes, and possibly seizures. Hyperphosphatemia is a phosphate excess, defined as a serum phosphate level greater than 4.5 mg/dL. It occurs when phosphate shifts out of the cells into extracellular fluids (e.g., due to tissue trauma or chemotherapy), in renal failure, or when excess phosphate is administered or ingested. Infants who are fed cow’s milk are at risk for hyperphosphatemia, as are people who use phosphate-containing enemas or laxatives. Manifestations of hyperphosphatemia include numbness and tingling around the mouth and in the fingertips, muscle spasms, and tetany.

Acid–Base Imbalances

Acid–base imbalances are usually classified as respiratory or metabolic by the general or underlying cause of the disorder. Carbonic acid levels are normally regulated by the lungs through the retention or excretion of carbon dioxide, and problems lead to respiratory acidosis or alkalosis. Bicarbonate and hydrogen ion levels are regulated by the kidneys, and problems lead to metabolic acidosis or alkalosis. Healthy regulatory systems will attempt to correct acid–base imbalances, a process called compensation.

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RESPIRATORY ACIDOSIS Any condition that causes carbon dioxide retention, either due to hypoventilation or impaired lung function, causes carbonic acid levels to increase and pH to fall below 7.35, a condition known as respiratory acidosis. Serious lung diseases such as asthma and chronic obstructive pulmonary disease (COPD) are common causes of respiratory acidosis. Central nervous system depression due to anesthesia or a narcotic overdose can slow the respiratory rate enough to cause carbon dioxide retention. When respiratory acidosis occurs, the kidneys retain bicarbonate to restore the normal carbonic acid to bicarbonate ratio. The kidneys are relatively slow to respond to changes in acid–base balance, however, so this compensatory response may require hours to days to restore normal pH. RESPIRATORY ALKALOSIS When a person hyperventilates, more carbon dioxide than normal is exhaled, carbonic acid levels fall, and the pH rises to greater than 7.45. This condition is called respiratory alkalosis. Psychogenic

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or anxiety-related hyperventilation is a common cause of respiratory alkalosis. Other causes include fever and respiratory infections. In respiratory alkalosis, the kidneys will excrete bicarbonate to return pH to within the normal range. Often, however, the cause of the hyperventilation is eliminated and pH returns to normal before renal compensation occurs.

METABOLIC ACIDOSIS When bicarbonate levels are low in relation to the amount of carbonic acid in the body, pH falls and metabolic acidosis develops. This may occur because of renal failure and the inability of the kidneys to excrete hydrogen ions and produce bicarbonate. It also may occur when too much acid is produced in the body, for example, in diabetic ketoacidosis or starvation when fat tissue is broken down for energy. Metabolic acidosis stimulates the respiratory center, and the rate and depth of respirations increase. Carbon dioxide is eliminated and carbonic acid levels fall, minimizing the change in pH. This respiratory compensation occurs within minutes of the onset of the pH imbalance.

ANATOMY & PHYSIOLOGY REVIEW Gas Exchange Bronchiole Pulmonary vein

Pulmonary artery branch

CO2

O2

Alveolar wall

Gas exchange. Oxygen from the alveoli moves into the blood, binds to red blood cells, and is carried to the body. Carbon dioxide dissolved in the blood or carried by red blood cells moves into the alveoli and is exhaled by the lungs. From Medical Language, 2nd ed., by S. M. Turley, 2011, Upper Saddle River, NJ: Pearson Education, Inc. Reproduced with permission of Pearson Education, Inc., Upper Saddle River, New Jersey.

QUESTIONS 1. Hypoventilation can affect gas exchange. What are some causes of hypoventilation? 2. How does shallow breathing and hypoventilation cause PaCO2 to increase and pH to decrease? 3. ABGs that indicate an increased PaCO2 and a decreased pH reflect which acid–base imbalance?

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O2

CO2

Capillary wall Red blood cell O2 molecule CO2 molecule

Blood

4. Hyperventilation can also affect gas exchange. What are some causes of hyperventilation? 5. How does hyperventilation cause a decreased PaCO2 and increased pH? 6. ABGs that indicate a decreased PaCO2 and an increased pH reflect which acid–base imbalance? See student resource website for answers.

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METABOLIC ALKALOSIS In metabolic alkalosis, the amount of bicarbonate in the body exceeds the normal 20-to-1 ratio. Ingestion of bicarbonate of soda as an antacid is one cause of metabolic alkalosis, as is prolonged vomiting with loss of hydrochloric acid from the stomach. The respiratory center is depressed in metabolic alkalosis, and respirations slow and become shallower. Carbon dioxide is retained and carbonic acid levels increase, helping balance the excess bicarbonate.

The risk factors and manifestations for acid–base imbalances are listed in Table 52–7. ●◯●

NURSING MANAGEMENT

Assessing Assessing clients for fluid, electrolyte, and acid–base balance and imbalances is an important nursing responsibility. Components of

TABLE 52–7   Acid–Base Imbalances Risk Factors RESPIRATORY ACIDOSIS Acute lung conditions that impair alveolar gas exchange (e.g., pneumonia, acute ­pulmonary edema, aspiration of foreign body, near-drowning) Chronic lung disease (e.g., asthma, cystic fibrosis, or emphysema) Overdose of narcotics or sedatives that depress respiratory rate and depth Brain injury that affects the respiratory center Airway obstruction

RESPIRATORY ALKALOSIS Hyperventilation due to: • Extreme anxiety • Elevated body temperature • Overventilation with a mechanical ventilator • Hypoxia • Salicylate overdose Brainstem injury Fever Increased basal metabolic rate METABOLIC ACIDOSIS Conditions that increase nonvolatile acids in the blood (e.g., renal impairment, diabetes mellitus, starvation) Conditions that decrease bicarbonate (e.g., prolonged diarrhea) Excessive infusion of chloride-containing IV fluids (e.g., NaCl) Excessive ingestion of acids such as salicylates Cardiac arrest METABOLIC ALKALOSIS Excessive acid losses due to: • Vomiting • Gastric suction Excessive use of potassium-losing diuretics Excessive adrenal corticoid hormones due to: • Cushing’s syndrome • Hyperaldosteronism Excessive bicarbonate intake from: • Antacids • Parenteral NaHCO3

Clinical Manifestations

Nursing Interventions

Increased pulse and respiratory rates Headache, dizziness Confusion, decreased level of consciousness (LOC) Convulsions Warm, flushed skin Chronic: Weakness Headache Laboratory findings: Arterial blood pH < 7.35 PaCO2 > 45 mmHg HCO3− normal or slightly elevated in acute; > 26 mEq/L in chronic

Frequently assess respiratory status and lung sounds. Monitor airway and ventilation; insert artificial airway and prepare for mechanical ventilation as necessary. Administer pulmonary therapy measures such as inhalation therapy, percussion and postural drainage, bronchodilators, and antibiotics as ordered. Monitor fluid intake and output, vital signs, and arterial blood gases. Administer narcotic antagonists as indicated. Maintain adequate hydration (2–3 L of fluid per day).

Complaints of shortness of breath, chest tightness Light-headedness with circumoral paresthesias and numbness and tingling of the extremities Difficulty concentrating Tremulousness, blurred vision Laboratory findings (in uncompensated respiratory alkalosis): Arterial blood pH > 7.45 PaCO2 < 35 mmHg

Monitor vital signs and ABGs. Assist client to breathe more slowly. Help client breathe in a paper bag or apply a rebreather mask (to inhale CO2).

Kussmaul’s respirations (deep, rapid respirations) Lethargy, confusion Headache Weakness Nausea and vomiting Laboratory findings: Arterial blood pH < 7.35 Serum bicarbonate less than 22 mEq/L PaCO2 < 38 mmHg with respiratory compensation

Monitor ABG values, intake and output, and LOC. Administer IV sodium bicarbonate carefully if ordered. Treat underlying problem as ordered.

Decreased respiratory rate and depth Dizziness Circumoral paresthesias, numbness and tingling of the extremities Hypertonic muscles, tetany Laboratory findings: Arterial blood pH > 7.45 Serum bicarbonate > 26 mEq/L PaCO2 > 45 mmHg with respiratory compensation

Monitor intake and output closely. Monitor vital signs, especially respirations, and LOC. Administer ordered IV fluids carefully. Treat underlying problem.

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the assessment include (a) the nursing history, (b) physical assessment of the client, (c) clinical measurements, and (d) review of laboratory test results.

Nursing History The nursing history is particularly important for identifying clients who are at risk for fluid, electrolyte, and acid–base imbalances. A client’s current and past medical history reveals conditions such as chronic lung disease or diabetes mellitus that can disrupt normal balances. Medications prescribed to treat acute or chronic conditions (e.g., diuretic therapy for hypertension) also may place a client at risk for altered homeostasis. Functional, developmental, and socioeconomic factors must also be considered in assessing a client’s risk. Older people and very young children, clients who must depend on others to meet their nutrition and hydration needs, and people who cannot afford or do not have the means to cook food for a balanced diet (e.g., homeless people) are at greater risk for fluid and electrolyte imbalances. Common risk factors are listed in Box 52–3. When obtaining a nursing history, the nurse needs to not only recognize risk factors but also gather data about the client’s food and fluid intake, fluid output, and the presence of signs or symptoms suggestive of altered fluid and electrolyte balance. The Assessment Interview provides examples of questions to elicit information regarding fluid, electrolyte, and acid–base balance. Physical Assessment Physical assessment to evaluate a client’s fluid, electrolyte, and acid– base status focuses on the skin, the oral cavity and mucous membranes, the eyes, the cardiovascular and respiratory systems, and neurologic and muscular status. Data from this physical assessment are used to expand and verify information obtained in the nursing history. Refer to Tables 52–4 through 52–8 for possible abnormal findings related to specific imbalances.

BOX 52–3

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Common Risk Factors for Fluid, Electrolyte, and Acid–Base Imbalances

CHRONIC DISEASES AND CONDITIONS • Chronic lung disease (COPD, asthma, cystic fibrosis) • Heart failure • Kidney disease • Diabetes mellitus • Cushing’s syndrome or Addison’s disease • Cancer • Malnutrition, anorexia nervosa, bulimia • Ileostomy ACUTE CONDITIONS • Acute gastroenteritis • Bowel obstruction • Head injury or decreased level of consciousness • Trauma such as burns or crushing injuries • Surgery • Fever, draining wounds, fistulas MEDICATIONS • Diuretics • Corticosteroids • Nonsteroidal anti-inflammatory drugs TREATMENTS • Chemotherapy • IV therapy and total parenteral nutrition • Nasogastric suction • Enteral feedings • Mechanical ventilation OTHER FACTORS • Age: Very old or very young • Inability to access food and fluids independently

Clinical Measurements Three simple clinical measurements that the nurse can initiate without a primary care provider’s order are daily weights, vital signs, and fluid intake and output.

ASSESSMENT INTERVIEW  Fluid, Electrolyte, and Acid–Base Balance CURRENT AND PAST MEDICAL HISTORY • Are you currently seeing a health care provider for t­ reatment of any chronic diseases such as kidney disease, heart disease, lung disease, high blood pressure, diabetes ­mellitus, diabetes insipidus, or thyroid, parathyroid, or adrenal disorders? • Have you recently experienced any acute conditions such as gastroenteritis, severe trauma, head injury, or surgery? MEDICATIONS AND TREATMENTS • Are you currently taking any medications on a regular basis such as diuretics, steroids, potassium supplements, calcium supplements, hormones, salt substitutes, or antacids? • Have you recently undergone any treatments such as dialysis, parenteral nutrition, tube feedings, or been on a ventilator? FOOD AND FLUID INTAKE • How much and what type of fluids do you drink each day? • Describe your diet for a typical day. (Pay particular attention to the client’s intake of foods high in sodium, and of protein, whole grains, fruits, and vegetables.) • Have there been any recent changes in your food or fluid intake, for example, as a result of following a weight-loss program? • Are you on any type of restricted diet?

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Has your food or fluid intake recently been affected by changes in appetite, nausea, or other factors such as pain or difficulty breathing?

FLUID OUTPUT • Have you noticed any recent changes in the frequency or amount of urine output? • Have you recently experienced any problems with vomiting, diarrhea, or constipation? • Have you noticed any other unusual fluid losses such as excessive sweating? FLUID, ELECTROLYTE, AND ACID–BASE IMBALANCES • Have you gained or lost weight in recent weeks? • Have you recently experienced any symptoms such as excessive thirst, dry skin or mucous membranes, dark or concentrated urine, or low urine output? • Do you have problems with swelling of your hands, feet, or ankles? Do you ever have difficulty breathing, especially when lying down or at night? How many pillows do you use to sleep? • Have you recently experienced any of the following symptoms: difficulty concentrating or confusion; dizziness or feeling faint; muscle weakness, twitching, cramping, or spasm; excessive fatigue; abnormal sensations such as numbness, tingling, burning, or prickling; abdominal cramping or distention; heart palpitations?

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Daily Weights

Daily weights provide a relatively accurate assessment of a client’s fluid status. Significant changes in weight over a short time, for example, more than 2.3 kg (5 lb) in a week or more than 1 kg (2.2 lb) in 24 hours, are indicative of acute fluid changes. Each kilogram ­(2.2 lb) of weight gained or lost corresponds to 1 L of fluid gained or lost. Such fluid gains or losses indicate changes in total body fluid volume rather than in any specific compartment, such as the intravascular compartment. Rapid losses or gains of 5% to 8% of total body weight indicate moderate to severe fluid volume deficits or excesses. To obtain accurate weight measurements, the scale should be balanced before each use, and the client should be weighed (a) at the same time each day (e.g., before breakfast and after the first void), (b) wearing the same or similar clothing, and (c) on the same scale. The type of scale (i.e., standing, bed, or chair) should be documented. Regular assessment of weight is particularly important for clients in the community and extended care facilities who are at risk for

fluid imbalance. For these clients, measuring intake and output may be impractical because of lifestyle or problems with incontinence. Regular weight measurement, either daily, every other day, or weekly, provides valuable information about the client’s fluid status. Vital Signs

Changes in vital signs may indicate, or in some cases precede, fluid, electrolyte, and acid–base imbalances. For example, elevated body temperature may be a result of dehydration or a cause of increased body fluid losses. Tachycardia is an early sign of hypovolemia. Pulse volume will decrease in FVD and increase in FVE. Irregular pulse rhythms may occur with electrolyte imbalances. Changes in respiratory rate and depth may cause respiratory acid–base imbalances or indicate a compensatory mechanism in metabolic acidosis or alkalosis. Blood pressure (BP), a sensitive measure for detecting blood volume changes, may fall significantly with FVD and hypovolemia or increase with FVE. Postural, or orthostatic, hypotension may also

TABLE 52–8   Focused Physical Assessment for Fluid, Electrolyte, or Acid–Base Imbalances System Skin

Assessment Focus Color, temperature, moisture

Technique Inspection, palpation

Turgor

Gently pinch up a fold of skin over sternum for adults, on the abdomen or medial thigh for children Inspect for visible swelling around eyes, in fingers, and in lower extremities Compress the skin over the dorsum of the foot, around the ankles, over the tibia, in the sacral area

Edema

Possible Abnormal Findings Flushed, warm, very dry Moist or diaphoretic Cool and pale Poor turgor: Skin remains tented for several seconds instead of immediately returning to normal position Skin around eyes is puffy, lids appear swollen; rings are tight; shoes leave impressions on feet Depression remains (pitting): See scale for describing edema in Figure 52–10.

Mucous membranes

Color, moisture

Inspection

Mucous membranes dry, dull in appearance; tongue dry and cracked

Eyes

Firmness

Gently palpate eyeball with lid closed

Eyeball feels soft to palpation

Fontanels (infant)

Firmness, level

Inspect and gently palpate anterior fontanel

Fontanel bulging, firm Fontanel sunken, soft

Cardiovascular system

Heart rate

Auscultation, cardiac monitor

Peripheral pulses Blood pressure

Palpation Auscultation of Korotkoff’s sounds BP assessment lying and standing Palpation Inspection of jugular veins and hand veins

Tachycardia, bradycardia; irregular; dysrhythmias Weak and thready; bounding Hypotension Postural hypotension Slowed capillary refill Jugular venous distention; flat jugular veins, poor venous refill

Capillary refill Venous filling Respiratory system

Neurologic

Respiratory rate and pattern

Inspection

Increased or decreased rate and depth of respirations

Lung sounds

Auscultation

Crackles or moist rales

Level of consciousness (LOC) Orientation, cognition Motor function Reflexes Abnormal reflexes

Observation, stimulation

Decreased LOC, lethargy, stupor, or coma Disoriented, confused; difficulty concentrating Weakness, decreased motor strength Hyperactive or depressed DTRs Facial muscle twitching including eyelids and lips on side of stimulus Carpal spasm: contraction of hand and fingers on affected side

Questioning Strength testing Deep-tendon reflex (DTR) testing Chvostek’s sign: Tap over facial nerve about 2 cm anterior to tragus of ear Trousseau’s sign: Inflate a blood pressure cuff on the upper arm to 20 mmHg greater than the systolic pressure, leave in place for 2–5 min

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occur with FVD and hypovolemia. To assess for orthostatic hypotension, measure the client’s BP and pulse in a supine position. Allow the client to remain in that position for 3 to 5 minutes, leaving the blood pressure cuff on the arm. Ask the client to stand up and immediately reassess the BP and pulse. A drop of 10 to 15 mmHg in the systolic BP with a corresponding drop in diastolic pressure and an increased pulse rate (by 10 or more beats per minute) is indicative of orthostatic or postural hypotension. Fluid Intake and Output

Measurement and recording of all fluid intake and output (I&O) during a 24-hour period provides important data about a client’s fluid and electrolyte balance. Generally, I&O are measured for hospitalized clients, particularly those at increased risk for fluid and electrolyte imbalance. The unit used to measure I&O is the milliliter (mL). In household measures, 30 mL is roughly equivalent to 1 fluid ounce, 500 mL to 1 pint, and 1,000 mL to 1 quart. To measure fluid intake, nurses convert household measures such as a cup or soup bowl to metric units. Most agencies have a form for recording I&O, usually a bedside or computer record on which the nurse lists all items measured and the quantities per shift (Figure 52–13 •).

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Usually these forms provide conversion tables, since the sizes of dishes vary from agency to agency. Examples of equivalents are given in Box 52–4. Some agencies have a different form for recording the specifics of IV fluids, such as the type of solution, additives, time started, amount absorbed, and amount remaining per shift. It is important to inform clients, family members, and all caregivers that accurate measurements of the client’s fluid I&O are required, explaining why and emphasizing the need to use a bedpan, urinal, commode, or in-toilet collection device (unless a urinary drainage system is in place). Instruct the client not to put toilet tissue into the container with urine. Clients who wish to be involved in recording fluid intake measurements need to be taught how to compute the values and what foods are considered fluids. To measure fluid intake, each item of fluid consumed or administered is recorded, specifying the time and type of fluid. All of the following fluids need to be recorded: • Oral fluids: Water, milk, juice, soft drinks, coffee, tea, cream, soup,

and any other beverages. Include water taken with medications. To measure the amount of water consumed from a water pitcher, measure how much water remains in the pitcher and subtract this amount from the volume of the full pitcher.

A

Figure 52–13  •  A, A sample EHR fluid intake and output record; B, A sample 24 hour EHR summary graph. “A-B Fluid I/O Record” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.

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BOX 52–4

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Commonly Used Fluid Containers and Their Volumes

Water glass Juice glass Cup Soup bowl  Adult  Child Teapot Creamer  Large  Small Water pitcher Jell-O, custard dish Ice cream dish Paper cup  Large  Small

200 mL 120 mL 180 mL 180 mL 100 mL 240 mL 90 mL 30 mL 1,000 mL 100 mL 120 mL 200 mL 120 mL

• Ice chips: Record the fluid volume as approximately one half the

•

•

•

•

•

volume of the ice chips. For example, if the ice chips fill a cup holding 200 mL and the client consumed all of the ice chips, the ­volume consumed would be recorded as 100 mL. Foods that are or become liquid at room temperature: These include ice cream, sherbert, custard, and gelatin. Do not measure foods that are pureed, because purees are simply solid foods prepared in a different form. Tube feedings: Remember to include the volume of water used for flushes before and after medication administration, intermittent feedings, residual checks, or any other water given via a feeding tube. Parenteral fluids: The exact amount of IV fluid administered must be recorded, since some fluid containers may be overfilled. Blood transfusions are included in the total. IV medications: IV medications that are administered as an intermittent or continuous infusion must also be included (e.g., ceftazidime 1 g in 50 mL of sterile water). Most IV medications are mixed in 50 to 100 mL of solution. Catheter or tube irrigants: Fluid used to irrigate urinary catheters, nasogastric tubes, and intestinal tubes must be recorded if not immediately withdrawn as part of the irrigation.

To measure fluid output, measure the following fluids (remember to observe appropriate infection control precautions): • Urinary output: Following each voiding, pour the urine into a mea-

suring container, note the amount, and record the amount and time on the I&O form. For clients with retention catheters, empty the drainage bag into a measuring container at the end of the shift (or at prescribed times if output is to be measured more often). Note and record the amount of urine output. In intensive care areas, urine output often is measured hourly. If a client is incontinent of urine, estimate and record these outputs. For example, for an incontinent client the nurse might record “Incontinent × 3” or “Drawsheet soaked in 12-in. diameter.” A more accurate estimate of the urine output of infants and incontinent clients may be obtained by first weighing diapers or incontinence pads that are dry, and then subtracting this weight from the weight of the soiled items. Each gram of weight left after subtracting is equal to 1 mL of urine. If urine is frequently soiled with feces, the number of voidings may be recorded rather than the volume of urine.

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• Vomitus and liquid feces: The amount and type of fluid and the

time need to be specified.

• Tube drainage: This includes gastric or intestinal drainage. • Wound and fistula drainage: Drainage may be recorded by docu-

menting the type and number of dressings or linen saturated with drainage, or by measuring the exact amount of drainage collected in a vacuum drainage (e.g., Hemovac) or gravity drainage system.

Fluid I&O measurements are totaled at the end of the shift (every 8 to 12 hours), and the totals are recorded in a client’s chart. In intensive care areas, nurses may record I&O hourly. Usually the staff on the night shift totals the amounts of I&O recorded for each shift and records the 24-hour total. To determine whether fluid output is proportional to fluid intake, or whether there are any changes in a client’s fluid status, (a) compare the total 24-hour fluid output measurement with the total 24-hour fluid intake measurement and (b) compare both to previous measurements. Urinary output is normally equivalent to the amount of fluid intake; the usual range is 1,500 to 2,000 mL in 24 hours, or 40 to 80 mL in 1 hour (0.5 mL/kg per hour). Clients whose output substantially exceeds intake are at risk for fluid volume deficit, whereas clients whose intake substantially exceeds output are at risk for fluid volume excess. In assessing a client’s fluid balance it is important to consider additional factors that may affect I&O. For example, a client who is extremely diaphoretic or has rapid, deep respirations has fluid losses that cannot be measured but must still be considered in evaluating fluid status. When there is a significant discrepancy between intake and output or when fluid intake or output is inadequate (for example, a urine output of less than 30 mL/h in an adult), this information should be reported to the primary care provider.

Laboratory Tests Many laboratory studies are conducted to determine a client’s fluid, electrolyte, and acid–base status. Some of the more common tests are discussed here. Serum Electrolytes

Serum electrolyte levels are often ordered for clients admitted to the hospital as a screening test for electrolyte and acid–base imbalances. Serum electrolytes also are routinely assessed for clients at risk in the community, for example, clients who are being treated with a diuretic for hypertension or heart failure. The most commonly ordered serum tests are for sodium, potassium, chloride, magnesium, and bicarbonate ions. Normal values of commonly measured electrolytes are shown in Box 52–5. Some primary care providers use a diagram BOX 52–5    Normal Electrolyte Values for Adults* Venous Blood Sodium Potassium Chloride Calcium, total Calcium, ionized Magnesium Phosphate (phosphorus) Serum osmolality

135–145 mEq/L 3.5–5.0 mEq/L 95–108 mEq/L 4.5–5.5 mEq/L or 8.5–10.5 mg/dL 56% of total calcium (2.5 mEq/L or 4.0–5.0 mg/dL) 1.5–2.5 mEq/L or 1.6–2.5 mg/dL 1.8–2.6 mEq/L or 2.5–4.5 mg/dL 280–300 mOsm/kg water

*Normal laboratory values vary from agency to agency.

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Cl

K

CO2

BUN

CR

of the urine is relatively acidic, averaging about 6.0, but a range of 4.6 to 8.0 is considered normal. In metabolic acidosis, urine pH should decrease as the kidneys retain bicarbonate and excrete hydrogen ions; in metabolic alkalosis, the pH should increase as the kidneys retain hydrogen ions and excrete bicarbonate. Arterial Blood Gases

B. 2

2

.2

2

.

Figure 52–14  •  A, Format for a diagram of serum electrolyte results; B, example that may be seen in a primary care provider’s documentation notes.

format for keeping track of the client’s electrolytes when documenting in their progress notes (Figure 52–14 •). Complete Blood Count

A complete blood count (CBC), another basic screening test, includes information about hematocrit (Hct), which measures the percentage of the volume of whole blood that is composed of RBCs. Hematocrit is a measure of the volume of cells in relation to plasma and is, therefore, affected by changes in plasma volume; hematocrit increases with dehydration and decreases with overhydration. Normal hematocrit values are 40% to 54% in men and 37% to 47% in women.

Arterial blood gases (ABGs) are performed to evaluate a client’s acid–base balance and oxygenation. Arterial blood is used because it provides a more accurate reflection of gas exchange in the pulmonary system than venous blood. Blood gases may be drawn by laboratory technicians, respiratory therapy personnel, or nurses with specialized skills. Because a high-pressure artery is used to obtain blood, it is important to apply pressure to the puncture site for at least 5 minutes after the procedure to reduce the risk of bleeding or bruising. Six measurements are commonly used to interpret arterial blood gas tests: • pH is a measure of the relative acidity or alkalinity of the blood,

•

Osmolality

Serum osmolality is a measure of the solute concentration of blood. The particles included are sodium ions, glucose, and urea (blood urea nitrogen, or BUN). Serum osmolality can be estimated by doubling the serum sodium value, because sodium and its associated chloride ions are the major determinants of serum o­ smolality. ­Serum osmolality is used primarily to evaluate fluid balance. ­Normal values are 280 to 300 mOsm/kg. An increase in serum ­osmolality indicates a fluid volume deficit; a decrease reflects a fluid volume excess. Urine osmolality is a measure of the solute concentration of urine. The particles included are nitrogenous wastes, such as creatinine, urea, and uric acid. Normal values are 500 to 800 mOsm/kg. An increased urine osmolality indicates a fluid volume deficit; a decreased urine osmolality reflects a fluid volume excess. Urine Specific Gravity

Specific gravity is an indicator of urine concentration that correlates with urine osmolality and it can be measured quickly and easily by nursing personnel. Normal specific gravity ranges from 1.005 to 1.030 (usually 1.010 to 1.025). When urine osmolality is high, in fluid volume deficit, the specific gravity rises; when urine osmolality is low, in fluid volume excess, the specific gravity is low. Urine pH

Measurement of urine pH may be obtained by laboratory analysis or by using a dipstick on a freshly voided specimen. Because the kidneys play a critical role in regulating acid–base balance, assessment of urine pH can be useful in determining whether the kidneys are responding appropriately to acid–base imbalances. Normally the pH

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and is an inverse measure of the number of hydrogen ions in a solution. An acidic solution has more hydrogen ions, and this is reflected in a lower pH. An alkaline solution has fewer hydrogen ions, and this is reflected in a higher pH. The normal range for arterial pH is narrow, and death may ensue with pH values below 6.8 or above 7.8. PaO2 is the partial pressure of oxygen dissolved in arterial plasma, and is an indirect measure of blood oxygen content. PaO2 represents one of the two forms in which oxygen is transported in blood, and accounts for only about 3% of the oxygen content of the blood. PaCO2 is the partial pressure of carbon dioxide in arterial plasma, and is the respiratory component of acid–base determination. Because carbon dioxide is regulated by the lungs, PaCO2 is used to determine if an acid–base imbalance is respiratory in origin. HCO3− is a measure of the bicarbonate dissolved in arterial plasma, and represents the metabolic component of acid–base balance. Base excess (BE) is a calculated value of bicarbonate levels, also reflective of the metabolic component of acid–base balance. If the number is preceded by a plus sign, it represents a base excess; a BE above +2 indicates alkalosis. If the number is preceded by a minus sign, it represents a base deficit; a BE below –2 indicates acidosis. SpO2 is oxygen saturation, which represents the percentage of hemoglobin that is combined (saturated) with oxygen. SpO2 is the other form in which oxygen is transported in the blood and accounts for about 97% of the oxygen in the blood.

Normal ABG values are listed in Table 52–9 along with changes associated with common acid–base imbalances. Note that although the PaO2 and SpO2 are important for assessing respiratory status, they generally do not provide useful information for assessing acid–base balance and so are not included in this table. When evaluating ABG results to determine acid–base balance, it is important to use a systematic approach such as the one outlined in Box 52–6. Nurses need to assess each measurement individually, and then look at the interrelationships to determine what type of acid–base imbalance may be present.

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TABLE 52–9   Arterial Blood Gas Values NORMAL VALUES OF ARTERIAL BLOOD GASES* pH 7.35–7.45 PaO2

80–100 mmHg

PaCO2

35–45 mmHg

HCO3−

22–26 mEq/L

Base excess

–2 to +2 mEq/L

O2 saturation

95–98%

ARTERIAL BLOOD GAS VALUES IN COMMON ACID–BASE DISORDERS Disorder Respiratory acidosis

Respiratory alkalosis

Metabolic acidosis

Metabolic alkalosis

ABG Values pH

45 mmHg (excess CO2 and carbonic acid)

HCO3−

Normal (or >26 mEq/L with renal compensation)

pH

>7.45

PaCO2

7.45, PaCO2 < 35 mmHg), if the HCO3− is less than 22 mEq/L, the kidneys are excreting bicarbonate to minimize the alkalosis: renal compensation. c. In metabolic acidosis (pH < 7.35, HCO3− > 22 mEq/L), if the PaCO2 is less than 35 mmHg, carbon dioxide is being eliminated to minimize the acidosis: respiratory compensation. d. In metabolic alkalosis (pH > 7.45, HCO3− > 26 mEq/L), if the PaCO2 is greater than 45 mmHg, carbon dioxide is being retained to compensate for excess base: respiratory compensation. Note: If the pH is within normal range, the body has completely compensated. Complete metabolic compensation takes time to develop and is the result of a chronic condition (e.g., chronic respiratory acidosis with COPD). If the pH is not within the normal range, compensation is partial.

Clinical applications of selected diagnoses are shown in the Nursing Care Plan and the Concept Map at the end of this chapter. Fluid, electrolyte, and acid–base imbalances affect many other body areas and as a consequence may be the etiology of other nursing diagnoses, such as these: • Impaired Oral Mucous Membrane related to fluid volume deficit • Impaired Skin Integrity related to dehydration and/or edema

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Chapter 52  •  Fluid, Electrolyte, and Acid–Base Balance • Decreased Cardiac Output related to hypovolemia and/or cardiac • • • •

dysrhythmias secondary to electrolyte imbalance (K+ or Mg2+) Ineffective Tissue Perfusion related to decreased cardiac output secondary to fluid volume deficit or edema Activity Intolerance related to hypervolemia Risk for Injury related to calcium shift out of bones into extracellular fluids Acute Confusion related to electrolyte imbalance.

Planning When planning care a nurse identifies nursing interventions that will assist the client to achieve these broad goals: • Maintain or restore normal fluid balance. • Maintain or restore normal balance of electrolytes in the intracel-

lular and extracellular compartments.

• Maintain or restore gas exchange and oxygenation. • Prevent associated risks (tissue breakdown, decreased cardiac

output, confusion, other neurologic signs).

Obviously, goals will vary according to the diagnosis and defining characteristics for each individual. Appropriate preventive and corrective nursing interventions that relate to these must be identified. Specific nursing activities can be selected to meet a client’s individual needs. Examples of application of these using NANDA, NIC, and NOC designations are shown in the Nursing Care Plan and the Concept Map at the end of this chapter. Examples of NIC interventions related to fluid, electrolyte, and acid–base balance include the following: • • • • •

Acid–base management Electrolyte management Fluid monitoring Hypovolemia management Intravenous (IV) therapy.

Specific nursing activities associated with each of these interventions can be selected to meet the individual needs of the client. Nursing activities to meet goals and outcomes related to fluid, electrolyte, and acid–base imbalances are discussed in the next section. These include (a) monitoring fluid intake and output, cardiovascular and respiratory status, and results of laboratory tests; (b) assessing the

client’s weight; location and extent of edema, if present; skin turgor and skin status; specific gravity of urine; and level of consciousness and mental status; (c) fluid intake modifications; (d) dietary changes; (e) parenteral fluid, electrolyte, and blood replacement; and (f) other appropriate measures such as administering prescribed medications and oxygen, providing skin care and oral hygiene, positioning the client appropriately, and scheduling rest periods.

Planning for Home Care To provide for continuity of care, a client’s needs for assistance with care in the home need to be considered. Home care planning includes assessment of a client’s and family’s resources and abilities for care, and the need for referrals and home health services. The accompanying Home Care Assessment describes the specific assessment data required to establish a home care plan. Based on the data gathered in assessment of the home situation, the nurse tailors the teaching plan for the client and family (see Client Teaching).

Implementing Promoting Wellness Most people rarely think about their fluid, electrolyte, or acid–base balance. They know it is important to drink adequate fluids and consume a balanced diet, but they may not understand the potential effects when this is not done. Nurses can promote clients’ health by providing wellness teaching that will help them maintain fluid and electrolyte balance. Enteral Fluid and Electrolyte Replacement Fluids and electrolytes can be provided orally in the home or hospital if a client’s health permits, meaning that the client is not vomiting, has not experienced an excessive fluid loss, and has an intact gastrointestinal tract and gag and swallow reflexes. Clients who are unable to ingest solid foods may be able to ingest fluids. Fluid Intake Modifications

Increased fluids (ordered as “push fluids”) are often prescribed for clients with actual or potential fluid volume deficits arising, for example, from mild diarrhea or mild to moderate fevers. Guidelines for helping clients increase fluid intake are shown in Practice Guidelines.

Home Care Assessment  Fluid, Electrolyte, and Acid–Base Balance CLIENT • Risk factors for imbalances: the client’s age, medications such as diuretic therapy or corticosteroids, and presence of chronic diseases such as diabetes mellitus, heart disease, lung disease, or dementia (see Box 52–3 on page 1327) • Self-care abilities for maintaining food and fluid intake: mobility; ability to chew and swallow; ability to access fluids and respond to thirst, to purchase food, and prepare a balanced diet • Current level of knowledge (as appropriate): prescribed diet, any fluid restrictions, activity restrictions, actions and side ­effects of prescribed medications, regular weight monitoring, gastric tube care and enteral feedings, central line or PICC catheter care, and parenteral fluids and nutrition FAMILY • Caregiver availability, skills, and responses: availability and ­willingness to assume responsibility for care, knowledge and

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ability to provide assistance with preparing food and maintaining adequate intake of food and fluids, knowledge of risk ­factors and early warning signs of problems • Family role changes and coping: effect on financial status, ­parenting and spousal roles, social roles • Alternate potential primary or respite caregivers: other family members, friends, volunteers, church members, paid caregivers or housekeeping services; available community respite care (e.g., adult day care, senior centers) COMMUNITY • Current knowledge of and experience with community ­resources: home health agencies, organizations that offer financial assistance or assistance with food preparation, ­Meals-on-Wheels or meal services (e.g., at senior centers, homeless shelters), pharmacies, home IV services, and ­respiratory care services

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CLIENT TEACHING

Promoting Fluid and Electrolyte Balance Consume six to eight glasses of water daily. Avoid excess amounts of foods or fluids high in salt, sugar, and caffeine. • Eat a well-balanced diet. Include adequate amounts of milk, milk products, or calcium-enriched alternatives to maintain bone calcium levels. • Limit alcohol intake because it has a diuretic effect. • Increase fluid intake before, during, and after strenuous exercise, particularly when the environmental temperature is high, and replace lost electrolytes from excessive perspiration as needed with commercial electrolyte solutions. • •

Maintain normal body weight and body mass index for age and gender. • Learn about and monitor side effects of medications that affect fluid and electrolyte balance (e.g., diuretics) and ways to handle side effects. • Recognize possible risk factors for fluid and electrolyte ­imbalance such as prolonged or repeated vomiting, frequent watery stools, or inability to consume fluids because of illness. • Seek prompt professional health care for notable signs of fluid imbalance such as sudden weight gain or loss, decreased urine volume, swollen ankles, shortness of breath, dizziness, or confusion. •

CLIENT TEACHING

Home Care and Fluid, Electrolyte, and Acid–Base Balance MONITORING FLUID INTAKE AND OUTPUT • Teach and provide the rationale for monitoring fluid intake and output to the client and family as appropriate, for example, how to use a commode or collection device (“hat”) in the toilet, how to empty and measure urinary catheter drainage, or how to count or weigh diapers. • Instruct and provide the rationale for regular weight monitoring to the client and family, including weighing at the same time every day, using the same scale, and with the client wearing the same amount of clothing. • Educate and provide the rationale to the client and family on when to contact a health care professional, such as in the cases of a significant change in urine output; any change of 5 pounds or more in a 1- to 2-week period or 2 pounds or more in 24 hours; prolonged episodes of vomiting, diarrhea, or inability to eat or drink; dry, sticky mucous membranes; extreme thirst; swollen fingers, feet, ankles, or legs; difficulty breathing, shortness of breath, need for an increased number of pillows to sleep on, or rapid heartbeat; and changes in behavior or mental status. MAINTAINING FOOD AND FLUID INTAKE • Instruct the client and family about any diet or fluid restrictions, such as a low-sodium diet. • Teach family members the rationale for the importance of ­offering fluids regularly to clients who are unable to meet their own needs because of age, impaired mobility or cognition, or other conditions such as impaired swallowing due to a stroke. • If the client is on enteral or IV fluids and feeding at home, teach and provide rationales to caregivers about proper administration and care. Contact a home health or home IV service to provide services and teaching. SAFETY • Instruct and provide the rationale to the client for changing positions slowly if appropriate, especially when moving from a supine to a sitting or standing position. • Inform and provide the rationale to the client and family about the importance of good mouth and skin care. Teach the client to change positions frequently and to elevate the feet when sitting for a long period.

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Teach the client and family how to care for IV access sites or gastric tubes. Include what to do if tubes become dislodged.

MEDICATIONS • Emphasize the importance of and rationale for taking ­medications as prescribed. • Instruct clients taking diuretics to take the medication in the morning. If a second daily dose is prescribed, they should take it in the late afternoon to avoid disrupting sleep to urinate. • Inform clients about any expected side effects of prescribed medications and how to handle them (e.g., if a potassiumdepleting diuretic is prescribed, increase intake of potassiumrich foods; if taking a potassium-sparing diuretic, avoid excess potassium intake such as using a salt substitute). • Teach clients when to contact their primary care provider, for example, if they are unable to take a prescribed medication or have signs of an allergic or toxic reaction to a medication. MEASURES SPECIFIC TO CLIENT’S PROBLEM • Provide instructions and rationales specific to the client’s fluid, electrolyte, or acid–base imbalance, such as: a. Fluid volume deficit b. Risk for fluid volume deficit c. Fluid volume excess d. Risk for fluid volume excess. REFERRALS • Make appropriate referrals to home health or community social services for assistance with resources such as meals, meal preparation and food delivery, IV infusions and access, enteral feedings, and homemaker or home health aide services to help with ADLs. COMMUNITY AGENCIES AND OTHER SOURCES OF HELP • Provide information about companies or agencies that can ­provide durable medical equipment such as commodes, lift chairs, or hospital beds for purchase, rental, or free of charge. • Provide a list of sources for supplies such as catheters and drainage bags, measuring devices, tube feeding formulas, and electrolyte replacement drinks. • Suggest additional sources of information and help such as the American Dietetic Association, the American Heart Association, and the American Lung Association.

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Facilitating Fluid Intake Explain to the client the reason for the required intake and the specific amount needed. This provides a rationale for the ­requirement and promotes compliance. • Establish a 24-hour plan for ingesting the fluids. For a hospitalized or long-term care client, half of the total volume is given during the day shift, and the other half is divided between the evening and night shifts, with most of that ingested during the evening shift. For example, if 2,500 mL is to be ingested in 24 hours, the plan may specify 7–3 (1,500 mL); 3–11 (700 mL); and 11–7 (300 mL). Try to avoid the ingestion of large amounts of fluid immediately before bedtime to prevent the need to ­urinate during sleeping hours. • Set short-term outcomes that the client can realistically meet. Examples include ingesting a glass of fluid every hour while awake or a pitcher of water by lunchtime. • Identify fluids the client likes and make available a variety of those items, including fruit juices, noncaffeinated soft drinks, and milk (if allowed). Remember that beverages such as coffee, •

Restricted fluids may be necessary for clients who have fluid retention (fluid volume excess) as a result of renal failure, heart failure, SIADH, or other disease processes. Fluid restrictions vary from “nothing by mouth” to a precise amount ordered by a primary care provider. The restriction of fluids can be difficult for some clients, particularly if they are experiencing thirst. Guidelines for helping clients restrict fluid intake are shown in Practice Guidelines. Dietary Changes

Specific fluid and electrolyte imbalances may require simple dietary changes. For example, clients receiving potassium-depleting diuretics need to be informed about foods with high potassium content (e.g., bananas, oranges, and leafy greens). Some clients with fluid retention need to avoid foods high in sodium. Most healthy clients can benefit from foods rich in calcium.

•

•

•

•

•

tea, and other caffeinated beverages have a diuretic effect, so their consumption should be limited. Help the client to select foods that tend to become liquid at room temperature (e.g., gelatin, ice cream, sherbet, custard), if these are allowed. For clients who are confined to bed, supply appropriate cups, glasses, and straws to facilitate adequate fluid intake, and keep fluids within easy reach. Make sure fluids are served at the appropriate temperature (i.e., hot fluids hot and cold fluids cold) and according to client preference. Encourage clients to participate in maintaining the fluid ­intake record if possible. This assists them to evaluate the ­achievement of desired outcomes. Be alert to any cultural implications of food and fluids. Some cultures may restrict certain foods and fluids, or temperatures of foods and fluids, and view others as having healing properties.

Oral Electrolyte Supplements

Some clients can benefit from oral electrolyte supplements, particularly when a medication is prescribed that affects electrolyte balance, when dietary intake is inadequate for a specific electrolyte, or when fluid and electrolyte losses are excessive, for example, as a result of excessive perspiration. Corticosteroids and many diuretics can cause too much potassium to be eliminated through the kidneys. For clients taking these medications, potassium supplements may be prescribed. Instruct clients taking oral potassium supplements to take the medication with juice to mask the unpleasant taste and reduce the possibility of gastric distress. Emphasize the importance of taking the medication as prescribed and seeing their primary care provider on a regular basis. Because hyperkalemia can have serious cardiac effects, clients should never increase the amount of potassium being taken without

PRACTICE GUIDELINES

Helping Clients Restrict Fluid Intake Explain the reason for the restricted intake and how much and what types of fluids are permitted orally. Many clients need to be informed that ice chips, gelatin, and ice cream, for example, are considered fluid. • Help the client decide the amount of fluid to be taken with each meal, between meals, before bedtime, and with medications. For a hospitalized or long-term care client, half the total volume is usually scheduled during the day shift, when the client is most active, receives two meals, and most oral medications. A large part of the remainder is scheduled for the evening shift to permit fluids with meals and evening visitors. • Identify fluids or fluid-like substances the client likes and make sure that these are provided, unless contraindicated. A client who is allowed only 200 mL of fluid for breakfast, for example, should receive the type of fluid he or she prefers. • Set short-term goals that make the fluid restriction more tolerable. For example, schedule a specified amount of fluid at one •

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or two hourly intervals between meals. Some clients may prefer fluids only between meals if the food provided at mealtime helps relieve thirst. Place allowed fluids in small containers such as a 4-ounce juice glass to allow the perception of a full container. Periodically offer the client ice chips as an alternative to water, because ice chips are approximately half of the frozen volume after they melt. Provide frequent mouth care and rinses to reduce the thirst sensation. Instruct the client to avoid ingesting or chewing salty or sweet foods (hard candy or gum), because these foods tend to ­produce thirst. Sugarless gum or candy may be an alternative for some clients. Encourage the client to participate in maintaining the fluid intake record if possible.

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an order to do so. In addition, inform clients that most salt substitutes contain potassium, so it is important to consult with their primary care provider before using salt substitutes. People who ingest insufficient milk and milk products benefit from calcium supplements. The recommended daily allowance for calcium is 1,000 to 1,500 mg. It is generally recommended that postmenopausal women take 1,500 mg of calcium per day to reduce the risk of osteoporosis. Long-term use of corticosteroid drugs can also cause calcium loss from the bone, and calcium supplements may help reduce this loss. Clients who take supplemental calcium need to maintain a fluid intake of at least 2,500 mL/day (unless contraindicated) to reduce the risk of kidney stones, which are commonly composed of calcium salts. Although routine supplements for other electrolytes generally are not recommended, clients who have poor dietary habits, who are malnourished, or who have difficulty accessing or eating fresh fruits and vegetables may benefit from electrolyte supplements. A daily multiple vitamin with minerals may achieve the desired goal. People who engage in strenuous activity in a warm environment need to be encouraged to replace water and electrolytes lost through excessive perspiration by consuming a sports drink through available commercial fluid and electrolyte solutions. Liquid nutritional supplements are often given to clients who are malnourished or have poor eating habits. They are used with frequency in older adults to bolster nutritional status and caloric intake. It is very important that clients read product labels accurately to be aware of the contents of the supplement. Some of them are very high in protein and high in potassium, which may be contraindicated in an individual with impaired renal function.

Parenteral Fluid and Electrolyte Replacement IV fluid therapy is essential when clients are unable to take sufficient food and fluids orally. It is an efficient and effective method of supplying fluids directly into the intravascular fluid compartment and replacing electrolyte losses. The primary care provider usually orders the IV fluid therapy. The nurse is responsible for administering and maintaining the therapy and for teaching the client and significant others how to continue the therapy at home if necessary.

Intravenous Solutions

IV solutions can be classified as isotonic, hypotonic, or hypertonic. Most IV solutions are isotonic, having the same concentration of solutes as blood plasma. Isotonic solutions are often used to restore vascular volume. Hypertonic solutions have a greater concentration of solutes than plasma; hypotonic solutions have a lesser concentration of solutes. Table 52–10 provides examples of IV solutions and nursing implications. IV solutions can also be categorized according to their purpose. Nutrient solutions contain some form of carbohydrate (e.g., dextrose, glucose, or levulose) and water. Water is supplied for fluid requirements and carbohydrate for calories and energy. For example, 1 L of 5% dextrose provides 170 calories. Nutrient solutions are useful in preventing dehydration and ketosis but do not provide sufficient calories to promote wound healing, weight gain, or normal growth in children. Common nutrient solutions are 5% dextrose in water (D5W) and 5% dextrose in 0.45% sodium chloride (dextrose in halfnormal saline). Electrolyte solutions contain varying amounts of cations and anions. Commonly used solutions are normal saline (0.9% sodium chloride solution), Ringer’s solution (which contains sodium, chloride, potassium, and calcium), and lactated Ringer’s solution (which contains sodium, chloride, potassium, calcium, and lactate). Lactate is metabolized in the liver to form bicarbonate. Saline and balanced electrolyte solutions are commonly used to restore vascular volume, particularly after trauma or surgery. They also may be used to replace fluid and electrolytes for clients with continuing losses, for example, those experiencing gastric suction or wound drainage. Lactated Ringer’s solution is an alkalizing solution that may be given to treat metabolic acidosis. Acidifying solutions, in contrast, are administered to counteract metabolic alkalosis. Examples of acidifying solutions are 5% dextrose in 0.45% sodium chloride and 0.9% sodium chloride solution. Volume expanders are used to increase the blood volume following severe loss of blood (e.g., from hemorrhage) or loss of plasma (e.g., from severe burns, which draw large amounts of plasma from the bloodstream to the burn site). Examples of volume expanders are dextran, plasma, albumin, and Hespan (a synthetic plasma expander).

TABLE 52–10  Selected Intravenous Solutions Type/Examples ISOTONIC SOLUTIONS 0.9% NaCl (normal saline) Lactated Ringer’s (a balanced electrolyte solution) 5% dextrose in water (D5W)

HYPOTONIC SOLUTIONS 0.45% NaCl (half normal saline) 0.33% NaCl (one-third normal saline) HYPERTONIC SOLUTIONS 5% dextrose in normal saline (D5NS) 5% dextrose in 0.45% NaCl (D5 1/2NS) 5% dextrose in lactated Ringer’s (D5LR)

Comments/Nursing Implications Isotonic solutions such as normal saline (NS) and lactated Ringer’s initially remain in the vascular compartment, expanding vascular volume. Assess clients carefully for signs of hypervolemia such as bounding pulse and shortness of breath. D5W is isotonic on initial administration but provides free water when dextrose is metabolized, expanding intracellular and extracellular fluid volumes. D5W is avoided in clients at risk for increased intracranial pressure (IICP) because it can increase cerebral edema. Hypotonic solutions are used to provide free water and treat cellular dehydration. These solutions promote waste elimination by the kidneys. Do not administer to clients at risk for IICP or third-space fluid shift. Hypertonic solutions draw fluid out of the intracellular and interstitial compartments into the vascular compartment, expanding vascular volume. Do not administer to clients with kidney or heart disease or clients who are dehydrated. Watch for signs of hypervolemia.

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Chapter 52  •  Fluid, Electrolyte, and Acid–Base Balance Peripheral Venipuncture Sites

The site chosen for venipuncture varies with the client’s age, length of time an infusion is to run, the type of solution used, and the condition of veins. For adults, veins in the arm are commonly used; for infants, veins in the scalp and dorsal foot veins are often used. The larger veins of the adult’s forearm are preferred over the metacarpal veins of the hand for infusions that need to be given rapidly and for solutions that are hypertonic, are highly acidic or alkaline, or contain irritating medications. The loss of subcutaneous tissue, thinning of the skin, and fragile veins in the older adult can be a challenge for the nurse when performing a venipuncture. It is common practice for the initial venipuncture to be in the most distal portion of the arm because this allows for subsequent venipunctures to move upward. The veins of the hands of the older adult, however, are not the best initial sites for venipuncture because of the loss of subcutaneous tissue and thinning of the skin (Phillips & Gorski, 2014). The metacarpal, basilic, and cephalic veins are common venipuncture sites (Figure 52–15B •). The ulna and radius act as natural splints at these sites, and the client has greater freedom of arm movement for activities such as eating. Although the antecubital basilic and median cubital veins are convenient, they are usually kept for Cephalic vein Median cubital vein

Basilic vein Insertion site for PICC

Accessory cephalic vein

Basilic vein

Cephalic vein

Medial antebrachial vein A

Radial vein

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Vein Selection Use distal veins of the arm first; subsequent IV starts should be proximal to the previous site. • Use the client’s nondominant arm whenever possible. • Select a vein that is: a. Easily palpated and feels soft and full b. Naturally splinted by bone c. Large enough to allow adequate circulation around the catheter. • Avoid using veins that are: a. In areas of flexion (e.g., the antecubital fossa) b. Highly visible, because they tend to roll away from the needle c. Damaged by previous use, phlebitis, infiltration, or sclerosis d. Continually distended with blood, or knotted or tortuous e. In a surgically compromised or injured extremity (e.g., following a mastectomy), because of possible impaired circulation and discomfort for the client. •

blood draws, bolus injections of medication, and insertion sites for a peripherally inserted central catheter (PICC) line (Figure 52–15A). See Practice Guidelines for vein selection and general tips for easier IV starts. Historically, nurses used their eyes and hands to locate a suitable vein for a venipuncture. This could be especially challenging in some clients such as older adults, dark-skinned clients whose veins may not be visible, or clients who are obese, because their veins may not be visible or palpable. The Infusion Nursing Standards of Practice (Infusion Nurses Society [INS], 2011a) state that nurses should “consider using visualization technologies to aid in vein identification and selection” (p. S41). Currently transillumination devices are available that use light to allow for the location and identification of blood vessels. The client’s skin color does not affect the ability to highlight veins. One type of device is applied to the client’s skin. Focusing bright visible light onto and under the skin helps the nurse locate superficial veins. Another device is used by holding it about 18 cm (7 in.) above the skin. The veins are displayed on the surface of the skin. Intravenous Infusion Equipment

B

Basilic vein Cephalic vein Dorsal venous network Dorsal metacarpal veins

Figure 52–15  •  Commonly used venipuncture sites: A, arm; B, hand. A also shows the site used for a peripherally inserted central catheter (PICC).

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Because equipment varies according to the manufacturer, nurses must become familiar with the equipment used in each particular agency. IV equipment consists of IV catheters, catheter stabilization devices, solution containers, infusion administration sets, IV filters, and IV poles. Intravenous Catheters  The Infusion Nurses Society Standards of Practice (2011a) state that the type of IV catheter to be used depends on the client’s vascular access needs, which are based on the prescribed therapy, length of treatment, vascular integrity, client preference, and ability and resources available to care for the device (p. S37). All catheters must be radiopaque. A peripheral-short catheter is used for usually less than 1 week. It comes in a variety of gauge sizes (i.e., 14 to 27) and types (e.g., winged or nonwinged, and over-the-needle) and the tip ends in a peripheral vein (INS, 2011a). Over-the-needle catheters (ONCs), also known as angiocatheters, are commonly used for adult clients.

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General Tips for Easier IV Starts •

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Review the client’s medical history. Avoid using an arm affected by hemiplegia or with a dialysis access, on the same side as a mastectomy, or near infections, below previous infiltrations or extravasations, and veins affected by phlebitis. Dilate the vein. Ways to do this include (a) dangle the client’s arm over the side of the bed to encourage dependent vein filling, (b) ask the client to open and close his or her fist, (c) stroke the vein downward or lightly tap the vein, or (d) apply warm compresses to the site for 10 minutes. Make sure the client is positioned comfortably and has been medicated for pain if appropriate. Pain and anxiety stimulate the sympathetic nervous system and trigger vasoconstriction. Because of the risk of nerve injuries, as well as discomfort and restriction of movement, hand veins should be a last choice. If the ordered IV medication is irritating to veins and therapy is expected to last more than a few days, consult with the IV

nurse or medical team to determine whether the client is a candidate for a midline catheter, a peripherally inserted central catheter, or another type of central venous access device. • Use the smallest gauge catheter that will accommodate the therapy and allow good venous flow around the catheter tip. For routine hydration or intermittent therapy, use #22- to #27-gauge catheters; for transfusion therapy, use #20- to #24-gauge catheters; and for therapy for neonates or clients with very small, fragile veins, use #24- to #27-gauge catheters. • Raise the bed or stretcher to a comfortable working height, and keep all equipment within reach. Stabilize the client’s hand or arm with your nondominant arm, tucking it under your forearm if necessary to prevent movement. • Limit your attempts to two. If you’re not successful after two tries, ask another nurse to try.

Evidence-Based Practice Does Black Pepper Essential Oil Enhance IV Catheter Insertion? Multiple attempts to insert an IV catheter are painful for the client and time consuming for the nurse. Nurses at a mid-Atlantic suburban community teaching hospital replicated a previous small, unpublished study that used black pepper essential oil to improve vein palpability and visualization. Black pepper (Piper nigrum) has a 4,000-year history of use as a spice. Hippocrates mentioned its medicinal uses and Kristiniak, Harpel, Breckenridge, and Buckle (2012) report that the antimicrobial activity of black pepper against Staphylococcus aureus in vitro is well documented. The 3-month study used a pretest, post-test, quasi-experimental design. The study involved 120 hospitalized clients. A team of six vascular nurses (VRNs) selected the participants by determining, prior to venipuncture, that the clients had no vein visibility or palpability. The clients were assigned to treatment and control groups. Each of the six VRNs carried out standard care on 10 clients who met the inclusion criteria (i.e., no vein visibility or palpability). Standard care included the application of a hot pack and/or vigorous tactile stimulation of the vein. The next 10 clients (for each of the six VRNs) were assigned to the experimental (treatment) group. The experimental or black pepper group received 20% black pepper essential oil in a base of aloe vera gel applied topically to the site via roller ball 10 minutes prior to venipuncture. Each participant in the black pepper group was patch-tested for any skin reaction prior to

The plastic catheter fits over a needle (stylet) used to pierce the skin and vein wall (Figure 52–16 •). Once inserted into the vein, the needle (stylet) is withdrawn and discarded, leaving the catheter in place. The nurse should use peripheral-short catheters equipped with a passive or active safety mechanism to prevent sharps injury. The active safety device requires activation by the nurse, and the passive safety device automatically activates after the stylet is removed from the catheter. CLINICAL ALERT! A peripheral-short catheter placed in an emergency situation where aseptic technique has been compromised shall be replaced as soon as possible and no later than 48 hours (INS, 2011b).

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EVIDENCE-BASED PRACTICE the intervention. If no reaction occurred, the VRN continued with the study. The maximum dose of the black pepper/aloe vera gel mixture was 3 mL. A tool was used to record vein visibility and palpability before and after the intervention. The scale for vein assessment was as follows: 0 = no vein visible or palpable; 1 = vein visible or palpable; and 2 = vein visible and palpable. Other data recorded included the number of attempts to access veins prior to the VRN’s referral by the bedside nurse, and the number of attempts post-intervention by the VRN; demographic data, including age and gender; and the use of hot pack applications or tactile stimulation for the control group. The results showed that black pepper made a significant difference to vein visibility and palpation. A higher percentage of clients achieved a vein score of 2 or improved scoring (vein score of 1 or 2) to the black pepper intervention than standard nursing care. The number of IV catheter attempts following black pepper application was also half that of the control (standard nursing care) group. IMPLICATIONS The data provided statistical evidence that using black pepper essential oil improved vein visibility and palpability more than standard nursing care. Black pepper essential oil may improve vein access, thus reducing the number of IV catheter attempts, which improves client care by reducing client discomfort.

Butterfly, or wing-tipped, needles with plastic flaps attached to the shaft are sometimes used (Figure 52–17 •). The flaps are held tightly together to hold the needle securely during insertion; after insertion, they are flattened against the skin and secured with tape. The butterfly needle is most frequently used for short-term therapy (e.g., less than 24 hours) such as with single-dose therapy, IV push medications, or blood sample retrieval (Phillips & Gorski, 2014). A peripheral-midline catheter is 7.6 to 20.3 cm (3 to 8 in.) in length and inserted near the antecubital area into the basilic, cephalic, or brachial veins, with the preference being the basilica vein because of its larger diameter. The tip is advanced no farther than the distal axillary vein in the upper arm; the tip does not enter the central vasculature. Although the INS classifies the midline catheter as a peripheral catheter, the midline catheter is managed differently than the peripheral-short

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Chapter 52  •  Fluid, Electrolyte, and Acid–Base Balance Introducer needle

Translucent catheter hub

Cannula

Tapered catheter tip

Short bevel introducer needle

Preview chamber

Luer-Lok tabs

Flashback chamber

Finger guard

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Filter vent

Needle bevel position indicator

Needle heel

Figure 52–16  •  Schematic of an over-the-needle catheter.

Stem

Catheter

Cap for needle

Superior vena cava

Subclavian vein

Plastic adapter Wings

A Tubing Catheter Internal jugular vein Subclavian vein Superior vena cava

Figure 52–17  •  Schematic of a butterfly needle with adapter.

catheter. For example, an angiocatheter may stay in a vein for up to 72 hours maximum; a midline catheter can last from 1 to 4 weeks. A peripherally inserted central venous catheter (PICC) is inserted in the basilic or cephalic vein just above or below the antecubital space of the right arm. The tip of the catheter rests in the superior vena cava. These catheters frequently are used for long-term IV access when the client will be managing IV therapy at home. When long-term IV therapy or parenteral nutrition is anticipated, or a client is receiving IV medications that are damaging to vessels (e.g., chemotherapy), a central venous access device (CVAD) may be inserted. A CVAD is defined by the location of the catheter tip in a central vein. The CVAD catheter tip should reside in the lower one third of the superior vena cava, above the right atrium (Phillips & Gorski, 2014, p. 279) (Figure 52–18 •). They may be inserted at a client’s bedside or, for longer term access, surgically inserted. CVADs permit freedom of movement for ambulation; however, there is greater risk of complications, including hemothorax or pneumothorax, cardiac perforation, thrombosis, and infection. Assess the client closely for signs and symptoms such as shortness of breath, chest pain, cough, hypotension, tachycardia, and anxiety after the insertion procedure. Implanted vascular access devices (IVADs) (Figures 52–19 • and  52–20 •) are used for clients with chronic illness who require long-term IV therapy (e.g., intermittent medications such as chemotherapy, total parenteral nutrition, and frequent blood samples). This type of device is designed to provide repeated access to the central

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B

Figure 52–18  •  Central vascular access devices with A, subclavian vein insertion, and B, left jugular insertion.

venous system, avoiding the trauma and complications of multiple venipunctures. Using local anesthesia, implantable ports are surgically placed into a small subcutaneous pocket under the skin, usually on the anterior chest near the clavicle, and no part of the port is exposed. The distal end of the catheter is placed in the subclavian or jugular vein. Special precautions need to be taken with all central lines and venous access ports to ensure asepsis and catheter patency. Nursing care of clients with these devices is outlined in Practice Guidelines. SAFETY ALERT!

SAFETY

2014 THE JOINT COMMISSION NATIONAL PATIENT SAFETY GOALS (2013) Goal 7: Reduce the Risk of Health Care–Associated Infections. Goal 7.04.01: Implement Evidence-Based Practices to Prevent Central Line–Associated Bloodstream Infections. • Perform hand hygiene prior to catheter manipulation. • Use a standardized protocol to disinfect catheter hubs and ­injection ports before accessing the ports.

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Catheter Lock

Self-sealing septum

A

Skin

secure peripheral IV catheters. The INS standards (2011a) now recommends the use of manufactured catheter stabilization devices (Figure 52–21 •) over other methods such as sterile tapes and surgical strips. Solution Containers  Solution containers are available in various sizes (50, 100, 250, 500, or 1,000 mL); the smaller containers are often used to administer medications. Most solutions are currently dispensed in plastic bags (Figure 52–22 •). However, glass bottles may need to be used if the administered medications are incompatible with plastic. Glass bottles require an air vent so that air can enter the bottle and replace the fluid that enters the client’s vein. Some bottles contain a tube that serves as a vent; other containers require a vent on the administration set. Air vents usually have filters to prevent contamination from the air that enters the container. Air vents are not required for plastic solution bags, because the bags collapse under atmospheric pressure when the solution enters the vein. It is essential that the solution be sterile and in good condition, that is, clear. Cloudiness, evidence that the container has been opened previously, or leaks indicate possible contamination. Always check the expiration date on the label. Return any questionable or contaminated solutions to the pharmacy or IV therapy department.

CLINICAL ALERT!

Catheter Suture Fluid flow B

Figure 52–19  •  An implanted vascular access device: A, ­components; B, the device in place.

Figure 52–20  •  Left, An implanted vascular access device; Right, a Huber needle with extension tubing.

Catheter Stabilization Devices Securing or stabilizing an IV

catheter helps decrease movement of the catheter at the insertion site, which helps prevent infection and the catheter from being dislodged (Gorski, 2010). Historically, nonsterile tape was used to

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Do not write directly on a plastic IV bag with a ballpoint pen (may puncture the bag) or indelible marker (may absorb through the bag into the solution). Infusion Administration Sets Infusion administration sets (also

called administration infusion sets) consist of an insertion spike, a drip chamber, a roller valve or screw clamp, tubing with secondary ports, and a protective cap over the connecter to the IV catheter (­­Figure 52–23 •). The insertion spike is kept sterile and inserted into the solution container when the equipment is set up and ready to start. The drip chamber permits a predictable amount of fluid to be delivered. A macrodrip drip chamber delivers between 10 and 20 drops (abbreviated gtts) per milliliter of solution. The specific amount is written on the package. Microdrip sets deliver 60 drops per milliliter of solution (Figure 52–24 •). Many infusion sets include an in-line filter to trap air, particulate matter, and microbes. A special infusion set may be required if the IV flow rate will be regulated by an infusion pump. Most infusion sets include one or more injection ports for administering IV medications or secondary infusions. Needleless systems are used because they reduce the risk of needlestick injury and contamination of the IV line. The needleless ports can be accessed with either a syringe that has a blunt cannula, or a Luer-Lok to administer medications, or an adapter can be added to the IV tubing for administration of secondary infusions (Figure 52–25 •). When more than one solution needs to be infused at the same time, secondary sets such as the tandem and the piggyback IV setups are used. Another variation is a volume-control set, which is used if the volume of fluid or medication administered is to be carefully controlled (see Chapter 35 ). Rather than using a continuous infusion, an intermittent infusion lock may be created by attaching a sterile injection cap or device (Figure 52–26 •) to an existing IV catheter. This keeps the venous access available for the administration of intermittent or emergency

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PRACTICE GUIDELINES

Caring for Clients with a Central Vascular Access Device •

After insertion, document the date; the insertion site; the brand, gauge, and catheter length; the location of the catheter tip (verified by x-ray); the length of the external segment; and client teaching. Do not use the access device until correct placement has been verified by x-ray.

SITE CARE • Use strict aseptic technique (including the use of sterile gloves and mask) when caring for CVADs. • The frequency of dressing changes is dependent on the dressing material. Transparent semipermeable membrane (TSM) dressings or tape and gauze are acceptable; however, gauze dressings do not allow for visualization of the insertion site and need to be changed every 48 hours or if the site requires visual inspection (Phillips & Gorski, 2014, p. 501). In contrast, TSM dressings allow for visualization and can be left in place for a maximum of 7 days if they remain clean, dry, and intact (INS, 2011a, p. S63). All dressings also should be changed when loose or soiled. • Assess the site for any redness, swelling, tenderness, or drainage. Compare the length of the external portion of the catheter with its documented length to assess for possible displacement. Report and document any position changes or signs of infection. • Follow agency protocol for cleaning solutions and types of dressings. Chlorhexidine gluconate is the preferred agent to clean the insertion site. • Clean the skin around the site with chlorhexidine solution, using a back-and-forth motion for at least 30 seconds (INS, 2011b). Allow the site to air dry. A round dressing impregnated with chlorhexidine can also be applied to the insertion site to prevent catheter-related bloodstream infections (CRBSIs). See Figure ❶. • Apply a new stabilization device. • Apply a sterile dressing. CATHETER CARE AND FLUSHING • Change the catheter cap as indicated by agency protocol. The catheter hub can be a source of infection. A 15-second scrub of the connection surface of the needleless connector has been shown to prohibit microorganism entry on the surface (Moureau & Dawson, 2010). Also available are commercial single-use Luer access valve disinfection caps. This cap contains isopropyl alcohol, which cleans the needleless connector before access and also protects it from contamination between uses. The cap is twisted onto the needleless connector and left in place until the next access to the connector is needed. The nurse removes and discards the old cap and the connector is ready for use without further wiping. See Figures ❷ to ❺. A study conducted by Wright et al. (2013) concluded that disinfecting caps filled with alcohol-soaked sponges reduced bacterial contamination in catheter hubs and the rate of CRBSIs.

•

•

• •

•

The solution used and frequency of flushing are determined by agency protocol for the specific type of port being used. ­Heparin-induced thrombocytopenia (HIT) has been reported with the use of heparin flush solutions. If heparin is used as part of the flushing protocol, the concentration should not be in amounts that cause systemic anticoagulation but in the lowest possible concentration to maintain patency (e.g., 10 units/mL). Many agencies are switching to needleless IV connectors that can be flushed with normal saline solution only. Flush the catheter before and after each dose of medication. The initial flush is to assess patency of the catheter, and the flush after administration of the medication is to ensure that the complete dose has entered the bloodstream and to prevent contact between incompatible medications. Use a 10-mL syringe to flush the catheter. Never apply force if you feel resistance. CVADs need to be locked after the final flush solution to decrease the risk of occlusion (INS, 2011a). Locking a catheter creates a column of fluid inside the lumen to maintain patency (Hadaway, 2012, p. 42). The process for locking a catheter varies depending on the manufacturer of the needleless connector. Blood reflux into the catheter lumen after flushing increases the risk of infection. Positive-pressure valve caps on central line catheters can help prevent blood reflux when used with negative-pressure needleless infusion caps (Mathers, 2011, p. 65). Thus, it is important for the nurse to know the type of needleless connector being used: positive-pressure, negativepressure, or neutral-displacement needleless connector.

TEACHING Provide clients with the following instructions: • Do not allow anyone to take a blood pressure on the arm in which a PICC line is inserted. • Wear a medical alert tag or bracelet if the device will be in place for a long period of time. • For a PICC line, activity does not need to be restricted, except that the arm should not be immersed in water. Showering is allowed if the site and catheter are covered by a TSM dressing. • For an implanted central venous access port, there are no activity restrictions, but the port or catheter tip can become dislodged. Signs of a dislodged catheter tip include pain in the neck or ear on the affected side, swishing or gurgling sounds, or palpitations; signs of a dislodged port include free movement of the port, swelling, or difficulty accessing the port. If any of these occur, or if symptoms of infection develop, notify the primary care provider immediately.

❸ Cap contains disinfecting solution.

❶ Protective disk with chlorhexidine gluconate (CHG) (BioPatch®).

❷ Disinfecting cap

❹ Twist cap onto needleless

❺ Remove outer packaging and

(SwabCap™).

connector.

leave cap in place.

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Promoting Physiological Health Protector cap for insertion spike Spike connector for fluid container Connector to IV catheter Drip chamber

Secondary port

Clamp

Figure 52–21  •  Manufactured catheter stabilization device. Secondary port

Clamp

Figure 52–23  •  A standard IV administration set.

A

Figure 52–22  •  A plastic intravenous fluid container.

medications. The device is commonly referred to as a saline lock because periodic injection with saline is used to keep blood from coagulating within the tubing. Intravenous Filters  IV filters are used to remove air and particu-

late matter from IV infusions and to reduce the risk of complications

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B

Figure 52–24  •  Infusion set spikes and drip chambers: A, nonvented macrodrip and B, nonvented microdrip.

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A

Figure 52–27  •  Two types of IV filters.

or slow the flow rate when debris accumulates; and (b) binding of some drugs (e.g., insulin and amphotericin B) to the surface of the filter. When using filters, the nurse must remember that the filter should never be considered a substitute for quality care and meticulous technique. B

Figure 52–25  •  Cannulas used to connect the tubing of additive sets to primary infusions: A, threaded-lock cannula; B, lever-lock cannula.

Intravenous Poles  IV poles (rods) are used to hang the solution container. Some poles are attached to hospital beds; others stand on the floor or hang from the ceiling. Still others are floor models with casters that can be pushed along when a client is up and walking. In the home, plant hangers or robe hooks (even kitchen cabinet knobs or an S-hook over the top of a door) may be used to hang solution containers. The height of most poles is adjustable. The higher the solution container, the greater the force of the solution as it enters the client and the faster the rate of flow. Starting an Intravenous Infusion

Although the primary care provider is responsible for ordering IV therapy for clients, nurses initiate, monitor, and maintain the prescribed IV infusion. This is true not only in hospitals and long-term care facilities but increasingly in community-based settings such as clinics and clients’ homes. Before starting an infusion, the nurse determines the following: • The type and amount of solution to be infused • The exact amount (dose) of any medications to be added to a

compatible solution

• The rate of flow or the time over which the infusion is to be

completed.

Figure 52–26  •  Intermittent infusion device with injection port.

(e.g., infusion-related phlebitis) associated with routine IV therapies (­Figure 52–27 •). Most IV filters in current use consist of a membrane (pore size of 0.22 micron, although sizes vary). Some problems associated with filters include (a) clogging of the filter surface, which may stop

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If solutions are prepared by the pharmacy or another department, the nurse must verify that the solution supplied exactly matches that which the primary care provider ordered. Understanding the purpose for the infusion is as important as assessing the client. For example, a nurse should question an order for 5% dextrose in water at 150 mL/h if the client has peripheral edema and other signs of fluid overload. To perform venipuncture and start an IV infusion, see Skill 52–1.

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Starting an Intravenous Infusion Before preparing the infusion, the nurse first verifies the primary care provider’s order indicating the type of solution, the amount to be

administered, the rate of flow or time over which the infusion is to be completed, and any client allergies (e.g., to tape or povidone-iodine).

PURPOSES • To supply fluid when clients are unable to take in an adequate volume of fluids by mouth • To provide salts and other electrolytes needed to maintain ­electrolyte balance

• • •

ASSESSMENT Assess • Vital signs (pulse, respiratory rate, and BP) for baseline data. • Allergy to latex (e.g., tourniquet), tape, or iodine. • Bleeding tendencies. • Disease or injury to extremities. • Status of veins to determine appropriate venipuncture site. Avoid sites that have been used recently. Rationale: Recently PLANNING Prior to initiating the IV infusion, consider how long the client is likely to have the IV, what kinds of fluids will be infused, and what medications the client will be receiving or is likely to receive. These factors may affect the choice of vein and catheter size. Review the client record regarding previous infusions. Note any complications and how they were managed.

DELEGATION Due to the need for knowledge of anatomy and use of sterile technique, IV infusion therapy is not delegated to UAP. UAP may care for clients receiving IV therapy, and the nurse must ensure that the UAP knows how to perform routine tasks such as bathing and positioning without disturbing the IV. The UAP should also know what complications or adverse signs, such as leakage, should be reported to the nurse. In many states, a licensed practical nurse or licensed vocational nurse with special IV therapy training may start IV infusions. Check the state’s nurse practice act.

IMPLEMENTATION Preparation • If possible, select a time to perform the venipuncture that is convenient for the client. Unless initiating IV therapy is urgent, provide any scheduled care before establishing the infusion to minimize excessive movement of the affected limb. Rationale: Moving the limb after the infusion has been established could dislodge the catheter. • Make sure that the client’s clothing or gown can be removed over the IV apparatus if necessary. Many agencies provide ­special gowns that open over the shoulder and down the sleeve for easy removal. • Visitors or family members may be asked to leave the room if desired by the nurse or the client. Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Venipuncture can cause discomfort for a few

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To provide glucose (dextrose), the main fuel for metabolism To provide water-soluble vitamins and medications To establish a lifeline for rapidly needed medications

used sites will be more prone to complications and discomfort. Determine if the client is right- or left-handed. Rationale: Do not use the dominant hand if possible. • The agency policy about clipping hair in the area before a ­venipuncture. Shaving is not recommended because of the ­possibility of nicking the skin and subsequent infection. Equipment Substitute appropriate supplies if the client has tape, antiseptic, or latex allergies • Infusion set • Sterile parenteral solution • IV pole • Nonallergenic tape • Clean gloves • Tourniquet • Antiseptic swabs such as 10% povidone-iodine or 2% chlorhexidine gluconate with alcohol or 70% isopropyl alcohol. Chlorhexidine is becoming the standard of practice and is the antiseptic preferred by the INS (Phillips & Gorski, 2014, p. 338). • IV catheter (Choose an IV catheter of the appropriate type and size based on the size of the vein and the purpose of the IV. A #20- to #22-gauge catheter is indicated for most adults. Always have an extra catheter and ones of different sizes available.) • Sterile gauze dressing or transparent semipermeable membrane (TSM) dressing (preferred) • Stabilization device • Splint, if required • Towel or bed protector • Local anesthetic (optional and per agency policy) • Electronic infusion device or pump (The nurse decides what device is needed as appropriate to the client’s condition.) seconds, but there should be no ongoing pain after insertion. If possible, explain how long the IV will need to remain in place and how it will be used. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Position the client appropriately. • Assist the client to a comfortable position, either sitting or lying. Expose the limb to be used but provide for client privacy. (Note: Steps 4 through 10 may be performed outside of the client’s room and then the system transported to the client’s bedside.) 4. Apply a medication label to the solution container if a ­medication is added. • In many agencies, medications are added and labels are applied to IV containers in the pharmacy; if they are not, apply the label upside down on the container. Rationale: The label is applied upside down so it can be read easily when the container is hanging up.

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Starting an Intravenous Infusion—continued

❶ Inserting the spike.

❷ Squeezing the drip chamber.

9. Prime the tubing as described below. The term prime means “to make ready” but in common use refers to flushing the ­tubing to remove air. • Remove the protective cap and hold the tubing over a ­container. Maintain the sterility of the end of the tubing and the cap. • Release the clamp and let the fluid run through the tubing until all bubbles are removed. Tap the tubing if necessary with your fingers to help the bubbles move. Rationale: The tubing is primed to prevent the introduction of air into the client. Air bubbles smaller than 0.5 mL usually do not cause problems in peripheral lines. • Reclamp the tubing and replace the tubing cap, maintaining sterile technique. • If an infusion control pump, electronic device, or controller is being used, follow the manufacturer’s directions for inserting the tubing and setting the infusion rate. 10. Perform hand hygiene again just prior to client contact. 11. Select the venipuncture site. • Use the client’s nondominant arm, unless contraindicated (e.g., mastectomy, fistula for dialysis). Identify possible ­venipuncture sites by looking for veins that are relatively straight. The vein should be palpable, but may not be v­ isible, especially in clients with dark skin. Consider the catheter length; look for a site sufficiently distal to the wrist or elbow such that the tip of the catheter will not be at a point of flexion. Rationale: Sclerotic veins may make initiating and maintaining the IV difficult. Joint flexion increases the risk of irritation of vein walls by the catheter. • Check agency protocol about shaving if the site is very hairy. Shaving is not recommended. Rationale: Shaving can cause microabrasions that can increase the risk of infection. • Place a towel or bed protector under the extremity to ­protect linens (or furniture if in the home). 12. Dilate the vein. • Place the extremity in a dependent position (lower than the client’s heart). Rationale: Gravity slows venous return and distends the veins. Distending the veins makes it easier to insert the needle properly. • Apply a tourniquet firmly 15 to 20 cm (6 to 8 in.) above the venipuncture site. ❸ Explain that the tourniquet will feel tight. Rationale: The tourniquet must be tight enough to obstruct venous flow but not so tight that it occludes arterial flow. Obstructing arterial flow inhibits venous filling. If a radial pulse can be palpated, the arterial flow is not obstructed. • Use the tourniquet on only one client. This avoids cross ­contamination to other clients. Be sure to ask if the client has a latex allergy. • For older adults with fragile skin, instead of applying a tourniquet, place the arm in a dependent position to allow the veins to engorge. Rationale: The tourniquet can cause tissue damage and may not be needed to allow the vein to dilate. • If the vein is not sufficiently dilated: a. Massage or stroke the vein distal to the site and in the ­direction of venous flow toward the heart. Rationale: This action helps fill the vein. b. Encourage the client to clench and unclench the fist. ­Rationale: Contracting the muscles compresses the distal veins, forcing blood along the veins and distending them. c. Lightly tap the vein with your fingertips. Rationale: ­Tapping may distend the vein. • If the preceding steps fail to distend the vein so that it is palpable, remove the tourniquet and wrap the extremity in a warm towel for 10 to 15 minutes. Rationale: Heat dilates superficial blood vessels, causing them to fill. Then repeat steps to dilate the vein.

SKILL 52–1

5. Open and prepare the infusion set. • Remove tubing from the package and straighten it out. • Slide the tubing clamp along the tubing until it is just below the drip chamber to facilitate its access. • Close the clamp. • Leave the ends of the tubing covered with the plastic caps until the infusion is started. Rationale: This will maintain the sterility of the ends of the tubing. 6. Spike the solution container. • Expose the insertion site of the bag or bottle by removing the protective cover. • Remove the cap from the spike and insert the spike into the insertion site of the bag or bottle. ❶ 7. Hang the solution container on the pole. • Adjust the pole so that the container is suspended about 1 m (3 ft) above the client’s head. Rationale: This height is needed to enable gravity to overcome venous pressure and facilitate flow of the solution into the vein. 8. Partially fill the drip chamber with solution. • Squeeze the chamber gently until it is half full of solution. ❷ Rationale: The drip chamber is partially filled with solution to prevent air from moving down the tubing.

Continued on page 1372

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Starting an Intravenous Infusion—continued

❸ Two types of tourniquets. 13. Minimize insertion pain as much as possible. • Although the pain of insertion should be brief, prevention can and should be offered. Transdermal analgesic creams (e.g., EMLA, Synera) may be used, depending on policy. Allow at least 30 to 60 minutes for the topical analgesic to take effect (Phillips & Gorski, 2014). • If desired and permitted by policy, inject 0.3 mL of 1% lidocaine (without epinephrine) intradermally over the site where you plan to insert the IV catheter. (Be sure to first apply gloves and clean the skin site as described in step 14.) Allow 5 to 10 seconds for the anesthetic to take effect (Phillips & Gorski, 2014). 14. Apply clean gloves and clean the venipuncture site. Rationale: Gloves protect the nurse from contamination by the client’s blood. • Clean the skin at the site of entry with a topical antiseptic swab (e.g., 2% chlorhexidine, or alcohol). Some institutions may use an anti-infective solution such as povidone-iodine (check agency protocol). Check for allergies to iodine or shellfish before cleansing skin with Betadine or iodine ­products. • When using chlorhexidine solution (preferred), use a backand-forth motion for a minimum of 30 seconds to scrub the insertion site and surrounding area (Phillips & Gorski, 2014). Allow the site to completely air dry before inserting the ­catheter. Do not fan, blow on, or wipe the skin. • When using povidone-iodine, apply using swab sticks in a concentric circle beginning at the catheter insertion site and moving outward. The iodine should be in contact with the

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skin for 2 minutes or longer to completely dry for adequate antisepsis (INS, 2011b, p. 66). 15. Insert the catheter and initiate the infusion. • Remove the catheter assembly from its sterile packaging. Review instructions for using the catheter because a variety of needle safety devices are manufactured. Remove the cover of the needle (stylet). • Use the nondominant hand to pull the skin taut below the entry site. Rationale: This stabilizes the vein and makes the skin taut for needle entry. It can also make initial tissue ­penetration less painful. • Holding the over-the-needle catheter at a 15- to 30-degree angle with needle (stylet) bevel up, insert the catheter through the skin and into the vein. A sudden lack of resistance is felt as the needle (stylet) enters the vein. Use a slow steady insertion technique and avoid jabbing or stabbing motions. • Once blood appears in the lumen or clear “flashback” chamber of the needle, lower the angle of the catheter until it is almost parallel with the skin, and advance the needle (stylet) and catheter approximately 0.5 to 1 cm (about 1/4 in.) farther. ❹ Holding the needle assembly steady, advance the catheter until the hub is at the venipuncture site. The exact technique depends on the type of device used. Rationale: The catheter is advanced to ensure that it, and not just the stylet, is in the vein. • If there is no blood return, try redirecting the catheter assembly again toward the vein. If the stylet has been withdrawn from the catheter even a small distance, or the catheter tip has been pulled out of the skin, the catheter must be discarded and a new one used. Rationale: Reinserting the stylet into the catheter can result in damage or slicing of the catheter. A catheter that has been removed from the skin is considered contaminated and cannot be reused. • If blood begins to flow out of the vein into the tissues as the catheter is inserted, creating a hematoma, the insertion has not been successful. This is sometimes referred to as a blown vein. Immediately release the tourniquet and remove the catheter, applying pressure over the insertion site with dry gauze. Attempt the venipuncture in another site, in the opposite arm if possible. Rationale: Placing the tourniquet back on the same arm above the unsuccessful site may cause it to bleed. Placing the IV below the unsuccessful site could result in infusing fluid into the already punctured vein, causing it to leak.

❹ Blood is noted in the flashback chamber once the stylet has entered the vein.

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Starting an Intravenous Infusion—continued • •

•

•

•

❺ Stabilize the catheter hub and occlude the vein with finger(s) while removing the stylet.

16. Stabilize the catheter and apply a dressing. • Secure the catheter according to the manufacturer’s instructions and agency policy. Several methods are used to stabilize the catheter including the use of a dressing and securement device. If tape is used, it must be sterile tape or surgical strips and they should be applied only to the catheter adapter and not placed directly on the catheter–skin junction site. Use of a manufactured stabilization device is preferred (INS, 2011a). • Apply a dressing. Two methods are used for applying a dressing: a sterile gauze dressing secured with tape and a TSM dressing. ❼ Most common is the TSM because it allows for continuous assessment of the site and is more comfortable than gauze and tape (Phillips & Gorski, 2014, p. 345). Do not use ointment of any kind under a TSM dressing. Additional tape may be used to secure the IV catheter below the TSM, if necessary. Do not place tape on the TSM dressing. • Label the dressing with the date and time of insertion, gauge, and your initials. ❽ • Apply an IV site protector, if available. Protective devices are available that help prevent dislodgement of the IV catheter and still provide easy assessment of the IV site. ❾ • Loop the tubing and secure it with tape. Rationale: Looping and securing the tubing prevent the weight of the tubing or any movement from pulling on the needle or catheter.

SKILL 52–1

•

Release the tourniquet. Put pressure on the vein proximal to the catheter to eliminate or reduce blood oozing out of the catheter. Stabilize the hub with thumb and index finger of the nondominant hand. Remove the protective cap from the distal end of the tubing and hold it ready to attach to the catheter, maintaining the sterility of the end. Stabilize the catheter hub and apply pressure distal to the catheter with your finger. ❺ Rationale: This prevents excessive blood flow through the catheter. Carefully remove the stylet, engage the needle safety device if it does not engage automatically, and attach the end of the infusion tubing to the catheter hub. Place the stylet directly into a sharps container. If this is not within reach, place the stylet into its original package and dispose in a sharps container as soon as possible. Initiate the infusion or flush the catheter with sterile normal saline. ❻ Rationale: Blood must be removed from the catheter lumen and tubing immediately. Otherwise, the blood will clot inside the lumen. Watch closely for any signs that the catheter is infiltrated. Infiltration occurs when the tip of the IV is outside the vein and the fluid is entering the tissues instead. It is manifested by localized swelling, coolness, pallor, and discomfort at the IV site. Rationale: Inflammation or infiltration necessitates removal of the IV needle or catheter to avoid further trauma to the tissue.

❼ Applying a sterile one-piece IV stabilization and TSM dressing device.

❻ The catheter is stabilized while gently flushing it to determine ❽ IV site is labeled with date, time, size of catheter, and initials.

patency.

Continued on page 1374

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SKILL 52–1

Starting an Intravenous Infusion—continued

❾ IV site protective device. 17. Discard the tourniquet. • Remove and discard gloves. • Perform hand hygiene. 18. Ensure appropriate infusion flow. • Apply a padded arm board to splint the joint if needed. • Adjust the infusion rate of flow according to the order. 19. Label the IV tubing. • Label the tubing with the date and time of attachment and your initials. ❿ This labeling may also be done when the infusion is started. Rationale: The tubing is labeled to ensure that it is changed at regular intervals (i.e., according to agency policy). 20. Document all assessments and interventions. • Record the venipuncture on the client’s chart. Some agencies provide a special form for this purpose. Include the date EVALUATION • Regularly check the client for intended and adverse effects of the infusion. • Perform follow-up based on findings or outcomes that ­deviated from expected or normal for the client. Relate findings to ­previous data if available. • At least every 4 hours, check the skin status at IV site (warm temperature and absence of pain, redness, or swelling), status Regulating and Monitoring Intravenous Infusions

Orders for IV infusions may take several forms, for example “3,000 mL over 24 hours,” “1,000 mL every 8 hours × 3 bags,” or “125 mL/h until oral intake is adequate.” The nurse initiating the IV calculates the correct flow rate, regulates the infusion, and monitors the client’s responses. Unless an infusion control device is used, the nurse manually regulates the drops per minute of flow using the roller clamp to ensure that the prescribed amount of solution will be infused in the correct time span. Problems that can result from incorrectly regulated infusions include hypervolemia, hypovolemia, electrolyte imbalances, and medication complications. The number of drops delivered per milliliter of solution varies with different brands and types of infusion sets. This rate,

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❿ Tubing labeled with date, time, and nurse’s initials. and time of the venipuncture; type, length, and gauge of the needle or catheter; venipuncture site, how many attempts were made, amount and type of solution used, including any additives (e.g., kind and amount of medications); flow rate; the type of dressing applied; and the client’s general response.

SAMPLE DOCUMENTATION 1/15/2015 0600 Inserted 20-gauge, 1-inch angiocath in the right cephalic vein 4 inches above the (L) wrist on first attempt. StatLock used to stabilize catheter and Tegaderm dressing applied. IV ­infusing at 125 mL/h. Explained reason for IV. Verbalized understanding. –––––––––––––––––––––––––––––––––––––– A. Luis, RN

of the dressing, the client’s ability to perform self-care activities, and the client’s understanding of any mobility limitations. • Report significant deviations from normal to the primary care provider.

called the drop factor, is printed on the package of the infusion set. Macrodrops commonly have drop factors of 10, 12, 15, or 20  drops/mL; the drop factor for microdrip sets is always 60 drops/mL (see Figure 52–24 earlier). To calculate flow rates, the nurse must know the volume of fluid to be infused and the specific time for the infusion. Two commonly used methods of indicating flow rates are designating (1) the number of milliliters to be administered in 1 hour (mL/h) or (2) the number of drops to be given in 1 minute (gtt/min). Occasionally, the IV rate order will read “keep vein open” (KVO) or “to keep open” (TKO). This order does not provide adequate direction for the nurse unless agency policy specifies the milliliters per hour equivalent for this order. Generally, the KVO rate is less than

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50 mL/h. Some IV pumps have a keep-open rate choice built in. If the IV is not on this type of pump and no policy exists, contact the primary care provider for clarification. Milliliters per Hour  Hourly rates of infusion can be calculated by

dividing the total infusion volume by the total infusion time in hours. For example, if 3,000 mL is infused in 24 hours, the number of milliliters per hour is 3,000 mL (total infusion volume) = 125 mL>h 24 h (total infusion time)

Nurses need to check infusions at least every hour to ensure that the indicated milliliters per hour have infused and that IV patency is maintained. Drops per Minute  The nurse who begins an infusion must regulate

the drops per minute to ensure that the prescribed amount of solution will infuse. Drops per minute are calculated by the following formula: Drops per minute =

Total infusion volume * drop factor Total time of infusion in minutes

If the requirements are 1,000 mL in 8 hours and the drip factor is 20 drops/mL, the drops per minute should be 1,000 mL * 20 8 * 60 min (480 min) = 41 drops>min The nurse regulates the drops per minute by tightening or releasing the IV tubing clamp and counting the drops for 15 seconds, then multiplying that number by 4. A number of factors influence flow rate (Box 52–7). Devices to Control Infusions

Historically, the nurse manually regulated the IV rate with the roller clamp on the administration set. Although a roller clamp can still be used, a number of other devices are currently available to control the rate of an infusion. The term flow-control device refers to any manual, mechanical, or electronic infusion device used to regulate the IV flow rate (INS, 2011a, p. S104). The INS Standards of Practice (2011a) state that the choice of a flow-control device (e.g., manual flow regulator, elastomeric balloon pump, electronic infusion pump) should consider the age and mobility of the client, severity of illness, type of therapy, and health care setting (p. S34).

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In the acute health care setting, electronic infusion devices (EIDs) are predominantly used to regulate the infusion rate at preset limits. EIDs are powered by electricity or battery and are programmed to regulate the IV flow rate in either drops per minute or milliliters per hour (Phillips & Gorski, 2014, p. 288). They use positive pressure to deliver the IV solution, provide an accurate flow rate, are easy to use, and have alarms that signal problems with the infusion (e.g., when the solution in the IV bag is low, when there is air in the tubing, or when flow is impeded by an occlusion). The alarms are helpful; however, the nurse must still conduct regular assessment and evaluation of the IV site to ensure safe infusion. CLINICAL ALERT! Many EIDs use low infusion pressures, often lower than the pressure of a gravity delivery. As a result, they do not detect infiltration. When an infiltration occurs, the inline pressure may even drop and not trigger an alarm. Thus, it is important for the nurse to assess for infiltration for clients with EIDs (Phillips & Gorski, 2014, p. 296).

Another type of flow-control device is the multichannel pump. This type of pump can deliver several medications and fluids at the same time, at multiple rates, from bags, bottles, or syringes (Phillips & Gorski, 2014, p. 292). The multichannel pump usually has two to four channels with each channel being programmed independently (­Figure 52–28 •). Newer systems, called smart pumps, are EIDs with a computer system. They are programmable and include drug libraries with dose rate calculators, automatic flushing between medications, dual or triple simultaneous line control, memory, multiple alarm settings, air in line, pressure/resistance, battery, schedule reminders, volume settings down to 0.1 mL, panel locks, and digital displays. Mechanical flow-control devices are often used to regulate infusion rates in home care and/or ambulatory settings. Examples of these nonelectric methods include use of a Dial-A-Flo in-line gravity control device and the elastomeric pump. The Dial-A-Flo in-line device (Figure 52–29 •) is a manual regulator that controls the amount

BOX 52–7  Factors Influencing Flow Rates •

•

•

•

•

The position of the forearm. Sometimes a change in the ­position of the client’s arm decreases flow. Slight pronation, supination, extension, or elevation of the forearm on a pillow can increase flow. The position and patency of the tubing. Tubing can be ­obstructed by the client’s weight, a kink, or a clamp closed too tightly. The flow rate also diminishes when part of the ­tubing dangles below the puncture site. The height of the infusion bottle. Elevating the height of the infusion bottle a few inches can speed the flow by creating more pressure. Possible infiltration or fluid leakage. Swelling, a feeling of ­coldness, and tenderness at the venipuncture site may ­indicate infiltration. Relationship of the size of the angiocath to the vein. A ­catheter that is too large may impede the infusion flow.

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Figure 52–28  •  Programmable multichannel infusion pumps.

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A

 

Figure 52–30  •  An elastomeric infusion pump showing medication in the reservoir and protected by an exterior shell.

B

Figure 52–29  •  A, The Dial-A-Flo in-line gravity control device; B, the manual rate-flow regulator.

of fluid to be administered. The Dial-A-Flo may be used in situations where a pump is not available or required, but prevention of fluid overload is important. The nurse presets the volume to be infused by rotating the dial to the desired rate. It is important for the nurse to remember that flow rate needs to be verified by counting the drops. The elastomeric infusion pump (Figure 52–30 •), a nonelectric portable disposable pump, is prefilled with a medication and connects to the client’s needleless connector. It is a lightweight, disposable pump that delivers medications at a controlled rate. The medication is held

in a reservoir (balloon) that is inside a rigid, transparent container. The balloon exerts positive pressure, which releases the solution into the tubing that is attached to the client’s vascular access device (­Broadhurst, 2012, p. 144). It has an integrated flow restrictor that controls the flow rate, which can be set from 0.5 to 500 mL/h (Phillips & Gorski, 2014, p. 287). The elastomeric infusion pump is portable and can be put in a loose pocket or bag while infusing, allowing the client to be mobile. When the infusion is finished, the entire device is discarded. The elastomeric pump provides ease of use in the home care setting. CLINICAL ALERT! A flow-rate-control device should be used when administering IV fluid to older adults or pediatric clients. Both of these age groups are especially at risk for complications of fluid overload, which can occur with rapid infusion of IV fluids.

Skill 52–2 outlines the steps involved in monitoring an IV infusion.

SKILL 52–2

Monitoring an Intravenous Infusion PURPOSES • To maintain the prescribed flow rate • To prevent complications associated with IV therapy ASSESSMENT Assess • Appearance of infusion site; patency of system • Type of fluid being infused and rate of flow • Response of the client PLANNING Review the client record regarding previous infusions and use of infusion devices. Note any complications and how they were managed. Gather the pertinent data.

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From the order, determine the type and sequence of solutions to be infused. • Determine the rate of flow and infusion schedule. •

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Monitoring an Intravenous Infusion—continued DELEGATION

Equipment None

IMPLEMENTATION Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Position the client appropriately. • Assist the client to a comfortable position, either sitting or lying. • Expose the IV site but provide for client privacy. 4. Ensure that the correct solution is being infused. • Compare the label on the container (including added ­medications) to the order. If the solution is incorrect, slow the rate of flow to a minimum to maintain the patency of the catheter. If the infusing solution is contraindicated for the client, stop the infusion and saline-lock the catheter. Rationale: Just stopping the infusion may allow a thrombus to form in the IV catheter. If this occurs, the catheter must be removed and another venipuncture performed before the infusion can be resumed. Because IV tubing contains approximately 12 to 15 mL, it may be desirable to prevent even this much additional incorrect solution to infuse when the correct IV solution container is hung on existing tubing. In this case, all tubing should be removed until new tubing, primed with the correct solution, can be started. • Change the solution to the correct one, using new tubing if indicated. • Document and report the error according to agency ­protocol. 5. Observe the rate of flow every hour. • Compare the rate of flow regularly, for example, every hour, against the infusion schedule. Rationale: Infusions that are off schedule can be harmful to a client. To read the volume in an IV bag, pull the edges of the bag apart at the level of the fluid and read the volume remaining. Rationale: Stretching the bag allows the fluid meniscus to fall to the proper level. • Observe the position of the solution container. If it is less than 1 m (3 ft) above the IV site, readjust it to the correct height of the pole. Rationale: If the container is too low with a gravity IV infusion, the solution may not flow into the vein because there is insufficient gravitational pressure to ­overcome the pressure of the blood within the vein. • If too much fluid has infused in the time interval, check agency policy. The primary care provider may need to be notified. • In some agencies, you will slow the infusion to less than the ordered rate so that it will be completed at the planned time. Rationale: Solution administered too quickly may cause a significant increase in circulating blood volume

SKILL 52–2

Due to the need for sterile technique and technical complexity, inspection of IV sites and regulation of IV rates is not delegated to UAP. UAP may care for clients with such devices, and the nurse must ensure that the UAP knows what complications or adverse signs should be reported to the nurse. In many states, a licensed practical nurse or licensed vocational nurse with special IV therapy training may manage infusions. Check the state’s nurse practice act.

(which is about 6 L in an adult). Hypervolemia may result in pulmonary edema and cardiac failure. Assess the client for manifestations of hypervolemia and its complications, including dyspnea; rapid, labored breathing; cough; crackles; ­tachycardia; and bounding pulses. • In other agencies, if the order is for a specified amount of fluid per hour, the IV may be adjusted to the correct rate and the client monitored for signs of fluid overload. • If the rate is too slow, adjust the IV to the prescribed rate. Also, check agency policy. Some agencies permit nursing personnel to adjust an IV that is behind time by a specified percentage. Adjustments above this amount may require a primary care provider’s order. Rationale: Solution that is administered too slowly can supply insufficient fluid, ­electrolytes, or medication for a client’s needs. • If the prescribed rate of flow is 150 mL/h or more, check the rate of flow more frequently, for example, every 15 to 30 minutes. 6. Inspect the patency of the IV tubing and catheter. • Observe the drip chamber. If it is less than half full, squeeze the chamber to allow the correct amount of fluid to flow in. • Inspect the tubing for kinks or obstructions to flow. Arrange the tubing so that it is lightly coiled and under no pressure. Sometimes the tubing becomes caught under the client’s body and the weight blocks the flow. • Observe the position of the tubing. If it is dangling below the venipuncture, coil it carefully on the surface of the bed. Rationale: The solution may not flow upward into the vein against the force of gravity. • Determine catheter position. Some methods include: a. Aspirate the catheter for a blood return. Do this slowly and gently. b. Lower the solution container below the level of the infusion site and observe for a return flow of blood from the vein. Rationale: A return flow of blood indicates that the needle is patent and in the vein. Blood returns in this instance because venous pressure is greater than the fluid pressure in the IV tubing. Absence of blood return may indicate that the needle is no longer in the vein or that the tip of the catheter is partially obstructed by a thrombus, the vein wall, or a valve in the vein. (Note: With some catheters, no blood may appear even with patency because the soft catheter walls collapse during siphoning.) c. If there is leakage, locate the source. If the leak is at the catheter connection, tighten the tubing into the catheter. If the leak is elsewhere in the tubing, slow the infusion and replace the tubing. Estimate the amount of solution lost, if it was substantial. If the IV insertion site is leaking, the catheter will have to be removed and IV access reestablished at a new site. Continued on page 1378

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Monitoring an Intravenous Infusion—continued 7. Inspect the insertion site for fluid infiltration. Infiltration is the unintentional administration of a nonvesicant solution or ­medication into the tissue surrounding the IV catheter (­Martin, 2013, p. 392). • If an infiltration is present, stop the infusion and remove the catheter. Restart the infusion at another site. • Start supportive treatment (e.g., elevate extremity or apply heat to the site (INS, 2011b). Rationale: Warmth promotes comfort and vasodilation, facilitating absorption of the fluid from interstitial tissues. • If the infiltration involves a vesicant, a medication or fluid that causes blisters, severe tissue injury, or necrosis if it escapes from the vein (Vacca, 2013), it is called ­extravasation and other measures are indicated. The extravasation of a vesicant drug should be considered an emergency. Usually, vesicants are administered only through central venous infusions and by specially certified nurses. Most nurses relate vesicants to chemotherapy medications, such as paclitaxel; however, there are a number of nonchemotherapeutic medications (e.g., vancomycin, dopamine, diazepam, digoxin) (Martin, 2013; Vacca, 2013). • For an extravasation: a. Stop the infusion immediately. b. For a peripheral-short catheter, disconnect the tubing from the catheter hub and attach a 3- or 5-mL syringe. Aspirate any fluid remaining in the hub and catheter. c. Remove the catheter. Use a dry gauze pad to control bleeding. d. Apply a new dry dressing. Do not apply excessive pressure to the area. e. For a CVAD, do not remove the catheter. Clamp and cap the catheter hub. Follow agency procedure for flushing when extravasation is suspected. f. Assess motion, sensation, and capillary refill distal to the injury. Measure the circumference of the extremity and compare it with the opposite extremity. g. Notify the primary care provider. h. Photograph the site if that is agency policy. i. The affected arm should be elevated and, depending on the drug, heat or cold therapy should be implemented. j. Pharmacologic treatment may be instituted depending on the type of vesicant that has caused the damage. Two such medications are hyaluronidase and phentolamine, EVALUATION Perform follow-up based on findings or outcomes that deviated from expected or normal for the client. Consider urinary output compared to intake, tissue turgor, specific gravity of urine, vital signs, and lung sounds compared to baseline data.

•

Changing Intravenous Containers and Tubing.

IV solution containers are changed when only a small amount of fluid remains in the neck of the container and fluid still remains in the drip chamber. However, all IV bags should be changed every 24 hours, regardless of how much solution remains, to minimize the risk of contamination. Change primary administration sets and secondary tubing that remains continuously attached to them “no more frequently than every 96 hours” (INS, 2011b, p. 84). Change

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which are used to lessen tissue injury. The best results occur when administered immediately after an extravasation (Martin, 2013). k. The lack of recommendations and guidelines for the treatment of extravasation requires health care facilities to develop their own policies and procedures. 8. Inspect the insertion site for phlebitis (inflammation of a vein). • Inspect and palpate the site at least every 8 hours. Phlebitis can occur as a result of injury to a vein, for example, because of mechanical trauma or chemical irritation. Chemical injury to a vein can occur from IV electrolytes (especially potassium and magnesium) and medications. The clinical signs are redness, warmth, and swelling at the IV site and burning pain along the course of a vein. • If phlebitis is detected, discontinue the infusion, and apply warm or cold compresses to the venipuncture site. Do not use this injured vein for further infusions. 9. Inspect the IV site for bleeding. • Oozing or bleeding into the surrounding tissues can occur while the infusion is freely flowing, but is more likely to occur after the catheter has been removed from the vein. • Observation of the venipuncture site is extremely important for clients who bleed readily, such as those receiving ­anticoagulants. 10. Teach the client ways to maintain the infusion system, for example: • Inform of any limitations on movement or mobility. • Explain alarms if an electronic control device is used. • Instruct to notify a nurse if: a. The flow rate suddenly changes or the solution stops dripping. b. The solution container is nearly empty. c. There is blood in the IV tubing. d. Discomfort or swelling is experienced at the IV site. • Inform that the nurse will be checking the venipuncture site. 11. Document relevant information. • Record the status of the IV insertion site and any adverse responses of the client. • Document the client’s IV fluid intake at least every 8 hours according to agency policy. Include the date and time; amount and type of solution used; container number; flow rate; and the client’s general response. In most agencies, the amount remaining in each IV container is also recorded at the end of the shift.

•

Regularly check the client for intended and adverse effects of the infusion. Report significant deviations from normal to the primary care provider.

intermittent infusion sets without a primary infusion every 24 hours or whenever their sterility is in question (INS, 2011b). Add-on devices (e.g., extension sets, filters, stopcocks) should be changed at the same time the administration set is changed (INS, 2011b). The INS Standards of Care (2011a) state “routine site care and dressing changes are not performed on short peripheral catheters unless the dressing is soiled or no longer intact” (p. S63). Skill 52-3 provides guidelines for changing an IV solution container and tubing.

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Changing an Intravenous Container and Tubing

SKILL 52–3

PURPOSES • To maintain the flow of required fluids • To maintain sterility of the IV system and decrease the incidence of phlebitis and infection • To maintain patency of the IV tubing ASSESSMENT Assess • Presence of fluid infiltration, leakage, bleeding, or phlebitis at IV site • Allergy to tape or iodine • Infusion rate and amount absorbed

• •

PLANNING Review primary care provider’s orders for changes in fluid administration.

Equipment • Container with the correct kind and amount of sterile solution • Administration set, including sterile tubing and drip chamber

Blockages in IV system Appearance of the dressing for integrity, moisture, and need for change

DELEGATION This procedure includes assessment of the IV site and should be completed by a registered nurse. In many states, licensed vocational nurses with IV certification may complete the procedure.

IMPLEMENTATION Preparation 1. Obtain the correct solution container. • Read the label of the new container. • Verify that you have the correct solution, correct client, ­correct additives (if any), and correct dose (number of bags or total volume ordered). Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Set up the IV equipment with the new container and label. See Skill 52–1, steps 1 to 10. • Label the tubing as shown in Figure ❿ in Skill 52–1. 4. Assess the IV site. • Inspect the IV site for the presence of infiltration or inflammation. Rationale: Inflammation or infiltration necessitates removal of the IV catheter to avoid further trauma to the ­tissues. • Go to step 5 or discontinue and relocate the IV site if ­indicated. See Skills 52-1 and 52-4. 5. Disconnect the used tubing or remove the cap on an ­intermittent device. • Apply clean gloves. • Place a sterile swab under the hub of the catheter. Rationale: This absorbs any leakage that might occur when the tubing is disconnected.

Clamp the tubing. With the fourth or fifth finger of the nondominant hand, apply pressure to the vein above the end of the catheter. Rationale: This helps prevent blood from ­coming out of the needle during the change of tubing. • Holding the hub of the catheter with the thumb and index finger of the nondominant hand, remove the tubing or cap with the dominant hand, using a twisting and pulling motion. Rationale: Holding the catheter firmly but gently maintains its position in the vein. • Remove the used IV tubing. • Place the end of the used tubing in the basin or other ­receptacle. 6. Connect the new tubing or cap and reestablish the infusion. • Continue to hold the catheter and grasp the new tubing with the dominant hand. • Remove the protective tubing cap and, maintaining sterility, insert the tubing end securely into the needle hub. Twist it to secure it. • Open the clamp to start the solution flowing. 7. Secure IV tubing with additional tape as required. 8. Regulate the rate of flow of the solution according to the order on the chart. 9. Document all relevant information. • Record the change of the solution container and tubing in the appropriate place on the client’s chart. Also record the fluid intake according to agency practice. Record the ­number of the container if the containers are numbered at the agency. Also record your assessments. •

EVALUATION Evaluate the following: • Status of IV site • Patency of IV system • Accuracy of flow

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When an IV infusion is no longer necessary to maintain the client’s fluid intake or to provide a route for medication administration, the infusion is either discontinued and the catheter removed or the

catheter is left in place and converted to a saline lock. Guidelines for discontinuing an IV infusion or converting the catheter to a lock are outlined in Skills 52–4 and 52–5, respectively.

Discontinuing an Intravenous Infusion

SKILL 52–4

PURPOSE • To discontinue an IV infusion when the therapy is complete or when the IV site needs to be changed ASSESSMENT Assess • Appearance of the venipuncture site • Any bleeding from the infusion site

• •

PLANNING Review the client record regarding the primary care provider’s orders. Note if there were any previous infusions and if there were any complications and how they were managed.

• • •

Amount of fluid infused Appearance of IV catheter

Equipment Clean gloves Linen-saver pad Small sterile dressing and tape

DELEGATION In some states and agencies, removal of a peripheral IV catheter may be delegated to UAP. In others, removal of IV infusions or devices is not delegated to UAP. In any case, the nurse must ensure that the UAP knows what complications or adverse signs following removal should be reported to the nurse. In many states, a licensed practical nurse or licensed vocational nurse with special IV therapy training may discontinue IV infusions. Check the state’s nurse practice act. IMPLEMENTATION Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Explain the reason for discontinuing the IV and that the procedure should cause no discomfort other than that associated with removing the tape. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Assist the client to a comfortable position, either sitting or ­lying. Expose the IV site but provide for client privacy. Place a ­linen-saver pad under the extremity that has the IV. 4. Prepare the equipment. • Clamp the infusion tubing. Rationale: Clamping the tubing prevents the fluid from flowing out of the needle onto the ­client or bed. • Apply clean gloves. • Remove the dressing, stabilization device, and tape at the venipuncture site while holding the needle firmly and applying countertraction to the skin. ❶ Rationale: Movement of the catheter can injure the vein and cause discomfort to the client. Countertraction prevents pulling the skin and causing discomfort. • Assess the venipuncture site. Rationale: Assess for signs of infection or phlebitis. • Apply the sterile gauze above the venipuncture site. Only touch the upper portion of the gauze pad and maintain sterility of the lower portion that is in contact with the ­venipuncture site. 5. Withdraw the catheter from the vein. • Withdraw the catheter by pulling it out along the line of the vein. Rationale: Pulling it out in line with the vein avoids injury to the vein. Do not press down on the sterile gauze pad while removing the catheter. ❷

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❶ Remove the dressing, stabilization device, and tape while holding the IV catheter firmly.

Immediately apply firm pressure to the site, using sterile gauze, for 2 to 3 minutes. Rationale: Pressure helps stop the bleeding and prevents hematoma formation. • Hold the client’s arm above heart level if any bleeding ­persists. Rationale: Raising the limb decreases blood flow to the area. • Teach the client to inform the nurse if the site begins to bleed at any time or the client notes any other abnormalities in the area. 6. Examine the catheter removed from the client. • Check the catheter to make sure it is intact. Rationale: If a piece of tubing remains in the client’s vein it could move centrally (toward the heart or lungs). • Report a broken catheter to the nurse in charge or primary care provider immediately. •

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Discontinuing an Intravenous Infusion—continued

SKILL 52–4

❷ Withdraw the IV catheter from the vein. Do not apply pressure on the sterile gauze pad until the catheter is completely removed.

A

❸ Apply new sterile dressing to the site with tape. If a broken piece can be palpated, apply a tourniquet above the insertion site. Rationale: Application of a tourniquet decreases the possibility of the piece moving until a primary care provider is notified. 7. Cover the venipuncture site. • Apply new sterile dressing to the site with tape. ❸ Rationale: The dressing continues the pressure and covers the open area in the skin, preventing infection. • Discard used supplies appropriately. • Remove and discard gloves. • Perform hand hygiene. 8. Read the amount remaining in the IV solution container. 9. Apply a black-out label ❹ over the existing IV solution label prior to discarding the IV solution into a biohazard container (2). Rationale: The existing IV label contains client information.

B

•

EVALUATION • Perform follow-up based on findings or outcomes that ­deviated from expected or normal for the client. Relate findings to ­previous data if available.

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❹ A, An IV black-out label; B, discarding an IV bag into a biohazard ­container after applying a black-out label to ensure client confidentiality

The black-out label conceals client information and ensures client confidentiality. These labels are called IV HIPAA-compliant labels. 10. Document all relevant information. • Record the amount of fluid infused on the intake and output record and in the record, according to agency policy. Include the container number, type of solution used, time of discontinuing the infusion, and the client’s response.

•

Report significant deviations from normal to the primary care provider.

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Changing an Intravenous Catheter to an Intermittent Infusion Lock

SKILL 52–5

PURPOSE • To permit IV administration of medications or fluids on an intermittent basis ASSESSMENT Assess • Patency of the IV catheter PLANNING Review the primary care provider’s order. • A specific order may be written to convert an IV access to a saline lock. The order also may be implied; for example, IV fluids are to be discontinued but the client has orders for an IV antibiotic every 6 hours or is receiving analgesics intravenously. • From the primary care provider’s order, determine the type and sequence of intermittent infusions. • Review the client record regarding previous infusions and use of infusion devices. Note any complications and how they were managed.

•

Appearance of the site (evidence of inflammation or infiltration)

Equipment Intermittent infusion cap or device Clean gloves TSM dressing Sterile 2×2 or 4×4 gauze Sterile saline for injection (without preservative) in a prefilled syringe, a 3-mL syringe with a needleless infusion device • Isopropyl alcohol wipes • Tape • Clean emesis basin • • • • •

DELEGATION Due to the need for sterile technique and technical complexity, this procedure is not delegated to UAP. UAP may care for clients with such devices, and the nurse must ensure that the UAP knows what complications or adverse signs should be reported to the nurse. In many states, a licensed practical nurse or licensed vocational nurse with special IV therapy training may manage intermittent infusion devices. Check the state’s nurse practice act. IMPLEMENTATION Preparation • Obtain the needed equipment and take to the client’s bedside. Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Explain the reason for the intermittent device and that changing an IV to a saline lock should cause no discomfort other than that associated with removing tape from the IV tubing. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Assist the client to a comfortable position, either sitting or lying. Expose the IV site but provide for client privacy. 4. Assess the IV site and determine the patency of the catheter (see Skill 52-2). If the catheter is not fully patent or there is ­evidence of phlebitis or infiltration, discontinue the catheter and establish a new IV site. • Expose the IV catheter hub and loosen any tape or dressing that is holding the IV tubing in place or that will interfere with insertion of the intermittent infusion plug into the catheter. • Clamp the IV tubing to stop the flow of IV fluid. • Open the gauze pad and place it under the IV catheter hub. Rationale: This absorbs any leakage that might occur when the tubing is disconnected. • Open the alcohol wipe and intermittent infusion plug, leaving the plug in its sterile package. 5. Remove the IV tubing and insert the intermittent infusion plug into the IV catheter. • Apply clean gloves. • Stabilize the IV catheter with your nondominant hand and use the little finger to place slight pressure on the vein above the end of the catheter. Twist the IV tubing adapter to loosen it from the IV catheter and remove it, placing the end of the tubing in a clean emesis basin.

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Pick up the intermittent infusion plug from its package and remove the protective sleeve from the male adapter (see Figure 52–26), maintaining its sterility. Insert the plug into the IV catheter, twisting it to engage the Luer-Lok. 6. Instill saline per agency policy. Rationale: Saline is used to maintain patency of the IV catheter when fluids are not infusing through the catheter. The intermittent lock will need to be flushed with a prescribed solution after each use or every 8 to 12 hours if not in use, according to agency policy. Some recommend flushing the lock by injecting saline using the push–pause method (a rapid succession of push–pause–push–pause movements exerted on the plunger of the syringe barrel) with the rationale that this creates a turbulence within the catheter lumen that causes a swirling effect to remove any debris (e.g., blood or medication) attached to the catheter lumen. However, no research supports this method of flushing. There are differences of opinion and practice regarding this type of flushing versus a smooth injection of the flush solution. Research is needed to provide evidence of which is the most effective (­Phillips & Gorski, 2014, p. 359). 7. Cover the site with a TSM dressing. Rationale: The TSM dressing provides protection from infection, allows for ease of assessment of the venipuncture site, and also promotes comfort, preventing the plug from catching on clothing or bedding. 8. Remove and discard gloves. • Perform hand hygiene. 9. Teach the client how to maintain the lock. • Notify the nurse or primary care provider if the plug or catheter comes out; if the site becomes red, inflamed, or painful; or if any drainage or bleeding occurs at the site. 10. Document all relevant information. • Record the date and time when the infusion device was converted, the status of the IV insertion site, and any adverse responses of the client. •

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Changing an Intravenous Catheter to an Intermittent Infusion Lock—continued •

Report significant deviations from normal to the primary care provider.

Complications of Infusion Therapy

Local complications of infusion therapy occur as adverse reactions and/or trauma to the venipuncture site. Correct venipuncture technique is a primary factor in prevention along with frequent assessments and monitoring of the venipuncture site. Common local complications include infiltration, extravasation, and phlebitis. Infiltration is the unintended administration of a nonvesicant drug or fluid into the subcutaneous tissue. Infiltration can be caused by puncture of the vein during venipuncture, dislodgement of the catheter, or a poorly secured infusion device (Phillips &­ Gorski, 2014). Extravasation is similar to infiltration with the difference between the two being the solution. That is, extravasation is the unintended administration of vesicant drugs or fluids into the subcutaneous tissue. Five measures can help prevent infiltration and extravasation. The first measure is the selection of the venipuncture site. Areas of joint flexion such as the hand, wrist, and antecubital fossa should be avoided. The gauge of the catheter should be the smallest that can deliver the prescribed therapy in an appropriate size vein. Knowing the osmolality and pH of medications and fluids is also important. For example, hypertonic fluids and medications should not be infused through a peripheral vein. Using a manufactured catheter stabilization device prevents unnecessary movement of the catheter in the vein is the fourth measure. Finally, the last measure is assessing patency of the catheter and vein frequently. Phlebitis is an inflammation of the vein of which there are three types. Mechanical phlebitis is caused by too large of a catheter in a small vein causing irritation of the vein. Chemical phlebitis occurs when a vein becomes inflamed by irritating or vesicant solutions or medications. Bacterial phlebitis is inflammation of the vein and a bacterial infection, which can be caused by poor aseptic technique during insertion of the IV catheter and/or breaks in the integrity of the IV equipment. See Box 52–8 for common signs and symptoms of infiltration, extravasation, and phlebitis. It is important for the nurse to assess all clients with an IV access for signs of phlebitis. One of the INS Standards directs nurses to document symptoms of phlebitis using a standardized scale (INS, 2011a). Ray-Barruel, Polit, Murfield and Rickard (2014), however, conducted a systematic review of 71 different phlebitis assessment scales and found an “absence of a universally accepted scale with strong demonstrated reliability” (p. 8). While there is still a need for a phlebitis scale that has strong measurement properties for use in clinical practice, there are two commonly used assessment scales that are also recommended by the INS: the INS Phlebitis Scale and the Visual Infusion Phlebitis (VIP) Scale. The INS Phlebitis Scale progresses from 0 (no symptoms) to 4 (all symptoms: pain, erythema, streak formation, ­palpable venous cord, purulent drainage)

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BOX 52–8

SKILL 52–5

EVALUATION • Perform follow-up based on findings or outcomes that deviated from expected or normal for the client. Relate findings to previous data if available. • Examine the IV site at regular intervals. Note patency and ease of flushing.

Signs and Symptoms of Common Local Complications of Infusion Therapy

INFILTRATION • Coolness of skin around site • Skin blanching, tautness (i.e., client states it feels “tight”) • Edema at, above, or below the insertion site • Leakage at insertion site • Absence of or “pinkish” blood return • Difference in size of opposite hand or arm EXTRAVASATION Same as infiltration and can also include: • Burning, stinging pain • Redness followed by blistering, tissue necrosis, and ulceration PHLEBITIS • Redness at the site • Skin warm • Swelling • Palpable cord along the vein • Increase in temperature From “Intravenous Therapy: A Review of Complications and Economic Considerations of Peripheral Access,” by S. Dychter, D. Gold, D. Carson, & M. Haller, 2012, Journal of Infusion Nursing, 35(2), pp. 84–91; and Manual of I.V. Therapeutics (6th ed.), by L. D. Phillips & L. A. Gorski, 2014, Philadelphia, PA: F.A. Davis Company.

(INS, 2011a, p. S65). The VIP Scale progresses from 0 (no symptoms) to 5 (all symptoms). In addition, it includes an action (observe to relocate cannula and consider or initiate treatment) for each score (Higginson & Parry, 2011). Prevention strategies for phlebitis include practicing good hand hygiene, assessing the length of time needed for the infusion therapy, and considering alternatives (e.g., midline catheter or PICC) for long-term therapy, choosing the smallest catheter, stabilizing the catheter, infusing solutions at the prescribed rate, avoiding insertion of a peripheral IV catheter in an area of flexion, and assessing the IV site at least every 4 hours (Phillips & Gorski, 2014, p. 549).

Blood Transfusions IV fluids can be effective in restoring intravascular (blood) volume; however, they do not affect the oxygen-carrying capacity of the blood. When red or white blood cells, platelets, or blood proteins are lost because of hemorrhage or disease, it may be necessary to replace these components to restore the blood’s ability to transport oxygen and carbon dioxide, clot, fight infection, and keep extracellular fluid within the intravascular compartment. A blood transfusion is the introduction of whole blood or blood components into venous circulation.

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TABLE 52–11 Blood Types

Promoting Physiological Health

The Blood Groups with Their Constituent Agglutinogens and Agglutinins

A

RBC Antigens (Agglutinogens) A

Plasma Antibodies (Agglutinins) B

B

B

A

AB

A and B

—

O

—

A and B

Blood Groups

Human blood is commonly classified into four main groups: A, B, AB, and O. The surface of an individual’s red blood cells contains a number of proteins known as antigens that are unique for each person. Many blood antigens have been identified, but the A, B, and Rh antigens are the most important in determining blood group or type. Because antigens promote agglutination or clumping of blood cells, they are also known as agglutinogens. The A antigen is present on the RBCs of people with blood group A, the B antigen is present on the RBCs of people with blood group B, and A and B antigens are both present on the RBCs in people with group AB blood. Neither antigen is present on the RBCs of people with group O blood. Preformed antibodies to RBC antigens are present in the plasma; these antibodies are often called agglutinins. People with blood group A have B antibodies (agglutinins); A antibodies are present in people with blood group B; and people with blood group O have antibodies to both A and B antigens. People with group AB blood do not have antibodies to either A or B antigens (Table 52–11). These naturally occurring antibodies are responsible for the rapid and severe reaction that occurs when ABO-incompatible blood is administered (Phillips & Gorski, 2014). Rhesus (Rh) Factor

The Rh factor antigen is present on the RBCs of approximately 85% of the people in the United States. Blood that contains the Rh factor is known as Rh positive (Rh+); blood that does not contain the Rh factor is known as Rh negative (Rh−). In contrast to the ABO blood groups, Rh− blood does not naturally contain Rh antibodies. However, after exposure to blood containing Rh factor (e.g., an Rh− mother carrying a fetus with Rh+ blood, or transfusion of Rh+ blood into a client who is Rh−), Rh antibodies develop. Subsequent exposure to Rh+ blood places the client at risk for an antigen–antibody reaction and hemolysis of RBCs. Blood Typing and Crossmatching

To avoid transfusing incompatible red blood cells, both blood donor and recipient are typed and their blood crossmatched. Blood typing Culturally Responsive Care

PATIENT-CENTERED CARE

Blood and Blood Products Jehovah’s Witnesses do not receive blood or blood ­products. Blood volume expanders are acceptable if they are not ­derivatives of blood. • Christian Scientists do not ordinarily use blood or blood products. •

From Cultural Diversity in Health and Illness (8th ed.), by R. Spector, 2013, Upper Saddle River, NJ: Pearson Education, Inc. Reprinted with permission.

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is done to determine the ABO blood group and Rh factor status. This test is also performed on pregnant women and neonates to assess for incompatibility between their blood types (particularly Rh factor incompatibilities). Because blood typing only determines the presence of the ABO and Rh antigens, crossmatching is also necessary prior to transfusion to identify possible interactions of minor antigens with their corresponding antibodies. RBCs from the donor blood are mixed with serum from the recipient; a reagent (Coombs’ serum) is added, and the mixture is examined for visible agglutination. If no antibodies to the donated RBCs are present in the recipient’s serum, agglutination does not occur and the risk of a transfusion reaction is small. Selection of Blood Donors

Screening of blood donors is rigorous. Criteria have been established to protect the donor from possible ill effects of donation and to protect the recipient from exposure to diseases transmitted through the blood. Blood donors are unpaid volunteers. Potential donors are eliminated by a history of hepatitis, HIV infection (or risk factors for HIV infection), heart disease, most cancers, severe asthma, bleeding disorders, or seizures. Donation may be deferred for people who have malaria, have been exposed to malaria or hepatitis, are anemic, have high or low BP, have low body weight, or who are pregnant, have had recent surgery, or take certain medications. Blood and Blood Products for Transfusion

Most clients do not require transfusion of whole blood. It is much more common for clients to receive a transfusion of a particular blood component specific to their individual needs. Table 52–12 lists some of the common blood products that may be transfused. Transfusion Reactions

Transfusion of ABO- or Rh- incompatible blood can result in a hemolytic transfusion reaction, which causes destruction of the transfused RBCs and subsequent risk of kidney damage or failure. To avoid hemolytic transfusion reactions, blood from the donor and from the recipient is tested for compatibility. This is referred to as a type and crossmatch. Other forms of transfusion reactions may also occur, including febrile or allergic reactions, circulatory overload, and sepsis. Because the risk of an adverse reaction is high when blood is transfused, clients must be frequently and carefully assessed before and during transfusion. Many reactions become evident within 5 to 15 minutes of initiating the transfusion, but reactions can develop any time during a transfusion; for this reason clients are most closely monitored during the initial period of the transfusion. Stop the transfusion immediately if signs of a reaction develop. Keep the line open with normal saline. Do not use the saline attached to the Y-set tubing because the filter contains blood and you do not want to give the client who is experiencing an acute transfusion reaction another drop of blood. Instead, use new IV tubing. Disconnect the infusion tubing from the hub of the IV catheter and replace with the new IV tubing. Do not piggyback the new tubing into the access port of the transfusion tubing, because it is possible that some of the blood product could be administered to the client. Hydrate the client with normal saline and notify the primary care provider. Continue to monitor vital signs (Phillips & Gorski, 2014). Possible transfusion reactions, their clinical signs and symptoms, and nursing implications are listed in Table 52–13.

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TABLE 52–12 

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Blood Products for Transfusion

Product Whole blood

Use Not commonly used except for extreme cases of acute hemorrhage. Replaces blood volume and all blood products: RBCs, plasma, plasma proteins, fresh platelets, and other clotting factors.

Packed red blood cells (PRBCs)

Used to increase the oxygen-carrying capacity of blood in anemias, surgery, and disorders with slow bleeding. One unit of PRBCs has the same amount of oxygen-carrying RBCs as a unit of whole blood. One unit raises hematocrit by approximately 2% to 3%.

Autologous RBCs

Used for blood replacement following planned elective surgery. Client donates blood for ­autologous transfusion 4–5 weeks prior to surgery.

Platelets

Replaces platelets in clients with bleeding disorders or platelet deficiency. Fresh platelets are most effective. Each unit should increase the average adult client’s platelet count by about 5,000 platelets/microliter.

Fresh frozen plasma

Provides clotting factors. Does not need to be typed and crossmatched (contains no RBCs).

Albumin and plasma protein fraction

Blood volume expander; provides plasma proteins.

Clotting factors and cryoprecipitate

Used for clients with clotting factor deficiencies. Each provides different factors involved in the clotting pathway; cryoprecipitate also contains fibrinogen.

TABLE 52–13 

Transfusion Reactions

Reaction: Cause Hemolytic reaction: incompatibility between ­client’s blood and donor’s blood

Clinical Signs Fever or chills, flank pain, and reddish or brown urine, tachycardia, hypotension

Nursing Intervention* 1. Discontinue the transfusion immediately. Note: When the transfusion is discontinued, the blood tubing must be ­removed as well. Use new tubing for the normal saline infusion. 2. Maintain vascular access with normal saline, or according to agency protocol. 3. Notify the primary care provider immediately. 4. Monitor vital signs. 5. Monitor fluid intake and output. 6. Send the remaining blood, bag, filter, tubing, a sample of the client’s blood, and a urine sample to the laboratory.

Febrile reaction: sensitivity of the client’s blood to white blood cells, platelets, or plasma proteins; does not cause hemolysis

Fever; chills; warm, flushed skin; headache; anxiety; nausea

1. 2. 3. 4.

Allergic reaction (mild): sensitivity to infused plasma proteins

Flushing, urticaria, with or without itching

1. Stop the transfusion immediately. Keep vein open with normal saline. 2. Notify the primary care provider. 3. Administer medication (antihistamines, steroids) as ordered.

Allergic reaction (severe): antibody–antigen reaction

Dyspnea, stridor, decreased oxygen saturation, chest pain, flushing

1. Stop the transfusion immediately. 2. Keep the vein open with a normal saline solution. 3. Notify the primary care provider immediately. 4. Monitor vital signs. Administer cardiopulmonary resuscitation if needed. 5. Administer medications and/or oxygen as ordered.

Circulatory overload: blood administered faster than the circulation can accommodate

Dyspnea, hypotension, orthopnea, crackles (rales), distended neck veins, tachycardia, hypertension

1. 2. 3. 4.

Stop the transfusion immediately. Place the client upright. Notify the primary care provider. Administer diuretics and oxygen as ordered.

Sepsis: contaminated blood administered

High fever, chills, vomiting, diarrhea, hypotension, oliguria

1. 2. 3. 4. 5. 6.

Stop the transfusion. Keep the vein open with a normal saline infusion. Notify the primary care provider. Administer IV fluids, antibiotics. Obtain a blood specimen from the client for culture. Send the remaining blood and tubing to the laboratory.

Discontinue the transfusion immediately. Keep the vein open with a normal saline infusion. Notify the primary care provider. Give antipyretics as ordered.

* Nurses should follow the agency’s protocol regarding interventions. These may vary among agencies.

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The hospital must have a protocol relating to transfusion reactions. Common measures include:

To saline To solution blood

• Notify the blood bank. • Examine the label on the blood container to check for errors in

Spikes

• Obtain laboratory specimens (e.g., blood work, urine sample). • Send blood container (whether or not it contains any blood), at-

Upper clamps

identifying the client, blood, or blood component.

tached infusion set, and IV solution to the blood bank (American Association of Blood Banks [AABB], 2009, p. 79).

Administering Blood

Special precautions are necessary when administering blood. When a transfusion is ordered, the nurse or other personnel obtain blood in plastic bags from the blood bank just before starting the transfusion. One unit of whole blood is 500 mL; a unit of packed red blood cells (RBCs) is 200 to 250 mL. Do not store the blood in the refrigerator on the nursing unit; lack of temperature control may damage the blood. Once blood or a blood product is removed from the blood bank refrigerator, it must be administered within a limited amount of time (e.g., packed RBCs should not hang for more than 4 hours after being removed from the blood bank refrigerator). Follow agency policies for verifying that the unit is correct for the client. The U.S. Food and Drug Administration (2011) requires blood products to have bar codes to allow for scanning and machine-readable information on blood and blood component container labels to help reduce medication errors. Traditionally, blood has usually been administered through an #18- to #20-gauge IV needle or catheter with the belief being that using smaller needles may slow the infusion and damage blood cells (hemolysis). However, studies have shown that blood infusions through smaller gauge catheters can be completed within 4 hours without hemolysis. Current practice guidelines established by the AABB and endorsed by the American Red Cross and the INS recommend that a #14- to #22 gauge IV catheter is acceptable for transfusion of cellular blood components in adults (Makic, Martin, Burns, Philbrick, & Rauen, 2013, p. 36). Large-bore IV catheters are difficult to insert in older adults and oncology clients. Using a smaller gauge catheter (i.e., #22-gauge) is more comfortable for the client, may reduce the number of needlesticks, and avoid complications (e.g., infiltration, hematomas, and phlebitis). Blood administration sets (Y-sets) are used to keep the vein open while starting the transfusion and to flush the line with normal saline before the blood enters the tubing (Figure 52–31 •). The infusion tubing has a filter inside the drip chamber. A transfusion should be completed within 4 hours of initiation. The maximum time for use of a blood filter is 4 hours (Phillips & Gorski, 2014). The SAFETY ALERT!

SAFETY

2014 THE JOINT COMMISSION NATIONAL PATIENT SAFETY GOALS (2013) Goal 1: Improve the accuracy of patient identification. Goal 01.03.01: Eliminate Transfusion Errors Related to Patient Misidentification. • Before initiating a blood or blood component transfusion: • Match the blood or blood component to the order. • Match the patient to the blood or blood component. • Use a two-person verification process or a one-person verification process accompanied by automated identification technology, such as bar coding.

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Drip chamber

Blood filter chamber

Main flow rate clamp

Slide clamp Y-Injection site

Adapter

Figure 52–31  •  Schematic of a Y-set for blood administration.

AABB (2009) states: “With the exception of 0.9% sodium chloride, no drug or medication should be added to blood or blood components unless they have been approved by the FDA or there is documentation that the addition is safe and does not adversely affect the blood or blood component” (p. 42). If an additional unit needs to be transfused, follow agency guidelines. A new blood administration set is to be used with each component (Phillips & Gorski, 2014). New IV tubing is used for administering other IV fluids following a transfusion. CLINICAL ALERT! Normal saline must always be used when giving a blood transfusion. If the client has an infusion of any other IV solution, stop that infusion and flush the line with saline prior to initiating the transfusion, or establish IV access through an additional site. Solutions other than saline can cause damage to the blood components.

To initiate, maintain, and terminate a blood transfusion, see Skill 52–6.

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Initiating, Maintaining, and Terminating a Blood Transfusion Using a Y-Set

ASSESSMENT Assess • Vital signs • Physical examination including fluid balance and heart and lung sounds as manifestations of hypo- or hypervolemia PLANNING • Review the client record regarding previous transfusions. Note any complications and how they were managed (e.g., allergies or previous adverse reactions to blood). • Confirm the primary care provider’s order for the number and type of units and the desired speed of infusion. • In some agencies, written consent for transfusion is required. Check policy and obtain as indicated. • Know the purpose of the transfusion. • Plan to begin the transfusion as soon as the component is ready. Typing and crossmatching can take several hours. • Note any premedication ordered by the primary care provider (e.g., acetaminophen or diphenhydramine). Schedule their administration (usually 30 minutes prior to the transfusion).

IMPLEMENTATION Preparation • If the client has an IV solution infusing, check whether the IV catheter and solution are appropriate to administer blood. The IV catheter size ranges between #14 and #22 gauge, and the solution must be normal saline. Dextrose (which causes lysis of RBCs), Ringer’s solution, medications and other additives, and hyperalimentation solutions are incompatible. Refer to step 6 below if the infusing solution is not compatible. • If the client does not have an IV solution infusing, check agency policies. In some agencies an infusion must be running before the blood is obtained from the blood bank. In this case, you will need to perform a venipuncture on a suitable vein (see Skill 52–1) and start an IV infusion of normal saline. Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Instruct the client to report promptly any sudden chills, nausea, itching, rash, dyspnea, back pain, or other unusual symptoms. 2. Provide for client privacy and prepare the client. • Assist the client to a comfortable position, either sitting or lying. Expose the IV site but provide for client privacy. 3. Perform hand hygiene and observe other appropriate infection prevention procedures. 4. Prepare the infusion equipment. • Ensure that the blood filter inside the drip chamber is suitable for the blood components to be transfused. Attach the blood tubing to the blood filter, if necessary. Rationale: Blood filters have a surface area large enough to allow

•

To provide plasma factors, such as antihemophilic factor (AHF) or factor VIII, or platelet concentrates, which prevent or treat bleeding

• • •

Status of infusion site Blood test results such as hemoglobin value or platelet count Any unusual symptoms

SKILL 52–6

PURPOSES • To restore blood volume after severe hemorrhage • To restore the oxygen-carrying capacity of the blood

DELEGATION Due to the need for sterile technique and technical complexity, blood transfusion is not delegated to UAP. The nurse must ensure that the UAP knows what complications or adverse signs can occur and should be reported to the nurse. In some states only RNs can administer blood or blood products. Equipment • Unit of whole blood, packed RBCs, or other component • Blood administration set • IV pump, if needed • 250 mL normal saline for infusion • IV pole • Venipuncture set containing a #14- to #22-gauge catheter (if one is not already in place) • Alcohol swabs • Tape • Clean gloves

the blood components through easily but are designed to trap clots. • Apply gloves. • Close all the clamps on the Y-set: the main flow rate clamp and both Y-line clamps. • Insert the piercing pin (spike) into the saline solution. • Hang the container on the IV pole about 1 m (39 in.) above the venipuncture site. 5. Prime the tubing. • Open the upper clamp on the normal saline tubing, and squeeze the drip chamber until it covers the filter and one third of the drip chamber above the filter. • Tap the filter chamber to expel any residual air in the filter. • Open the main flow rate clamp, and prime the tubing with saline. • Close both clamps. 6. Start the saline solution. • If an IV solution incompatible with blood is infusing, stop the infusion and discard the solution and tubing according to agency policy. • Attach the blood tubing primed with normal saline to the IV catheter. • Open the saline and main flow rate clamps and adjust the flow rate. Use only the main flow rate clamp to adjust the rate. • Allow a small amount of solution to infuse to make sure there are no problems with the flow or with the venipuncture site. Rationale: Infusing normal saline before initiating the transfusion also clears the IV catheter of incompatible ­solutions or medications. Continued on page 1388

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SKILL 52–6

Initiating, Maintaining, and Terminating a Blood Transfusion Using a Y-Set—continued 7. Obtain the correct blood component for the client. • Check the primary care provider’s order with the ­requisition. • Check the requisition form and the blood bag label with a laboratory technician or according to agency policy. Specifically, check the client’s name, identification number, blood type (A, B, AB, or O) and Rh group, the blood donor number, and the expiration date of the blood. Observe the blood for abnormal color, RBC clumping, gas bubbles, and extraneous material. Return outdated or abnormal blood to the blood bank. • With another nurse (most agencies require an RN), verify the following before initiating the transfusion (Phillips & Gorski, 2014, p. 731): a. Order: Check the blood or component against the ­primary care provider’s written order. b. Transfusion consent form: Ensure the form is completed per facility policy. c. Client identification: The name and identification number on the client’s identification band must be identical to the name and number attached to the unit of blood. d. Unit identification: The unit identification number on the blood container, the transfusion form, and the tag ­attached to the unit must agree. e. Blood type: The ABO group and Rh type on the primary label of the donor unit must agree with those recorded on the transfusion form. f. Expiration: The expiration date and time of the donor unit should be verified as acceptable. g. Compatibility: The interpretation of compatibility testing must be recorded on the transfusion form and on the tag attached to the unit. h. Appearance: There should be no discoloration, foaming, bubbles, cloudiness, clots or clumps, or loss of integrity of the container.

CLINICAL ALERT!

9. Establish the blood transfusion. • Close the upper clamp below the IV saline solution container. • Open the upper clamp below the blood bag. The blood will run into the saline-filled drip chamber. If necessary, squeeze the drip chamber to reestablish the liquid level with the drip chamber one third full. (Tap the filter to expel any residual air within the filter.) • Readjust the flow rate with the main clamp. • Remove and discard gloves. • Perform hand hygiene. 10. Observe the client closely for the first 15 minutes. • Phillips and Gorski (2014) report that the AABB recommends that “transfusions of RBCs be started at 1–2 mL/min for the first 15 minutes of the transfusion” (p. 732). Rationale: This small amount is enough to produce a severe reaction but small enough that the reaction could be treated successfully. • Note adverse reactions, such as chills, nausea, vomiting, skin rash, dyspnea, back pain, or tachycardia. Rationale: The earlier a transfusion reaction occurs, the more severe it tends to be. Promptly identifying such reactions helps to minimize the consequences. • Remind the client to call a nurse immediately if any unusual symptoms are felt during the transfusion such as chills, ­nausea, itching, rash, dyspnea, or back pain. • If any of these reactions occur, report these to the nurse in charge, and take appropriate nursing action. See Table 52–13 on page 1359. 11. Document relevant data. • Record starting the blood, including vital signs, type of blood, blood unit number, sequence number (e.g., #1 of three ordered units), site of the venipuncture, size of the catheter, and drip rate.

SAMPLE DOCUMENTATION

It is safer to have one nurse read the information for verification to the other nurse; this avoids errors that can be made if both nurses look at the tags together.

1/21/2015 1400 1 unit of PRBCs (#65234) hung to be infused over 3 hours. IV site in (L) forearm with 20 G angiocath. VS taken (see transfusion record). Informed to contact nurse if begins to experience any discomfort during transfusion. Stated he would use the call light –––––––––––––––––––––––––––––––––––––––––– C. Jones, RN

If any of the information does not match exactly, notify the charge nurse and the blood bank. Do not administer blood until discrepancies are corrected or clarified. • Sign the appropriate form with the other nurse according to agency policy. • Make sure that the blood is left at room temperature for no more than 30 minutes before starting the transfusion. Agencies may designate different times at which the blood must be returned to the blood bank if it has not been started. Rationale: As blood components warm, the risk of bacterial growth also increases. If the start of the transfusion is unexpectedly delayed, return the blood to the blood bank after 30 minutes. Do not store blood in the unit refrigerator. Rationale: The temperature of unit refrigerators is not ­precisely regulated and the blood may be damaged. 8. Prepare the blood bag. • Invert the blood bag gently several times to mix the cells with the plasma. Rationale: Rough handling can damage the cells. • Expose the port on the blood bag by pulling back the tabs. • Insert the remaining Y-set spike into the blood bag. • Suspend the blood bag.

12. Monitor the client. • Fifteen minutes after initiating the transfusion (or according to agency policy), check the vital signs. If there are no signs of a reaction, establish the required flow rate. Most adults can tolerate receiving one unit of blood in 1.5 to 2 hours. Do not transfuse a unit of blood for longer than 4 hours. • Assess the client, including vital signs, per agency policy. If the client has a reaction and the blood is discontinued, send the blood bag and tubing to the laboratory for investigation of the blood. 13. Terminate the transfusion. • Apply clean gloves. • If no infusion is to follow, clamp the blood tubing. Check agency protocol to determine if the blood component bag needs to be returned or if the blood bag and tubing can be disposed of in a biohazard container. The IV line can be discontinued or capped with an adapter or a new infusion line and solution container may be added. If another transfusion is to follow, clamp the blood tubing and open the saline infusion arm. Check agency protocol. A new blood administration set is to be used with each component (Phillips & Gorski, 2014, p. 733).

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Initiating, Maintaining, and Terminating a Blood Transfusion Using a Y-Set—continued

EVALUATION • Perform follow-up based on findings or outcomes that ­deviated from expected or normal for the client. Relate findings to ­previous data if available.

Remove and discard gloves. Perform hand hygiene. 15. Document relevant data. • Record completion of the transfusion, the amount of blood absorbed, the blood unit number, and the vital signs. If the primary IV infusion was continued, record connecting it. Also record the transfusion on the IV flow sheet and intake and output record. • •

SKILL 52–6

If the primary IV is to be continued, flush the maintenance line with saline solution. Disconnect the blood tubing system and reestablish the IV infusion using new tubing. Adjust the drip to the desired rate. Often a normal saline or other solution is kept running in case of delayed reaction to the blood. • Measure vital signs. 14. Follow agency protocol for appropriate disposition of the used supplies. • Discard the administration set according to agency practice. • Dispose of blood bags and administration sets. a. On the requisition attached to the blood unit, fill in the time the transfusion was completed and the amount transfused. b. Attach one copy of the requisition to the client’s record and another to the empty blood bag if required by agency policy. c. Agency policy generally involves returning the bag to the blood bank for reference in case of subsequent or ­delayed adverse reaction. •

SAMPLE DOCUMENTATION 4/21/2015 1420 c/o feeling warm, headache, & backache. Skin flushed. T 102.6°F, BP 140/90, P 112, R 28. Approximately 50 mL PRBCs (#65234) infused over past 20 minutes. Infusion stopped. IV tubing changed, NS infusing at 15 mL/hr. Blood & attached tubing sent to blood bank. Dr. Riley notified. –––––––––––––– C. Jones, RN

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Report significant deviations from normal to the primary care provider.

than 1,300 mL per day and within 500 mL of intake” is not achieved, questions to be considered might include the following:

Evaluating Using the overall goals identified in the planning stage of maintaining or restoring fluid balance, maintaining or restoring pulmonary ventilation and oxygenation, maintaining or restoring normal balance of electrolytes, and preventing associated risks of fluid, electrolyte, and acid–base imbalances, the nurse collects data to evaluate the effectiveness of interventions. If desired outcomes are not achieved, the nurse, client, and support person if appropriate need to explore the reasons before modifying the care plan. For example, if the outcome “Urine output is greater

• Have other outcome measures for the goal of achieving fluid bal-

ance been met?

• Does the client understand and comply with planned fluid intake? • Is all urinary output being measured? • Are unusual or excessive amounts of fluid being lost by another

route (e.g., gastric suction, excessive perspiration, fever, rapid respiratory rate, wound drainage)? • Are prescribed medications being taken or administered as ordered?

NURSING CARE PLAN  Deficient Fluid Volume Assessment Data

Nursing Diagnosis

Desired Outcomes*

Nursing Assessment Merlyn Chapman, a 27-year-old sales clerk, reports weakness, malaise, and flu-like symptoms for 3–4 days. Although thirsty, she is unable to tolerate fluids because of nausea and vomiting, and she has liquid stools 2–4 times per day.

Deficient Fluid Volume related to nausea, vomiting, and diarrhea as evidenced by decreased urine output, increased urine concentration, weakness, fever, decreased skin/tongue turgor, dry mucous membranes, increased pulse rate, and decreased blood pressure

Fluid Balance [0601] as evidenced by not compromised: • 24-hour intake and output balance • Urine specific gravity • Blood pressure • Pulse rate • Temperature • Skin turgor • Moist mucous membranes

Physical Examination

Diagnostic Data

Height: 160 cm (5′3′′) Weight: 66.2 kg (146 lb) Mild fever: 38.6°C (101.5°F) Pulse: 96 beats/min Respirations: 24/min Scant urine output BP: 102/84 mmHg Dry oral mucosa, furrowed tongue, cracked lips

Urine specific gravity: 1.035 Serum sodium 145 mEq/L Serum potassium 3.5 mEq/L Chest x-ray negative

Continued on page 1390

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NURSING CARE PLAN Deficient Fluid Volume—continued Nursing Interventions*/Selected Activities

Rationale

Fluid Management [4120] Weigh daily and monitor trends.

Weight helps to assess fluid balance.

Maintain accurate I&O record.

Accurate records are critical in assessing the client’s fluid balance.

Monitor vital signs as appropriate.

Vital sign changes such as increased heart rate, decreased blood ­pressure, and increased temperature indicate hypovolemia.

Give fluids as appropriate.

As her nausea decreases encourage oral intake of fluids as tolerated, again to replace lost volume.

Administer IV therapy as prescribed.

Mrs. Chapman will probably require IV replacement of fluid. This is ­especially true because her oral intake is limited because of nausea and vomiting.

Evaluation Outcomes met. Mrs. Chapman remained hospitalized for 48 hours. She required fluid replacement of a total of 5 liters. Her blood pressure increased to 122/74 mmHg, pulse rate decreased to a resting level of 74 beats/min, and respirations decreased to 12/min. Her urine output increased as the fluid was replaced and was adequate at >0.5 mL/kg per hour by the time of discharge. The urine specific gravity was 1.015. Lab work on the day of discharge was K+: 3.8 and Na+: 140. She had elastic skin turgor and moist mucous membranes. She was taking oral fluids and was able to discuss symptoms of deficient fluid volume that would necessitate her calling her health care provider. *The NOC # for desired outcomes and the NIC # for nursing interventions and selected activities are listed in brackets following the appropriate outcome or intervention. Outcomes, interventions, and activities selected are only a sample of those suggested by NOC and NIC and should be further individualized for each client.

APPLYING CRITICAL THINKING 1. Offer suggestions for ways to help Mrs. Chapman increase her oral intake. 2. Mrs. Chapman asks why you weigh her every morning. How do you respond? See Critical Thinking Possibilities on student resource website.

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CONCEPT MAP Deficient Fluid Volume

MC 27 y.o. female

assess

• Sales clerk, reports weakness, malaise, and flu-like symptoms for 3–4 days. Although thirsty, is unable to tolerate fluids because of nausea and vomiting, and has liquid stools 2–4 times per day.

• Height: 160 cm (5' 3") • Weight: 66.2 kg (146 lbs) • T: 38.6°C; P: 96 BPM; • R: 24; BP: 102/84 • Dry mucous membranes • Decreased skin turgor

• • • •

Urine specific gravity: 1.035 Serum sodium: 155 mEq/L Serum potassium 3.2 mEq/L Chest x-ray negative

generate nursing diagnosis Deficient Fluid Volume r/t nausea, vomiting, diarrhea aeb decreased urine output, increased urine concentration, weakness, fever, decreased skin turgor, dry mucous membranes, increased pulse, and decreased BP outcome Outcomes met: • BP: 122/74 • P: 74 • Urine output increased • Specific gravity: 1.015 • Moist mucous membranes • Elastic skin turgor

evaluation

Fluid balance aeb not compromised • 24 hour intake and output • Blood pressure, pulse, and temperature • Skin turgor • Urine specific gravity • Mucous membranes

nursing intervention Fluid Management activity

activity

Give fluids as appropriate

Weigh daily and monitor trends

activity

activity

Administer IV therapy as prescribed activity

Monitor vitals signs as appropriate

Maintain accurate intake and output record

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Chapter 52 Review CHAPTER HIGHLIGHTS • A balance of fluids, electrolytes, acids, and bases in the body is •

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necessary for good health. Body fluid is divided into two major compartments: intracellular fluid (ICF) inside the cells and extracellular fluid (ECF) outside the cells. ECF is subdivided into two compartments: intravascular (plasma) and interstitial. It constitutes about one third of total body fluid. ECF is in constant motion throughout the body. It is the transport system that carries nutrients to and waste products from the cells. The percentage of total body fluid varies according to an individual’s age, body fat, and gender. The younger a person is, and the less body fat present, the greater the proportion of body fluid; postadolescent females have a smaller percentage of fluid in relation to total body weight than men. There are two types of body electrolytes (ions): positively charged ions (cations) and negatively charged ions (anions). The principal ions of ECF are sodium (cation), chloride (anion), and bicarbonate (anion); the principal ions of ICF are potassium and magnesium (cations), and phosphate and sulfate (anions). Fluids and electrolytes move among the body compartments by osmosis, diffusion, filtration, and active transport. The major fluid pressures exerted as part of the movement of fluid and electrolytes from one compartment to another are osmotic pressure and hydrostatic pressure. The three sources of body fluid are liquids and food, which are ingested, and the oxidation of food. Fluid intake is regulated by the thirst mechanism. Fluid output occurs chiefly through excretion of urine, although body fluid is also lost through sweat, feces, and respiration. In healthy adults, measurable fluid intake and output should balance (about 1,500 mL per day). The output of urine normally approximates the oral intake of fluids. Water from food and oxidation is balanced by fluid loss through urine, feces, and insensible losses, such as losses through the skin as perspiration. A number of body systems and organs are involved in regulating the volume and composition of body fluids: the kidneys, lungs, the cardiovascular and gastrointestinal systems, and the endocrine system. The kidneys are the primary regulator of fluid and electrolyte balance. Substances such as antidiuretic hormone, the renin-angiotensinaldosterone system, and atrial natriuretic factor are also involved in maintaining fluid balance. The acid–base balance (pH range) of body fluids is maintained within a precise range of 7.35 to 7.45. Acid–base balance is regulated by buffers, which neutralize excess acids or bases; the lungs, which eliminate or retain carbon dioxide, a potential acid; and the kidneys, which excrete or conserve bicarbonate and hydrogen ions. Factors that influence an individual’s fluid, electrolyte, and acid– base balance include age, gender and body size, environmental

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temperature, and lifestyle. Illness, trauma, surgery, and certain medications can place individuals at risk for fluid, electrolyte, and acid–base imbalances. Fluid imbalances include fluid volume deficit (FVD), also referred to as hypovolemia; fluid volume excess (FVE), also referred to as hypervolemia; dehydration, a deficit in water and an increase in serum sodium level; and overhydration, an excess of water and decrease in serum sodium level. Acid–base imbalance occurs when the normal 20-to-1 ratio of bicarbonate to carbonic acid is upset. Imbalances may be either respiratory or metabolic in origin; either can result in acidosis or alkalosis. Fluid, electrolyte, and acid–base imbalances are most accurately determined through laboratory examination of blood plasma. Assessment relative to fluid, electrolyte, and acid–base balances includes (a) a nursing history; (b) physical examination of the skin, oral cavity, eyes, jugular vein, veins of the hand, and the neurologic system; (c) measurement of body weight, vital signs, and fluid intake and output; and (d) diagnostic studies of blood and urine. A nursing history includes data about the client’s fluid and food intake; fluid output; signs of fluid, electrolyte, and acid–base imbalances; and medications, therapies, or disease processes that may disrupt these balances. NANDA-approved nursing diagnoses that relate specifically to fluid, electrolyte, and acid–base imbalances include Deficient Fluid Volume, Excess Fluid Volume, Risk for Imbalanced Fluid Volume, Risk for Deficient Fluid Volume, and Impaired Gas Exchange. Other diagnoses that may be relevant are Impaired Oral Mucous Membrane, Impaired Skin Integrity, Decreased Cardiac Output, Ineffective Tissue Perfusion, Activity Intolerance, Risk for Injury, and Acute Confusion. In many instances, fluids and electrolytes can be provided orally to clients who are experiencing or at risk of developing fluid deficits. The nurse needs to establish with the client a 24-hour plan for ingesting the necessary fluids and to respect the client’s fluid preferences. For clients with fluid retention, fluids may need to be restricted; a schedule and short-term goals that make the fluid restriction more tolerable need to be developed. For clients experiencing excessive fluid losses, the administration of fluids and electrolytes intravenously is necessary. Meticulous aseptic technique is required when caring for clients with IV infusions. Preventing complications such as infiltration, extravasation, and phlebitis is an important aspect of IV therapy. The administration of blood transfusions involves accurately matching and identifying the blood for the individual, correctly identifying the recipient, and monitoring the client throughout the procedure for transfusion reactions.

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TEST YOUR KNOWLEDGE 1. A client tells the nurse about passing out after following a fasting diet for 5 days. Which acid–base imbalance would the nurse expect to assess in this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 2. Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. What action by the nurse is priority? 1. Notify the client’s physician. 2. Discontinue the transfusion. 3. Slow the rate of the transfusion. 4. Prepare to resuscitate the client. 3. The nurse administers an IV solution of D5 1/2NS to a ­postoperative client. This is classified as what type of ­intravenous solution? _____________ 4. An older client comes to the emergency department experiencing chest pain and shortness of breath. An arterial blood gas is ordered. Which of the following ABG results indicates respiratory acidosis? 1. pH 7.54; PaCO2 28 mmHg; HCO3 22 mEq/L 2. pH 7.32; PaCO2 46 mmHg; HCO3 24 mEq/L 3. pH 7.31; PaCO2 35 mmHg; HCO3 20 mEq/L 4. pH 7.50; PaCO2 37 mmHg; HCO3 28 mEq/L 5. The intake and output (I&O) record of a client with a nasogastric tube who has been attached to suction for 2 days shows greater output than input. Which nursing diagnoses are most applicable? Select all that apply. 1. Deficient Fluid Volume 2. Risk for Deficient Fluid Volume 3. Impaired Oral Mucous Membranes 4. Impaired Gas Exchange 5. Decreased Cardiac Output

6. Which client statement indicates a need for further teaching ­regarding treatment for hypokalemia? 1. “I will use avocado in my salads.” 2. “I will be sure to check my heart rate before I take my digoxin.” 3. “I will take my potassium in the morning after eating breakfast.” 4. “I will stop using my salt substitute.” 7. A client has had a subclavian central venous catheter inserted. What should the nurse assess as a priority for this client’s care? 1. Presence of bibasilar crackles 2. Tachycardia 3. Decreased pedal pulses 4. Headache 8. The client’s arterial blood gas results are pH 7.32; PaCO2 58; HCO3 32. The nurse knows that the client is experiencing which acid–base imbalance? 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 9. A client is admitted to the hospital for hypocalcemia. Nursing interventions relating to which system would have the highest priority? 1. Renal 2. Cardiac 3. Gastrointestinal 4. Neuromuscular 10. The nurse would assess for signs of hypomagnesemia in which of the following clients? Select all that apply. 1. A client with renal failure 2. A client with pancreatitis 3. A client taking magnesium-containing antacids 4. A client with excessive nasogastric drainage 5. A client with chronic alcoholism See Answers to Test Your Knowledge in Appendix A.

READINGS AND REFERENCES Suggested Readings Crawford, A., & Harris, H. (2011). I.V. fluids. What nurses need to know. Nursing, 41(5), 30–38. doi:10.1097/ 01.NURSE.0000396282.43928.40 This article reviews how fluid acts within the body and discusses when and why various IV fluids can be used to maintain homeostasis. McCarron, K. (2013). Blood essentials. Nursing made Incredibly Easy!, 11(2), 16–24. doi:10.1097/01 .NME.0000426305.72862.5f In a clear and succinct review, the author describes the many blood components, how they are used, and appropriate practice guidelines. Wunderlich, R. (2013). Principles in the selection of intravenous solutions replacement: Sodium and water balance. Journal of Infusion Nursing, 36, 126–130. doi:10.1097/ NAN.0b013e318283440d This article provides an excellent and concise review of the basic pathophysiology of sodium imbalances and therapeutic interventions for their correction.

Related Research Sakr, Y., Rother, S., Ferreira, A. M. P., Ewald, C., Dunishch, P., Riedemmann, N., & Reinhart, K. (2013). Fluctuations in serum sodium level are associated with an increased risk of death in surgical ICU patients. Critical Care Medicine, 41(1), 133–142. doi:10.1097/CCM.0b013e318265f576

Woody, G., & Davis, B. A. (2013). Increasing nurse competence in peripheral intravenous therapy. Journal of Infusion Nursing, 36, 413–419. doi:10.1097/ NAN.0000000000000013

References American Association of Blood Banks. (2009). Standards for blood banks and transfusion services (26th ed.). Bethesda, MD: Author. Broadhurst, D. (2012). Transition to an elastomeric infusion pump in home care: An evidence-based approach. Journal of Infusion Nursing, 35, 143–151. doi:10.1097/ NAN.0b013e31824d1b7a Bulechek, G. M., Butcher, H. K., Dochterman, J. M., & Wagner, C. M. (Eds.). (2013). Nursing interventions classifications (NIC) (6th ed.). St. Louis, MO: Mosby Elsevier. Crawford, A., & Harris, H. (2011). Balancing act: Na+ sodium K+ potassium. Nursing, 41(7), 44–50. doi:10.1097/ 01.NURSE.0000397838.20260.12 Dychter, S. S., Gold, D. A., Carson, D., & Haller, M. (2012). Intravenous therapy: A review of complications and economic considerations of peripheral access. Journal of Infusion Nursing, 35, 84–91. doi:10.1097/ NAN.0b013e31824237ce Gorski, L. A. (2010). Central venous access device associated infections: Recommendations for best practice in home

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infusion therapy. Home Healthcare Nurse, 28, 221–229. doi:10.1097/NHH.0b013e3181d6c3ad Hadaway, L. (2012). Needleless connectors for IV catheters. American Journal of Nursing, 112(11), 32–44. doi:10.1097/01.NAJ.0000422253.72836.c1 Herdman, T. H., & Kamitsuru, S. (2014). (Eds.). NANDA International nursing diagnoses: Definitions and classification, 2015–2017. Oxford, United Kingdom: Wiley-Blackwell. Higginson, R. & Parry, A. (2011). Phlebitis: Treatment, care and prevention. Nursing Times, 107 (36), 18–21. Infusion Nurses Society. (2011a). Infusion nursing standards of practice. Norwood, MA: Author. Infusion Nurses Society. (2011b). Policies and procedures for infusion nursing (4th ed.). Norwood, MA: Author. The Joint Commission. (2013). Hospital: 2014 national patient safety goals. Retrieved from http://www.jointcommission .org/hap_2014_npsgs Kristiniak, S., Harpel, J., Breckenridge, D. M., & Buckle, J. (2012). Black pepper essential oil to enhance intravenous catheter insertion in patients with poor vein visibility: A controlled study. Journal of Alternative and Complementary Medicine, 18, 1003–1007. doi:10.1089/acm.2012.0106 LeMone, P., Burke, K., & Bauldoff, G. (2011). Medical–surgical nursing: Critical thinking in patient care (5th ed.). Upper Saddle River, NJ: Pearson Education.

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Makic, M. B. F., Martin, S. A., Burns, S., Philbrick, D., & Rauen, C. (2013). Putting evidence into nursing practice: Four traditional practices not supported by the evidence. Critical Care Nurse, 33(2), 28–44. doi:10.4037/ ccn2013787 Martin, S. M. (2013). Extravasation management of nonchemotherapeutic medications. Journal of Infusion Nursing, 36, 392–396. doi:10.1097/NAN.0000000000000010 Martini, F. H., Nath, J. L., & Bartholomew, E. F. (2015). Fundamentals of anatomy and physiology (10th ed.). Upper Saddle River, NJ: Pearson Education. Mathers, D. (2011). Evidence-based practice: Improving outcomes for patients with a central venous access device. Journal of the Association for Vascular Access, 16, 64–72. doi:10.2309/java.16-2-3 Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Mosby Elsevier. Moureau, N. L., & Dawson, R. B. (2010). Keeping needleless connectors clean, part 2. Nursing, 40(6), 61–63. Phillips, L. D., & Gorski, L. A. (2014). Manual of I.V. therapeutics. Evidence-based practice for infusion therapy (6th ed.). Philadelphia, PA: F.A. Davis. Ray-Barruel, G., Polit, D. F., Murfield, J. E., & Rickard, C. M. (2014). Infusion phlebitis assessment measures: A systematic review. Journal of Evaluation in Clinical Practice, 20(2), 191–202. doi:10.1111/jep.12107 Spector, R. (2013). Cultural diversity in health and illness (8th ed.). Upper Saddle River, NJ: Pearson.

U.S. Food and Drug Administration. (2011). Bar code label requirements for blood and blood components questions and answers. Retrieved from http://www.fda.gov/ BiologicsBloodVaccines/DevelopmentApprovalProcess/ AdvertisingLabelingPromotionalMaterials/BarCodeLabelRequirements/ucm133136.htm Vacca, V. M. (2013). Vesicant extravasation. Nursing, 43(9), 21–22. doi:10.1097/01.NURSE.0000432917.59376.55 Wright, M. O., Tropp, J., Schora, D. M., Dillon-Grant, M., Peterson, K., Boehm, S., . . . Peterson, L. R. (2013). Continuous passive disinfection of catheter hubs prevents contamination and bloodstream infection. American Journal of Infection Control, 41, 33–38. doi:10.1016/j .ajic.2012.05.030

Selected Bibliography Argame, J. (2014). Picking up on PICC lines. Nursing made Incredibly Easy!, 12(1), 14–16. doi:10.1097/ 01.NME.0000432874.05582.bf Chamberlain, L. (2012). Hyponatremia caused by polydipsia. Critical Care Nurse, 32(3), e11–20. doi:10.4037/ ccn2012173 Collins, M., & Claros, E. (2011). Recognizing the face of dehydration. Nursing, 41(8), 26–31. doi:10.1097/01 .NURSE.0000399725.01678.b7 Crawford, A., & Harris, H. (2011). Balancing act: Hypomagnesemia & hypermagnesemia. Nursing, 41(10), 52–55. doi:10.1097/01.NURSE.0000403378.71042.fo

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Crawford, A., & Harris, H. (2012). Balancing act: Calcium & phosphorus. Nursing, 42(1), 36–42. doi:10.1097/01 .NURSE.0000408492.25896.04 Crawford, A., & Harris, H. (2012). SIADH: Fluid out of balance. Nursing, 42(9), 50–58. doi:10.1097/ 01.NURSE.0000418617.99217.49 Harvey, S., & Jordan, S. (2010). Diuretic therapy: Implications for nursing practice. Nursing Standard, 24(43), 40–50. doi:10.7748/ns2010.06.24.43.40.c7879 Hughes, T. (2012). Providing information to children before and during venipuncture. Nursing Children and Young People, 24(5), 23–28. doi:10.7748/ncyp2012.06.24.5.23.c9142 Scales, K. (2011). Reducing infection associated with central venous access devices. Nursing Standard, 25(36), 49–56. doi:10.7748/ns2011.05.25.36.49.c8517 Stickley, T. (2011). From SOLER to SURETY for effective nonverbal communication.Nurse Education in Practice, 11(6), 395–398. doi:10.1016/j.nepr.2011.03.021 Tolich, D. J., Blackmur, S., Stahorsky, K., & Wabeke, D. (2013). Blood management: Best practice transfusion strategies. Nursing, 43(1), 40–47. doi:10.1097/ 01.NURSE.0000423955.22755.b1 Weeks, K. (2012). Intermittent IV infusions in acute care: Special considerations. Nursing, 42(12), 66–68. doi:10.1097/01.NURSE.0000421393.74230.73 Williams, W. (2013). Fluid management basics. Nursing Made Incredibly Easy!, 11(4), 48–51. doi:10.1097/ 01.NME.0000426300.80485.91

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UNIT

10

Meeting the Standards This unit discusses the fundamentals of physiological health including activity and exercise, sleep, pain management, nutrition, urinary and fecal elimination, oxygenation, circulation, fluid and electrolyte balance, and acid–base balance. Most clients in the acute care setting will have one or more ­issues related to these physiological requirements and the nurse must be alert to the client’s needs to prevent complications from developing.

CLIENT: Agnes  AGE: 71  CURRENT MEDICAL DIAGNOSES: Fractured left hip Medical History: Agnes is a healthy and active African American woman who lives alone. Agnes and her sisters decided it would be fun to go roller skating, and she fell and fractured her left hip. The fracture was diagnosed by x-ray in the emergency department. She underwent open reduction of the fracture and was admitted to the orthopedic unit of the hospital. She will be transferred to a rehabilitation facility once her condition has stabilized. Agnes has a 30-year history of hypertension that she controls with diet and atenolol 50 mg once daily and hydrochlorothiazide 25 mg once per day.

Personal and Social History: Agnes is single and has no children, but she has many friends as well as two sisters and a brother who live nearby. Even in the emergency department after hearing the diagnosis, she and her sisters have been laughing about what fun it will be telling people she broke her hip roller skating. She has a wonderful sense of humor and is often heard laughing. She retired 6 years ago after having worked for 45 years as a pediatric nurse.

Questions American Nurses Association Standard of Professional Performance #3 is Outcomes Identification: The nurse identifies expected outcomes for a plan individualized to the client or situation by considering associated risks, benefits, costs, current scientific evidence, expected trajectory of the condition, and clinical expertise when formulating expected outcomes. 1. Develop an expected outcome for this client related to chapters in this unit including activity and exercise, pain management, fecal elimination, and circulation. 2. What risks can you identify for this client related to activity and exercise, sleep, nutrition, and oxygenation? American Nurses Association Standard of Professional Performance #4 is Planning: The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes by establishing the plan priorities with the health care consumer, family, and others as appropriate.

3. When planning care with Agnes related to activity and exercise, pain management, nutrition, fecal elimination, oxygenation, and circulation, establish the priorities of care. American Nurses Association Standard of Professional Performance #5A is Coordination of Care: The registered nurse coordinates the delivery of care with a focus on maximizing the client’s independence and quality of life. 4. Of activity and exercise, sleep, pain management, nutrition, urinary elimination, fecal elimination, oxygenation, circulation, and fluid, electrolyte, and acid–base balance, which one carries the greatest risk to Agnes’s independence and quality of life? 5. What actions can the nurse take to promote and maximize ­Agnes’s independence? American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author. See Suggested Answers to End-of-Unit Meeting the Standards Questions on student resource website.

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Appendix A Answers to Test Your Knowledge Chapter 1: Historical and Contemporary Nursing Practice

1. Answer: 4. Rationale: Option 1, Clara Barton is noted for establishing the American Red Cross. Option 2 and 3, Lillian Wald and Mary Brewster are considered the founders of public health nursing. Cognitive Level: Analyzing. Client Need: Safe Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 1-1. 2. Answer: 2. Rationale: A clinical nurse specialist has an advanced degree or expertise and is considered to be an expert in a specialized area of practice (oncology in this case). The nurse provides direct client care, educates others, consults, conducts research, and manages care. A nurse practitioner usually deals with nonemergency acute or chronic illness and provides primary ambulatory care. The nurse educator is responsible for classroom and often clinical teaching. A nurse entrepreneur usually has an advanced degree, manages a healthrelated business, and may be involved in education, consultation, or research. Cognitive Level: Understanding. Client Need: N/A. Nursing ­Process: N/A. Learning Outcome: 1-3. 3. Answer: 2. Rationale: Continuing education refers to formalized experiences designed to enhance the knowledge or skill of practi­ tioners. The other answers are examples of in-service education, which is designed to upgrade the knowledge or skills of current employees with regard to the specific setting, and is usually less formal in presentation. Cognitive Level: Analyzing. Client Need: Safe, Effective Care ­Environment. Nursing Process: N/A. Learning Outcome: 1-4. 4. Answer: 3. Rationale: Health promotion focuses on maintaining normal status without consideration of diseases. Option 1 is an example of illness prevention. Option 2 is aesthetic (i.e., not needed for health promotion or disease prevention). Option 4 focuses on disease detection. Cognitive Level: Remembering. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 1-6. 5. Answer: 3. Rationale: All are noted nurses. Linda Richards was America’s first trained nurse, and Mary Mahoney was America’s first Black trained nurse. Cognitive Level: Remembering. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 1-2. 6. Answer: 2. Rationale: Option 1, the advanced beginner, demonstrates marginally acceptable performance. Option 3, the proficient practi­ tioner, has 3 to 5 years of experience and has developed a holistic understanding of the client. Option 4, the expert practitioner, demonstrates highly skilled intuitive and analytic ability in new situations. Cognitive Level: Remembering. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 1-11. 7. Answer: 4. Rationale: The National Student Nurses Association developed the Code of Academic and Clinical Conduct for nursing students in 2001. Option 1, ANA, developed Standards of Nursing Practices. Option 2, NLN, focuses on nursing education. Option 3, the American Association of Colleges of Nursing (AACN), is the national organization that focuses on the advancement and maintenance of America’s baccalaureate and higher degree nursing education programs. Cognitive Level: Remembering. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 1-13. 8. Answer: 1. Rationale: All will impact nursing but not necessarily the supply and demand issue. The aging population contributes to more older adults needing specialized care (increasing the demand). Fewer nursing faculty to educate students and fewer nurses practicing because of retirement contribute to the decreasing supply. ­Cognitive Level: Analyzing. Client Need: N/A. Nursing Process: N/A. ­Learning Outcome: 1-12.

9. Answer: 4. Rationale: Wellness involves individual and community activities to enhance healthy lifestyles. The goal of illness prevention is to maintain optimal health by preventing disease, which would include immunization, prenatal and infant care, and prevention of sexually transmitted disease (options 1 and 2). Teaching clients about recovery activities, such as exercises that accelerate recovery after a stroke, would focus on health restoration. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation Learning Outcome: 1-9. 10. Answer: Progression Rationale: The focus has changed to academic progression for all nurses. Cognitive Level: Remembering. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 1-3.

Chapter 2: Evidence-Based Practice and Research in Nursing

1. Answer: 4. Rationale: Trial and error is not considered valid evidence, and may even be harmful to clients. Clinical experience (option 1), the opinions of experts (option 2), and client values and preferences (option 3) are all considered valid evidence in evidence-based practice. Cognitive Level: Remembering. Client Need: N/A Nursing Process: N/A. Learning Outcome: 2-3 2. Answer: 2. Rationale: In experimental design the investigator manipulates the independent variable by administering an experimental treatment to some participants while withholding it from others. In a nonexperimental design, the investigator does no manipulation of the independent variable. A pilot study is a test study before the actual one begins and is not a type of research design. Cognitive Level: Understanding Client Need: N/A. Nursing Process: N/A. Learning Outcome: 2-4. 3. Answer: 3. This study investigates the subjective experience of stress, through the collection of narrative data. Options 1, 2, and 4 are examples of quantitative research using numbers and values. Cognitive Level: Applying. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 2-4. 4. Answer: 2. Rationale: The key purpose of a study’s methodology is to generate data that are reliable and valid, thus controlling ­extraneous variables is a major function. The hypotheses that are tested are formed during the problem identification phase of a study (option 1). Grants and funding sources are not related to methodology (option 3). ­Protecting subjects’ rights (option 4) is an important consideration, but not the key purpose of a methodology. Cognitive Level: Understanding. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 2-5. 5. Answer: 2. Rationale: PICO stands for patient/client, population, or problem; intervention; comparison; and outcome. These are helpful components of a research question and help to identify key terms for a literature search. Options 1, 3, and 4 are incorrect. Cognitive Level: Remembering. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 2-5. 6. Answer: 3. Rationale: All nurses, including new graduates, could help to identify clinical problems in direct client care (option 1). Nurse managers would most likely use research findings to develop policies and procedures and may not necessarily have an advanced degree (option 2). All nurses, including new graduates, could ­participate in data collection (option 4). Cognitive Level: Applying. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 2-6.

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Appendix A 7. Answer: 1. Rationale: The research problem has significance if it has the potential to contribute to nursing science by enhancing client care, testing or generating a theory, or resolving a day-to-day clinical problem. If the adolescents are showing improved behavior, then these techniques have significance in enhancing client care. Cognitive Level: Understanding. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 2-5. 8. Answer: 4. Rationale: The right to self-determination means that subjects feel free of constraints, coercion, or any undue influence to participate in a study. There is not enough information given to indicate if any of the other rights in options 1, 2, and 3 have been violated. Cognitive Level: Applying. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 2-7. 9. Answer: 3, 2, 1, 5, 4, 6. Cognitive Level: Remembering. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 2-2. 10. Answer: 3. Rationale: There may have been unique aspects to this research that would not be applicable in a different setting or with ­different clients. Not all research is flawed (option 1) and it may or may not have taken cost into consideration (option 2). Research is not ­limited to the study of physiological problems (option 4). Cognitive Level: Understanding. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 2-1.

Chapter 3: Nursing Theories and Conceptual Frameworks

1. Answer: 3. Rationale: A supposition or system of ideas proposed to explain a given phenomenon is a theory. Concepts are mental images that are included within a theory (option 1); a conceptual framework is a group of related ideas, statements, or concepts (option 2); and a paradigm is a pattern of shared understandings and assumptions about reality and the world (option 4). Cognitive Level: Remembering. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 3-1. 2. Answer: 2. Rationale: A group of related ideas or statements is a conceptual framework. A philosophy is a belief system (option 1); a supposition or system of ideas proposed to explain a given phenomenon is a theory (option 3); and a paradigm is a pattern of shared understandings and assumptions about reality and the world (option 4). Cognitive Level: Remembering. Client Need: N/A. Nursing Process: N/A. ­Learning Outcome: 3-1. 3. Answer: 4. Rationale: A set of shared understandings and assumptions about reality and the world is a paradigm. A concept is a mental image (option 1); a conceptual framework is a group of related ideas, statements, or concepts (option 2); and a practice discipline is a field of study in which the central focus is performance of a professional role (option 3). Cognitive Level: Remembering. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 3-1. 4. Answer: 1, 2, 5. Rationale: Some nursing scholars think that grounding research in theories from other disciplines detracts from the development of nursing as a separate discipline and makes nursing research less relevant. Other disciplines regularly share research findings, and it does not detract from the professional source. Some scholars believe that bringing insights and perspectives from other disciplines helps to broaden values of the profession (option 3). Other disciplines are also attentive to the human condition (option 4). Cognitive Level: Applying. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 3-5. 5. Answer: 4. Rationale: The four major concepts in Option 4 can be superimposed on almost any theoretical work in nursing. They are collectively referred to as a metaparadigm for nursing. Options 1, 2, and 3 do not include the ‘pattern’ associated with the four concepts that comprise a metaparadigm. Cognitive Level: Remembering. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 3-3. 6. Answer: 1. Rationale: Practice theories assist the nurse to reflect on nursing care. Theories describing the interrelationships among a broad range of concepts within nursing are grand theories, not midlevel, and both require more testing through nursing research (option 2). Schools

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of nursing in the United States may or may not be organized around any theory or conceptual model (option 3). Nursing theory guides the direction of research and education and practice (option 4). Cognitive Level: Applying. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 3-4. 7. Answer: 1, 2, 3, 5. Rationale: While important, economic frugality is not a central concept of nursing care (option 4). Cognitive Level: Analyzing. Client Need: N/A. Nursing Process: N/A. Learning ­Outcome: 3-2.

Chapter 4: Legal Aspects of Nursing

1. Answer: 4. Rationale: Obtaining informed consent for specific medical treatment is the responsibility of the person who is going to perform the procedure, in this case the physician. Informed consent suggests that the client has been given complete information, including benefits, risks, and alternatives if the treatment is not given. It is the physician’s responsibility to make sure the client’s understanding is clear. It is important that the person obtaining the consent (the physician in this case) answer the client’s questions. If the client has questions, he should not sign the form, and it is not the nurse’s responsibility to answer the questions (options 1 and 2). Telling the client what he “should have” done is demeaning and not an appropriate therapeutic response (option 3). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Assessment. Learning Outcome: 4-4. 2. Answer: 4. Rationale: Battery is the willful touching of a person without permission. Another name for an unintentional tort is professional negligence/malpractice. This situation is an intentional tort because the nurse executed the act on purpose. Assault is the attempt or threat to touch another person unjustifiably or without permission. Invasion of privacy injures the feelings of the person and does not take into consideration how revealing information or exposing the client will affect the client’s feelings. Cognitive Level: Analyzing. Client Need: Safe, ­Effective Care Environment. Nursing Process: N/A. Learning Outcome: 4-10. 3. Answer: 2. Rationale: The nurse should call the person who wrote the order for clarification. Administering the medication is incorrect because knowing the dose is outside the normal range and not questioning the order could lead to client harm and liability for the nurse. Calling the pharmacist is not the best answer because it will not solve the problem, and the nurse needs to seek clarification from the person who wrote the order. The nurse should suspend administration but not refuse to administer the medication until the issue is resolved. ­Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 4-7. 4. Answer: 1. Rationale: Foreseeability is the link between the nurse’s act and the injury suffered. The client did not use the call light and got out of bed unassisted. Nighttime confusion occurs with some clients but unless the nurse had knowledge or awareness that this would happen, there was no link between the nurse’s action and the client’s fall. Damages and injury may well be present, but these ­probably are not due to any action or inaction on the nurse’s part (options 2 and 3). Duty was addressed as the call light was within reach (option 4). Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Evaluation. Learning Outcome: 4-9. 5. Answer: 2. Rationale: While taking vital signs was an appropriate task to delegate to the UAP, the responsibility of the action—in this case, the inaction since the vitals were recorded inaccurately—is not fully assumed by the UAP and remains with the nurse. Delegating this task was not the responsibility of the nurse manager and so the responsibility of the action is not his/hers (option 4). Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 4-7.

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Appendix A

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Answers to Test Your Knowledge

6. Answer: 3. Rationale: A DNR order only controls CPR and similar lifesaving treatments. All other care continues as previously ordered. Competent clients can still decide about their own care (including the DNR order). Nothing about the DNR order is related to when the client may die. Because clients’ medical conditions and their views of their lives can change, a new DNR order is required for each admission to a health care agency. Once admitted, that order stands until changed or until it expires according to agency policy. Cognitive Level: ­Applying. Client Need: Psychosocial Integrity. Nursing Process: ­Planning. Learning Outcome: 4-7. 7. Answer: 3. Rationale: The only person entitled to information without written consent is the client and those providing direct care. The nurse has open access to information regarding assigned clients only. ­Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 4-11. 8. Answer: 1, 2, and 5. Rationale: The nurse is subject to the limitation of the state law and should be familiar with the Good Samaritan laws in the specific state. Gross negligence would be described by the individual state law. Unless there is another equally or more qualified person present, the nurse needs to stay until the injured person leaves. The nurse should ask someone else to call or go for additional help. Since there was no prior agreement, the nurse cannot accept compensation. Also, the nurse is not employed by the accident victim. The same client rights apply at the scene of an accident as well as those in the workplace. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcome: 4-12. 9. Answer: 1, 3, and 4. Rationale: Interacting with others (versus isolating self from others) and setting limits on the number of hours working are positive behaviors and not indicative of possible impairment. The other options are warning signs for impairment. Cognitive Level: ­Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Evaluation. Learning Outcome: 4-6. 10. Answer: 2 and 3. Rationale: Standards of practice require a complete assessment. A nurse needs to be sure the client’s needs have been met. They both can impact client safety and do not follow standards of care. The other options meet the standards of practice. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 4-7.

Chapter 5: Values, Ethics, and Advocacy

1. Answer: 1. Rationale: A nurse’s actions in an ethical dilemma must be defensible according to moral and ethical standards. The nurse may have strong personal beliefs but distancing oneself from the situation does not serve the client (option 2). A team is not always required to reach decisions (option 3), and the nurse is not obligated to follow the client’s wishes automatically when they may have negative consequences for self or others (option 4). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcome: 5-2. 2. Answer: 2. Rationale: The nurse has an ethical responsibility to act only when actions are safe or risks minimized. This nurse is putting the client at unnecessary risk for a medication error. Many medical practices are controversial but not necessarily unethical (option 1). The nurse should follow agency policy. Although some may view nurses’ strikes as unethical, supporting others who are striking is a personal decision (option 3). Although a client statement in confidence to a nurse may have ethical overtones, it does not automatically constitute an ethical dilemma. Since the assigned health care provider is a member of the team, principles of confidentiality do not include him or her (option 4). Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: N/A. Learning Outcome: 5-4.

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3. Answer: 1. Rationale: Autonomy is the client’s (or surrogate’s) right to make his or her own decision. The nurse is obliged to respect a client’s or significant other’s informed decision. These parents may modify their decision as time goes on and the child’s condition, or their feelings, change. This situation is not clearly one of nonmaleficence (do no harm) in option 2 or beneficence (do good) in option 3 since there are many aspects of both. If the child appeared to be suffering or an effective treatment was being denied, these principles might apply. Justice (fairness) generally applies when the rights of one client are being balanced against those of another client (option 4). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing ­Process: N/A. Learning Outcome: 5-3. 4. Answer: 3. Rationale: In values clarification, clients are assisted to think about the factors that influence their beliefs and decisions. Any judgmental statement that reflects the rightness or wrongness of the client’s thoughts or actions will impede this process (options 1, 2, and 4). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 5-2. 5. Answer: 1. Rationale: Resource allocation and financial considerations are major issues in home health care. When clients are in their own home, they operate from their own values and client autonomy must be respected. Community resources may be of benefit for this client to be able to afford the proper supplement at the correct dose or to provide assistance in other financial areas so the client has the treatment needs met. The client already knows she should take the prescribed amount (option 2). Telling the physician will not help to solve the situation (option 3). Weighing the client merely assesses the need, which has already been established (option 4). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 5-5. 6. Answer: 4. Rationale: Altruism is a concern for the welfare and well-being of others. A professional behavior of this value is demonstrating the understanding of cultures, beliefs, and perspectives of others. ­Human dignity, social justice, and autonomy are not the values ­described here. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcome: 5-1.

Chapter 6: Health Care Delivery Systems

1. Answer: 3. Rationale: Actions such as diet modification that help to prevent an illness or detect it in its early stages are primary preventions. Treatment of a disease such as with antibiotic therapy (option 1) or surgery (option 4) is secondary prevention, while rehabilitation efforts following an illness (option 2) are considered tertiary prevention. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: N/A. Learning Outcome: 6-1. 2. Answer: 3. Rationale: Patient-focused care is a delivery model that brings all services and care providers to the client. Activities provided by auxiliary personnel (physical therapy, respiratory therapy, ECG testing, and phlebotomy) are moved close to the client, thereby decreasing the number of personnel involved and the number of steps needed to get the work done. Cognitive Level: Understanding. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 6-2. 3. Answer: 3. Rationale: Differentiated practice is a system in which the best possible use of nursing personnel is based on their educational preparation and resultant skill sets. This model consists of specific job descriptions for nurses according to their education or training. Patient-focused care, shared governance, and managed care are not the models described in the stem. Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcome: 6-3.

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Appendix A 4. Answer: 2, 3, 5, 6. Rationale: Though there is an increase in complementary and alternative medicine use, this does not affect how health care is delivered (option 1). Chronic illness is prevalent in this group (option 4). Cognitive Level: Understanding. Client Need: N/A. ­Nursing Process: Diagnosis. Learning Outcome: 6-4. 5. Answer: 4. Rationale: A health maintenance organization involves a set monthly membership fee and predictable visit or deductible costs. Medicare covers a minimal number of preventive and outpatient services so the cost cannot be anticipated (option 1). Individual fee-for-service insurance is perhaps the most costly to the client, with potentially large differences between the amount of coverage the insurance company pays and the provider’s charges (option 2). PPOs are less costly than fee-for-service entities, but more expensive than HMOs (option 3). Cognitive Level: Analyzing. Client Need: Safe, ­Effective Care Management. Nursing Process: Planning. Learning Outcome: 6-6.

Chapter 7: Community Nursing and Care Continuity

1. Answer: 2. Rationale: PHC involves issues of the environment, agriculture, and housing. It also involves other social, economic, and political issues such as poverty, transportation, unemployment, and economic development to sustain the population. Distribution and participation are two of the five principles incorporated in PHC. Consumerism and governmental subsidies are not part of the PHC makeup. Low life expectancies and high mortality rates among children are two concerns about health care that led to the global health strategy of primary health care. Cognitive Level: Applying. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 7-1. 2. Answer: 1. Rationale: The Pew Commission identified the need for modern health care providers to be proficient in the use of technology. Care should be emphasized in primary, rather than tertiary, settings (option 2). The commission also identified the need for contemporary (not traditional) clinical strategies (option 3) and for collaborative decision making with clients (option 4). Cognitive Level: Analyzing. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 7-5. 3. Answer: 3. Rationale: Social interparticipation refers to community activities that are designed to meet people’s needs for companionship. Socialization refers to the process of transmitting values, knowledge, culture, and skills to others. Social control refers to the way in which order is maintained in a community. Mutual support refers to the community’s ability to provide resources at a time of illness or disaster. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: N/A. Learning ­Outcome: 7-4. 4. Answer: 2. Rationale: In collaboration, each member of the team, including the client, participates in sharing ideas and reaching consensus on the best plan of care. The team is generally led by the health care professional most skilled in the client’s specific areas of need (option 1). Once the plan is established, it may be implemented by any member of the team or a designate at an appropriate time and place (option 3). It is not necessarily delegated by the nurse (option 4). Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: N/A. Learning Outcome: 7-6. 5. Answer: 4. Rationale: Effective discharge planning would have included an assessment of home care needs prior to the client leaving the hospital. The kind of care is determined before the client leaves the current setting. That is why it is called discharge “planning.” Following a thorough assessment, the client would be taught self-care strategies and a basic plan of care for the coming days (option 3). Obtaining medications and a ride home does not indicate the client possesses the knowledge and skills needed to manage care after discharge (option 2). If the client will need care at home, those referrals would be made by the discharge planner and communicated to the client. Option 4

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indicates the client knows and accepts these referrals. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Evaluation. Learning Outcome: 7-7. 6. Answer: 4. Rationale: Production, distribution, and consumption of goods and services are the means by which the community provides for the economic needs of its members. It includes supplying food and clothing as well as providing water, electricity, police and fire protection, and the disposal of refuse. Cognitive Level: Applying. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 7-5.

Chapter 8: Home Care

1. Answer: 3. Rationale: Although hospitals have recently become more welcoming to families, a major strength of home care is the involvement and proximity of loved ones. Curative and lifesaving approaches may be used both at home and in the hospital (option 1). An asset of home care nurses is their ability to manage complex symptoms (option 2). This includes expertise in pain management, but the same legal strategies are available in either in-home care or hospitals (option 4). Cognitive Level: Applying. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 8-2. 2. Answer: 4. Rationale: Indirect care is provided by the home health nurse to the client each time the nurse consults with other health care providers about ways to improve nursing care for the client. Hands-on care, direct care, and client advocacy are not described in the stem (options 1, 2, and 3). Cognitive Level: Understanding. Client Need: Safe and Effective Care Environment. Nursing Process: Planning. Learning Outcome: 8-4. 3. Answer: 4. Rationale: Home health nurses can express concern when a situation suggests the possibility for injury. They must document information they provide and the family’s response to instruction as well as make ongoing assessments about the family’s use of safety precautions. While not inappropriate, the client is not likely to act upon the information the nurse provides in option 1. Nurses cannot expect to change a family’s living space and lifestyle and such an intervention may be resented by the client (option 2). The nurse has an obligation to bring safety issues to the client’s attention (option 3). Cognitive Level: Applying. Client Need: Safe Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 8-6 4. Answer: 1. Rationale: If the caregiver’s own health is becoming threatened, it may be a sign of overload. It would be appropriate for the caregiver to ask for assistance from others (option 2), or to ask for clarification of ways he or she can assist the client (option 3). Sadness related to a poor prognosis would be a normal and expected response as long as it does not evolve into depression (option 4). Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Diagnosis. Learning Outcome: 8-7. 5. Answer: 4. Rationale: A physician’s authorization of the plan of care is needed before home health care by a nurse can be initiated. Insurance coverage is not required although the agency may need proof of the client’s ability to pay if insurance is not available or adequate (option 1). Many clients benefit from home health care even if there is no in-home caregiver present or needed (option 2). The health problem for which home care is needed may be chronic or acute and may necessitate preventive, curative, or palliative therapy (option 3). Cognitive Level: Applying. Client Need: Safe and Effective Care Environment. Nursing Process: Planning. Learning Outcome: 8-3. 6. Answer: 1, 3, and 6. Rationale: Nurses may work with hospice clients as a subset of home health. In home health, nurses care for both client and family and perform physical, psychosocial, and emotional interventions. Skilled nursing facilities are not considered locations for home health nursing (option 2). Home health can include high-tech equipment and procedures (option 4). Clients may have home care

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whether or not they can afford other health care. Cognitive Level: ­Remembering. Client Need: Safe and Effective Care Environment. Nursing Process: Planning. Learning Outcome: 8-4. 7. Answer: 4. Rationale: The emergency response necklace only works within the client’s home in proximity to the base station. It will not activate away from home. The client needs to wear it at all times when home. It can be worn when away from home but the client must understand that activating it when away will not summon assistance. It is appropriate for the client to wear a medical alert bracelet at all times (option 1) and have a list of medications posted on the refrigerator ­(option 2). Area rugs should be removed if clients could trip on them ­(option 3). Cognitive Level: Applying. Client Need: Safe and Effective Care Environment. Nursing Process: Evaluation. Learning Outcome: 8-6.

Chapter 9: Electronic Health Records and Information Technology 1. Answer: 2. Rationale: Maintaining privacy and security of data is a significant issue. One way that computers can protect data is by the use of passwords; only those persons who have a legitimate need to access the data receive the password. Information in a computer data system may not always be safe, and it would be inappropriate for the nurse to say this (option 1). A nurse’s involvement does not ensure security (option 3). Reminding the client that there is indeed cause for privacy concerns is not therapeutic (option 4). Cognitive Level: Applying. Client Need: Safe Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 9-2, 9-4. 2. Answer: 3. Rationale: Control over who has access to confidential computerized data is the greatest concern. Computer hackers can bypass codes and gain access to personal information, which could result in identity theft. The benefits often outweigh the cost (option 1). Computerized data can be much more accurate than paper-and-pencil data (option 2). Due to ease of making copies and backups, electronic data can last forever (option 4). Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: N/A. ­Learning Outcome: 9-2. 3. Answer: 4. Rationale: Since learners may do their online work at different times and do much of their work offline, it may be harder for them to feel and act like a class group. The courses are often selfpaced and, thus, may take a longer or shorter time to complete than on-campus courses (option 1). Interpersonal communication is possible through e-mail and chat, plus audio and video file sharing allow learners to see and hear the faculty as well as each other (option 2). For most web-based courses, learners may log on at their convenience (option 3). Cognitive Level: Understanding. Client Need: N/A. Nursing ­Process: N/A. Learning Outcome: 9-1. 4. Answer: 1. Rationale: The Cumulative Index to Nursing and Allied Health Literature (CINAHL) focuses on nursing and allied health articles, including research. The user can search systematically for articles that are related to nursing research, peer reviewed, published, and so on. The Google search engine gives a variety of sites, both health-­related and non-health-related, but there are no restrictions for accuracy with this database. Educational Resources Information Center (ERIC) would include all areas of academia, not just nursing. PsychINFO includes only psychological abstracts. Cognitive Level: Applying. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 9-5. 5. Answer: 4. Rationale: Spreadsheets are programs that can manipulate numbers. Data are arranged in columns and rows. Spreadsheets are used for budgets and are useful for working with staffing, scheduling, invoicing, research, and other analyses. A database is used to manage detailed information (option 1). In Word processing, documents are checked for spelling and grammar, and individualized to include pictures, charts, and designs (option 2). Graphics programs have become popular with their ability to create charts, tables, and pictures (option 3). Cognitive Level: Applying. Client Need: Health Promotion

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and Maintenance. Nursing Process: Implementation. Learning Outcome: 9-3.

Chapter 10: Critical Thinking and Clinical Reasoning

1. Answer: 2. Rationale: The nurse has inferred and concluded something that is beyond the available information (and in this case may not be accurate). The prescription and the diarrhea are facts (option 1). It would be judgment and opinion if the nurse stated that the laxative would make the diarrhea worse and should not be given (options 3 and 4). (Note: Critical thinking will cause this nurse to examine the assumptions made and gather more data before acting.) Cognitive Level: Analyzing. Client Need: N/A. Nursing Process: Evaluation. Learning Outcome: 10-1. 2. Answer: 2. Rationale: Nurses who utilize good critical-thinking skills are able to think and act in areas where there are neither clear answers nor standard procedures. Treatment options, especially for the home health client, can be extensive. There are many points to consider (good and bad), and choosing between treatment options can cause conflict among family members. The nurse in this case must use creativity, analysis based on science, and problem-solving skills, all of which contribute to critical-thinking skills. Options 1, 3, and 4 do not require much reasoning. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 10-1. 3. Answer: 2. Rationale: Reviewing evidence-based literature and identifying similarities in the clinical manifestations of symptoms is an act of clinical reasoning. Past experiences in care enhance the nurse’s ability to recognize and respond in the delivery of client-centered care. Clinical judgment in nursing is a decision-making process to ascertain the right action to implement at the appropriate time during client care (option 1). Reflection is the nurse’s review of the care provided to determine strategies to improve future care (option 3), Intuition is a problem-solving approach that relies on a nurse’s inner sense (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: N/A. Learning Outcome: 10-2. 4. Answer: 1. Rationale: The research method uses a research studybased approach to problem solving. Trial and error (option 2) and intuition (option 3) would involve unstructured approaches resulting in less predictable results. The nursing process generally uses application of known interventions, previously determined by the scientific (research) process (option 4). Cognitive Level: Applying. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 10-5. 5. Answer: 2. Rationale: Intuition is the understanding or learning of things without the conscious use of reasoning. It is also known as sixth sense, hunch, instinct, feeling, or suspicion. Clinical experience allows the nurse to recognize cues and patterns and begin to reach correct conclusions using intuition. Finding no cause for concern in the physical assessment of the client, the nurse is not satisfied and continues to assess the client’s surroundings, finding the error. Trial and error is solving problems through a number of approaches until a solution is found (option 1). Judgment is not part of problem solving (option 3). The scientific method requires that the nurse evaluate potential solutions to a given problem in an organized, formal, and systematic approach (option 4). Cognitive Level: Applying. Client Need: N/A. Nursing Process: Planning. Learning Outcome: 10-4 6. Answer: 2. Rationale: The nurse’s intuition is like a sixth sense that allows the nurse to recognize cues and patterns to reach correct conclusions. The nurse appropriately obtains vital signs and an oxygen saturation to assess the client’s clinical picture more fully. Option 1 supports appropriate nursing actions, but the client’s respiratory status should be assessed first. Usually, a physician must order a chest x-ray (option 2). The rapid response team (option 4) may be needed if the client’s condition becomes more critical. Cognitive Level: Applying.

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Client Need: Physiological Integrity. Nursing Process: Implementing. Learning Outcome: 10-2. Answer: 1. Rationale: By reconsidering the type of dressing used based on research, the nurse is using integrity. Options 2 and 3 are critical thinking attitudes characterized by an awareness of the limits of one’s own knowledge, and being trustworthy. Option 4 indicates an attitude of not being easily swayed by the opinions of others. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 10-4. Answer: 1, 2, 4, 5. Rationale: While option 3 might be true, medicine and nursing have evolved tremendously, and so has the need for nurses to be critical thinkers. According to R. Alfaro LeFevre’s Top 10 Reasons to Improve Thinking, patients are sicker, with multiple problems, and so nursing care requires a more critical form of thinking in order to meet their nursing needs; redesigning care delivery is useless if nurses don’t have the thinking skills required to deal with today’s world; consumers and payers demand to see evidence of benefits, ­efficiency, and results; and today’s progress often creates new problems that can’t be solved by old ways of thinking. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 10-1 Answer: 2. Rationale: The nurse recognizes the need to obtain further information from the client in order to respond directly to the client’s statement. Option 1 passes off the client’s educational needs to another practitioner. Options 3 and 4 are nontherapeutic. Cognitive Level: ­Applying. Client Need: Physiological Integrity. Nursing Process: ­Planning. Learning Outcome: 10-5. Answer: 4. Rationale: A nurse thinks critically, evaluates possible solutions, and uses problem solving. Intuition (option 1) is not a sufficient basis for implementing wound care when significant data on alternative care strategies are available. Research (option 2) is a more comprehensive rigorous process and not typically implemented while caring for an infected wound. Trial and error (option 3) is unsafe and inappropriate for care of an infected wound. Cognitive Level: ­Understanding. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 10-5.

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Chapter 11: Assessing

1. Answer: 3. Rationale: Delivery or organized care is not part of the nursing process, though each phase is interrelated (option 1). The nursing process is not part of the medical model as nurses treat the client’s response to the disease or problem (option 2). The nursing process is individualized for each client’s care plan. It is not about standardizing care (option 4). Cognitive Level: Applying. Client Need: N/A. Nursing Process: Diagnosis. Learning Outcome: 11-1. 2. Answer: 1, 2, 5. Rationale: Diagnosing is analyzing and synthesizing data in order to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions as well as developing a list of nursing and collaborative problems. Developing a plan and specifying goals and outcomes is part of the planning phase. Cognitive Level: Applying. Client Need: N/A. Nursing Process: Assessment. Learning Outcome: 11-1. 3. Answer: 2. Rationale: Primary data come from the client (option 4), whereas secondary data come from any other source (chart, family). Subjective data are covert (reported or an opinion), whereas objective data can be measured or validated (weight—option 1, edema—option 3). If the spouse had stated that the client had eaten only toast and tea, this would be secondary objective (measured) data. Cognitive Level: Applying. Client Need: N/A. Nursing Process: Assessment. Learning Outcome: 11-5. 4. Answer: 2. Rationale: The nurse should use a combination of directive and nondirective approaches during the interview to determine areas of concern for the client. Simply noting the concern, without dealing with it,

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or passing the questions off to the doctor can leave the impression that the nurse does not care about the client’s concerns or dismisses them as unimportant (options 1 and 3). A closed question (option 4) does not allow the client to offer much information, besides yes/no or one-word answers. Cognitive Level: Applying. Client Need: N/A. Nursing Process: Assessment. Learning Outcome: 11-8. Answer: 4. Rationale: Frameworks help the nurse be systematic in data collection. Other members of the health care team may use very different conceptual organizing frameworks so data may not correlate (option 1). Cost-effective care (option 2) is more likely to occur with systematic application of the nursing process, but use of a framework for assessment alone may not accomplish this goal. Because the framework is structured and because of the nature of client needs/problems, creativity and intuition in care planning are not assured (option 3). Cognitive Level: Applying. Client Need: N/A. Nursing Process: Assessment. Learning Outcome: 11-10. Answer: 1. Rationale: Assessing provides a database of the client’s physiological and psychosocial responses to his or her health status. Client strengths and problems (option 2) are identified in the diagnosing phase of the nursing process, a care plan is established (option 3) in the planning phase, and care, prevention, and wellness promotion (option 4) are part of the implementing phase. Cognitive Level: Remembering. Client Need: N/A. Nursing Process: Assessment. Learning Outcome: 11-3. Answer: 3. Rationale: In validating, the nurse confirms that data is complete and accurate. Subjective data is collected in the collecting activity (option 1), a framework is applied to the data in the organizing activity (option 2), and data is recorded in the documenting activity (option 4). Cognitive Level: Understanding. Client Need: N/A. Nursing Process: Assessment. Learning Outcome: 11-4. Answer: 1. Rationale: The nursing process focuses on client needs. It is dynamic rather than static (option 2), emphasizes client responses rather than physiology and illness (option 3), and is collaborative rather than used exclusively by nurses (option 4). Cognitive Level: ­Understanding. Client Need: N/A. Nursing Process: Assessment. Learning Outcome: 11-4. Answer: 4. Rationale: Interpreting collected data is necessary to help validate its accuracy. Observing includes the senses of smell, hearing, and touch in addition to vision (option 1). Using priority setting, observing must often be performed simultaneously with other activities (option 2). A systematic approach to observing data helps ensure nothing is missed and the nurse pays attention to the most important data first (option 4). Cognitive Level: Understanding. Client Need: N/A. Nursing Process: Assessment. Learning Outcome: 11-6. Answer: 2, 4, and 5. Rationale: The nurse plans the interview so that privacy is observed. A comfortable distance between nurse and client to respect the client’s personal space is about 3 feet. Using a standard form will help ensure the nurse doesn’t omit gathering any vital information. Lighting should be at a normal level—neither bright nor dim (option 1). The nurse should be at the same height as the client, usually sitting, at approximately a 45° angle facing the client. The nurse standing over the client creates an uncomfortable atmosphere for an interview (option 3). Cognitive Level: Applying. Client Need: N/A. Nursing Process: Planning. Learning Outcome: 11-9.

Chapter 12: Diagnosing

1. Answer: 3. Rationale: Learning from peers and seasoned nurses is helpful, but does not take the place of didactic information (options 1 and 2). Experience teaches much information, but it never takes the place of concrete, scientific theory (option 4). Cognitive Level: ­Applying. Client Need: N/A. Nursing Process: Diagnosis. Learning Outcome: 12-4. 2. Answer: 2. Rationale: Because the venous return is impaired, fluid is static, resulting in swelling. Therefore, decreased venous return is the

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cause (etiology) of the problem. Excess Fluid Volume is the nursing diagnosis, and edema of the lower extremity is the sign/symptom or critical attribute. The cause is known. Cognitive Level: Application. Client Need: N/A. Nursing Process: Diagnosis. Learning Outcome: 12-6. Answer: 1. Rationale: States the relationship between the stem (caregiver role strain) and the cause of the problem. Option 2: The diagnostic statement says the same thing as the related factor (falls and collapse). Option 3: It is inappropriate to use medical diagnoses such as stroke within a nursing diagnosis statement. Option 4 is vague. The statement must be specific and guide the plan of care (fatigue may be a result of sleep deprivation and does not direct intervention). ­Cognitive Level: Applying. Client Need: N/A. Nursing Process: Diagnosis. ­Learning Outcome: 12-2. Answer: 2, 3, 4, 6. Rationale: The Taxonomy II system codes diagnoses according to seven axes that includes age, time, health status, and unit of care. Health patterns and gender are not axes upon which diagnoses are coded. Cognitive Level: Understanding. Client Need: N/A. Nursing Process: Diagnosis. Learning Outcome: 12-5. Answer: 1. Rationale: A collaborative (multidisciplinary) problem is indicated when both medical and nursing interventions are needed to prevent or treat the problem. If nursing care alone (whether that care involves independent or dependent nursing actions) can treat the problem, a nursing diagnosis is indicated. If medical care alone can treat the problem, a medical diagnosis is indicated. Cognitive Level: Applying. Client Need: N/A. Nursing Process: Diagnosis. Learning Outcome: 12-3. Answer: 1. Rationale: A syndrome diagnosis is associated with a cluster of other diagnoses (in this situation, urinary elimination alteration, impaired skin integrity, and powerlessness). Currently, there are six syndrome diagnoses on the NANDA International list. The others are incorrect options. Cognitive Level: Understanding. Client Need: N/A. Nursing Process: Diagnosis. Learning Outcome: 12-2. Answer: 3. Rationale: Diagnostic labels are continuously reviewed and revised as indicated by research—much more of which is needed. The original taxonomy has been replaced by Taxonomy II and is no longer based on a nurse theorist (options 1 and 2). New diagnoses are approved by NANDA International’s Diagnostic Review Committee, not by a vote of nurses (option 4). Cognitive Level: Remembering. Client Need: N/A. Nursing Process: Diagnosis. Learning Outcome: 12-7. Answer: 1, 4, and 5. Rationale: A client’s movement toward a goal (option 1) or whose behavior is inconsistent with population norms (options 4 and 5) represents a cue that further analysis toward creating a nursing diagnosis is required. Corrected vision (option 2) and bladder and bowel control at age 18 months (option 3) are consistent with population norms. Cognitive Level: Analyzing. Client Need: N/A. Nursing Process: Diagnosis. Learning Outcome: 12-4.

Chapter 13: Planning

1. Answer: 4. Rationale: Strategic planning is an ongoing process focused on organizational change rather than individual clients so it is least useful and not relevant in this case. The client requires initial planning because he has just arrived on the orthopedic unit for the first time (option 1). Of the three types of planning that need to be done at this time, initial is the highest priority since he has just had surgery. The client also requires the ongoing type of planning necessary to determine the care appropriate for this shift (option 2). Discharge planning needs to start on admission to ensure adequate client preparation for management of health needs outside the health agency (option 3). ­Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcome: 13-2. 2. Answer: 2. Rationale: The nurse must consider a variety of factors when assigning priorities, including resources available to the nurse

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and client. Factors in this case include the distance between the client’s home and the hospital and the fact that therapy is ordered on a twice daily basis. Driving 80 miles two times a day may not be feasible, but perhaps there are other alternatives that could be considered (e.g., a neighbor who might be willing to drive the client, or someone in the area who may be able to assist with the therapy). Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Planning. Learning Outcome: 13-5. Answer: 2. Rationale: More detailed assessment data and consultation with the client would be needed to absolutely confirm the priority. Postoperative nausea to the level of inhibiting oral intake has the greatest likelihood of leading to complications and requires nursing intervention now. The client’s pain level is not extreme considering the recency of the surgery, and pain intervention can be assumed to be effective (option 1). Although the constipation is probably bordering on abnormal, a nursing intervention would most likely begin with oral treatment, which is not possible due to the nausea. More invasive interventions such as an enema or suppository would not be commonly administered the first day postoperative (option 3). Wound infection can occur, but there are no data to indicate that this requires a change in the current plan (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 13-5. Answer: 1. Rationale: Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Ambulating without a walker by a certain date is specific as well as measurable. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 13-8. Answer: 3. Rationale: Although there may be standard policies or routines for measuring intake and output, the nursing intervention should specify if this is to be done “routinely” or at specific intervals (e.g., q4h). The nurse is also aware, however, that critical thinking indicates that the intake and output should be monitored more frequently than ordered if assessment reveals abnormal findings. Cognitive Level: Understanding. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 13-9. Answer: 3, 1, 4, and 2. Rationale: In planning, first the nurse sets priorities and then writes goals/outcomes, selects interventions, and then writes the nursing care plan. Cognitive Level: Understanding. Client Need: N/A. Nursing Process: Planning. Learning Outcome: 13-1. Answer: 4. Rationale: An individualized care plan is tailored to meet the unique needs of a specific client, needs that are not addressed by the standardized care plan. In this situation, the client had complications following a relatively routine procedure, something that is unplanned and a rare occurrence and must fit with the needs of the client. Cognitive Level: Understanding. Client Need: N/A. Nursing Process: Planning. Learning Outcome: 13-3. Answer: 1. Rationale: Goal statements provide the standard against which outcomes are measured. Nursing diagnoses are prioritized before goals are written (option 2). Both independent and dependent interventions may be appropriate for any goal (option 3). Clarity of the goal does not influence delegation of the intervention (option 4). ­Cognitive Level: Analyzing. Client Need: N/A. Nursing Process: Planning. Learning Outcome: 13-6. Answer: 4. Rationale: NOC outcomes should reflect both the nurse’s and the client’s values of what is trying to be achieved. The outcomes still must be customized (option 1), but address only one nursing diagnosis at a time (option 2). Outcomes are narrow/specific end points, not broad (option 3). Cognitive Level: Applying. Client Need: N/A. Nursing Process: Planning. Learning Outcome: 13-7. Answer: 1. Rationale: Interventions should address the etiology of the nursing diagnosis. Both independent and dependent interventions

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Appendix A should be selected if appropriate (option 2) and several interventions may be needed for a single outcome (option 3). Both action and assessment-type interventions can be used (option 4). Cognitive Level: Applying. Client Need: N/A. Nursing Process: Planning. Learning Outcome: 13-10.

Chapter 14: Implementing and Evaluating

1. Answer: 2, 4, 5. Rationale: Evaluating the outcome of the interventions is part of the evaluation phase (option 1). Documentation of the history and physical is part of the initial assessment (option 3). ­Cognitive Level: Understanding. Client Need: N/A. Nursing ­Process: Implementation. Learning Outcome: 14-3. 2. Answer: 4. Rationale: It is never acceptable practice for the nurse to document a nursing activity before it is carried out. This would be very unsafe because many things can cause an activity to be postponed or canceled and prior charting would be inaccurate, misleading, and potentially dangerous. In a few situations, it may be permissible to chart frequent or routine activities some time following the activities such as at the end of a shift or after a particular interval (e.g., every 4 hours) rather than immediately following the activity. Cognitive Level: Applying. Client Need: N/A. Nursing Process: Implementation. ­Learning Outcome: 14-4. 3. Answer: 4. Rationale: Though assessment is the first phase of the nursing process it is carried out during all phases (option 1). Evaluation is continuous (option 2). In option 3, though the two processes overlap, there is a difference between the data collected. Assessment data are collected for the nurse to make a diagnosis and evaluate desired outcomes. Evaluation data are collected for the purpose of comparing them to prescribed goals and judging the effectiveness of the nursing care. Cognitive Level: Understanding. Client Need: N/A. Nursing Process: Evaluation. Learning Outcome: 14-5. 4. Answer: 2. Rationale: There is no reason to delete (option 1) or modify (option 3) the nursing diagnosis or demote its priority (option 4) because the risk factors that prompted it are still present. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Evaluation. Learning Outcome: 14-7. 5. Answer: 2. Rationale: Because this assessment focuses on how care is provided, it is a process evaluation. A structure evaluation (option 1) would focus on the setting (e.g., how well equipment functions), and outcome evaluations (option 3) focus on changes in client status (e.g., whether reported satisfaction levels vary with type of person who answers the call light). An audit (option 4) would be a chart or document review. Cognitive Level: Analyzing. Client Need: N/A. Nursing Process: Evaluation. Learning Outcome: 14-8. 6. Answer: 1, 2, 3, 4. Rationale: Successful evaluation depends on the effectiveness of the steps that precede it. During the evaluation step, the nurse collects data for the purpose of comparing it with preselected goals/outcomes and judging the effectiveness of the nursing care. During the assessment phase, the nurse collects data for the purpose of making diagnoses. Cognitive Level: Applying. Client Need: N/A. Nursing Process: Evaluation. Learning Outcome: 14-1. 7. Answer: 3. Rationale: This client needs psychosocial support rather than skills related to knowledge (options 1 and 2) or hands-on activity (option 4). Cognitive Level: Understanding. Client Need: N/A. Nursing Process: Evaluation. Learning Outcome: 14-2. 8. Answer: 1, 4, and 5. Rationale: Nurses should always have clear rationales for their actions, clients should be given options whenever possible, and client teaching is a constant, integral part of implementing. Primary care provider orders must be critically evaluated and modified to meet individual client needs (option 2). Clients may have nurses provide needed care but should take care of themselves whenever possible since dependency has its own complications (option 3).

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­ ognitive Level: Analyzing. Client Need: N/A. Nursing Process: C Evaluation. Learning Outcome: 14-4. 9. Answer: 2. Rationale: Evaluating requires that client behavior be compared to expected outcomes. Goals may be partially met in addition to completely met or unmet (option 1). An outcome may be achieved but not be a direct result of the plan or interventions (option 3). A care plan should be continued, modified, or terminated based on achievement of outcomes (option 4). Cognitive Level: Analyzing. Client Need: N/A. Nursing Process: Evaluation. Learning Outcome: 14-6. 10. Answer: 4. Rationale: Quality improvement (QI) plans corrective actions for problems. QI focuses on process rather than outcomes (option 1), client care rather than structure (option 2), and aims for improvement rather than confirmation of quality (option 3). Cognitive Level: Understanding. Client Need: N/A. Nursing Process: Evaluation. Learning Outcome: 14-9.

Chapter 15: Documenting and Reporting

1. Answer: 3. Rationale: All of the other answers endanger the client’s confidentiality. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning ­Outcome: 15-1. 2. Answer: 1. Rationale: Subjective data consist of information obtained from what the client says. When possible, the nurse quotes the client’s words; otherwise, they are summarized. Objective data consist of information that is measured or observed. Assessment is the interpretation or conclusion drawn about the subjective and objective data. This is the area where the problems are documented initially. The client’s condition and level of progress are subsequently described. Planning is the care designed to resolve the problem. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Assessment. Learning Outcome: 15-3. 3. Answer: 4. Rationale: When a mistake is recorded, a line should be drawn through it and the words “mistaken entry” written above or next to the original entry, then initial or signature, whichever is agency policy. The original entry must remain visible. Erasure, blotting out, or correction fluid should not be used (options 1 and 2). When a mistake is recorded the correction applies to only the erroneous information not the entire page (option 3). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Evaluation. Learning Outcome: 15-6. 4. Answer: 4. Rationale: Option 4 is the “best” answer although it could be more complete by adding the response of the primary care provider. Option 1 is too vague because it is not clear if the nurse found the client or was present when the client fell. Also, there is no need to write the word client because it is the client’s chart. Option 2 is judgmental, revealing a negative attitude toward the person. It would be better to describe specific signs and symptoms such as staggering, slurred speech, and smell of alcohol on breath. Option 3 is too general and can be more specific by charting “2 cm × 3 cm purplish bruise on mid-inner thigh along with color.” Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Evaluation. ­Learning Outcome: 15-6. 5. Answer: 1. No known allergies; 2. Bathroom privileges; 3. When necessary; 4. Diet as tolerated. Cognitive Level: Remembering. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 15-6. 6. Answer: 2. Rationale: The graphic record provides the trend of the vital signs. Option 1, verbal information, is not appropriate for validation assessment that is measurable. This is more appropriate for pain or dizziness. The medication record would not include documentation of blood pressure ranges (option 3). The progress notes (option 4)

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provide information about how the client is progressing. It may have information about the client’s BP if it was a problem. The best answer is option 2. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Assessment. Learning Outcome: 15-4. Answer: 1, 2, and 4. Rationale: Option 3 is incorrect because it could be a HIPAA violation if others hear protected health information. Option 5 is not needed unless it is a concern and it would not be done for every client. Cognitive Level: Analyzing. Client Need: Safe, ­Effective Care Environment. Nursing Process: Implementation. Learning ­Outcome: 15-8. Answer: 2, 3, and 5. Rationale: Option 1: “MS” is on the “Do Not Use” list—the nurse needs to write out morphine sulfate. Option 4 has three errors—should not have a trailing zero after the decimal point; “u” and “SQ” are on the “Do Not Use” list. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 15-7. Answer: 3. Rationale: It should never be assumed that the client fell out of bed, became tangled in bedding, or anything else (options 1, 2, and 4). Accurate notations consist of facts or observations rather than opinions or interpretations. The client was found on the floor, and the call light was activated. Those are the only things known until the nurse gets further information from questioning the client. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Evaluation. Learning Outcome: 15-6. Answer: 1, 2, and 4. Rationale: Military time is commonly used; documenting worries or concerns provides clues to other nurses; gossip, unprofessional comments or thoughts, or personnel issues should not be recorded in the client’s chart. Option 3 is incorrect because charting should be done as events occur. Waiting until the end of the shift increases the chance of forgetting something. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 15-6.

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Chapter 16: Health Promotion

1. Answer: 1. Rationale: The concept of holism emphasizes that nurses must keep the whole person in mind and strive to understand how one area of concern relates to the whole person. In this situation, the stress from a job loss will affect the person’s chronic condition. The nurse must also consider the relationship of the individual to the external environment and to others. Options 2, 3, and 4 only focus on the physiology of the person’s condition. Cognitive Level: Understanding. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 16-1. 2. Answer: 3. Rationale: Learning about sleep will increase the older adult’s well-being, which is the focus of health promotion. Prevention of falls (option 1) is health protection because the focus is avoiding injury. Learning about cardiovascular risk factors (option 2) relates to health protection/disease prevention. How to stop smoking (option 4) focuses on health protection and avoiding illness. Cognitive Level: ­Applying. Client Need: Health Promotion/Maintenance and Psychosocial Integrity. Nursing Process: Planning. Learning Outcome: 16-5. 3. Answer: 2. Rationale: Choices are often related to learned experiences, lifestyle, and values. The client obviously values the business more than physical health. When a person feels strongly enough, a lower level need (rest) can be postponed until a higher level need (success, safety) is met. It is very likely that no one else can meet that need for him and the lower need must still be met eventually. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 16-3. 4. Answer: 3. Rationale: A person in this stage recognizes there is a problem, is seriously considering changing, actively gathers information, and verbalizes plans to change in the near future. Option 1 reflects the precontemplation stage in which the person denies there

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is a problem. Option 2 reflects the planning stage in which the person makes final plans to accomplish the change, and option 4 is the maintenance stage in which the person made the change and demonstrates the appropriate behavioral change. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 16-8. Answer: 2. Rationale: In the elderly population, health promotion and illness prevention are important, but the focus is often on learning to adapt to and live with increasing changes and limitations. Maximizing strengths continues to be of prime importance in maintaining optimal function and quality of life. Rest and exercise, and high obesity percentages are life span considerations of children (options 1 and 3). Safety promotion and injury prevention are life span considerations for adolescents. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 16-8. Answer: 2, 3, and 5. Rationale: The Healthy People 2020 goals are broad based. Options 1 and 4 are specific methods to promote healthy behaviors and would be seen in the objectives for a Healthy People 2020 topic area. Cognitive Level: Comprehending. Client Need: Health Promotion and Maintenance. Nursing Process: N/A. Learning ­Outcome: 16-4. Answer: 1. Rationale: Option 2 is a strategy for the contemplation stage, option 3 is a strategy for the preparation stage, and option 4 is a strategy for the maintenance stage. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: ­Implementation. Learning Outcome: 16-9. Answer: 4. Rationale: Change is a complex process and a nurse should not give up or assume that the client does not want to change (option 1). People often resist a tough approach because it can make them feel cornered. This approach may work for some people but not for everyone (option 2). The goal of teaching is to try to help the client become the expert as well (option 3). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 16-11. Answer: 1, 2, 4. Rationale: Options 3 and 5 are not examples of a homeostatic mechanism. Self-regulation, compensation, negative feedback, and utilizations of multiple mechanisms to correct a physiological imbalance are homeostatic mechanisms. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 16-2. Answer: 3. Rationale: Option 1 is a physiological need. Option 2 is a love and belonging need, and option 4 is a safety and security need. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 16-3.

Chapter 17: Health, Wellness, and Illness

1. Answer: 2. Rationale: The social component of wellness focuses on the ability to interact successfully with people and within the environment of which each person is a part, to develop and maintain intimacy with significant others, and to develop respect and tolerance for those with different opinions and beliefs. Cognitive Level: Understanding. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 17-2. 2. Answer: 2. Rationale: The mother has taken on the sick role by expecting to be excused from her usual role responsibilities. The sick role states that individuals are not answerable for their illness, contrary to the obese client’s perspective (option 1). In the sick role, the client tries to get better as opposed to the man who misses his physical therapy appointments (option 3). The older adult is not following the sick role expectation to rely on competent help (option 4). Cognitive Level: Applying. Client Need: Health Promotion/Maintenance and Physiological Adaptation. Nursing Process: Assessment. Learning Outcome: 17-7.

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Appendix A 3. Answer: 1. Rationale: Locus of control (LOC) is a concept from social learning theory. People who exercise internal control are more likely than others to take the initiative on their own health care and to be more knowledgeable about their health. They are also more likely to adhere to prescribed health care regimens such as taking medication, making and keeping appointments with physicians, maintaining diets, and giving up smoking. People who believe their health is largely controlled by outside forces (chance or others) are referred to as externals. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Analysis. Learning Outcome: 17-3. 4. Answer: 2, 3, and 4. Rationale: Significant evidence exists that a trusting relationship with the provider, effectiveness of the medication, and simple dosing regimen are important predictors of adherence to a medical regimen. Neither education nor sex has been shown to be a predictive factor (options 1 and 5). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 17-5. 5. Answer: 1. Rationale: Although not always practical, direct observation is the best method to measure adherence (for example, watching heroin addicts actually take their methadone dose). Because lack of adherence may be life threatening or damaging to the client as well as others, waiting until the client displays illness and waiting until laboratory values reflect a lack of adherence are not the best methods (options 2 and 3). Client report or recall is not always accurate, even if the client believes he or she is telling the truth (option 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 17-5. 6. Answer: 4. Rationale: The actual term used to describe the diagnosis is less important because the client may have no frame of reference for it. That is not to say that the diagnosis is unimportant because clients may be familiar with common diagnoses such as heart disease or cancer and ascribe historical meaning to them. Ability to perform usual activities, culture, and availability of health care will all be strong influences on the client’s definition of health or wellness (options 1, 2, and 3). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 17-1. 7. Answer: 4. Rationale: Genetics is an internal variable affecting health. Options 1, 2, and 3 are all external variables. Cognitive Level: Remembering. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 17-4. 8. Answer: 2. Rationale: By definition, a chronic illness has no known cure, the person will always have it to some degree. Although acute illnesses may have severe symptoms, many chronic illnesses also have severe symptoms (option 1). Although signs and symptoms of chronic illnesses may never go completely away, they can get better and worse at different times (option 3). Chronic illnesses can be treated, just not cured (option 4). Cognitive Level: Understanding. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 17-6. 9. Answer: 3, 5, 1, 4, and 2. Rationale: The proper sequence of Suchman’s stages of illness are signs and symptoms appear, the client takes on the sick role, the client makes contact with medical care, the client takes on a dependent role, and the client goes into rehabilitation/recovery. Cognitive Level: Remembering. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 17-8. 10. Answer: 1, 2, 3, and 5. Rationale: In the sick role, she would likely feel guilt and some anger but give up usual roles and accept help from others, and decrease social interactions. The only reaction that would be unlikely is that the woman would take on a job to pay expenses. This would be inconsistent with the sick role. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 17-9.

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Chapter 18: Culturally Responsive Nursing Care

1. Answer: 1, 2, 5. Rationale: REACH: Racial and Ethnic Approaches to Community Health is an initiative of the Centers for Disease Control and Prevention. Six core health areas that are the focus of this initiative include infant mortality, deficits in breast and cervical cancer screening and management, cardiovascular diseases, diabetes, HIV infections/ AIDS, and child and adult immunizations. This initiative was congruent with the identification of the leading causes of death in the United States, which include chronic lower respiratory disease and stroke, along with heart disease, cancer, unintentional injuries, and diabetes. Cognitive Level: Understanding. Client Need: Psychosocial Integrity. Nursing Process: N/A. Learning Outcome: 18-3. 2. Answer: 4. Rationale: “Right” and “wrong” terms should be avoided in culturally sensitive areas and where differing views are present (option 1). The nurse, not the physician, is the caregiver in this situation, so it is the nurse’s responsibility to teach and see that the plan of care is carried out (option 2). If the client’s views can lead to harmful behavior or outcomes, then an attempt is made to shift the client’s ­perspectives to the scientific view (option 3). Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: N/A. Learning Outcome: 18-10. 3. Answer: 3. Rationale: The nurse should indicate that he or she is open to diverse views and practices. Option 1 assumes the client follows this particular cultural practice, which may not be the case. The nurse should assess before intervening. It may be good to learn more about the culture (option 2), but that is not the best starting place to care for the client. Subcultures exist among all cultures. Reading books is helpful, but assessment of individual situations is the best approach. Option 4 reflects an incorrect approach to culturally appropriate care. The nurse needs to assess which customs and practices the individual client performs before drawing conclusions. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: N/A. ­Learning Outcome: 18-10. 4. Answer: 4, 5. Rationale: Race has been a term used to refer to groupings of people according to common origin or background and associated with perceived biological markers (option 1). Diversity occurs not only between cultural groups but also within cultural groups (option 2). A subculture is usually composed of people who have a distinct identity and yet are related to a larger cultural group (option 3). ­Cognitive Level: Applying. Client Need: Psychosocial Integrity. ­Nursing Process: N/A. Learning Outcome: 18-4. 5. Answer: 3. Rationale: National cultural health goals include providing equal access to quality health care for everyone. It would be inappropriate for all cultures to receive the same care; care should be customized (option 1). The same life expectancy for all U.S. citizens is not realistic (option 2). Assimilation (option 4) is not an appropriate health goal because assimilation is a conscious effect. Therefore, it is not always possible and this may cause severe stress and anxiety. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Evaluation. Learning Outcome: 18-3. 6. Answer: 1. Rationale: Herbal teas are an example of a restoring health action. Prayer (option 2) and exercise (option 4) would be examples of maintaining actions, whereas wearing symbolic objects (option 3) is a protective action. Cognitive Level: Understanding. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 18-6. 7. Answer: 2. Rationale: Steam is a natural substance and would be compatible with folk healing preferences. Hospitalization and medications are typical Western medical strategies (options 1 and 3). A watch-andwait approach (option 4) is not particularly associated with a folk healing perspective. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Planning. Learning Outcome: 18-5. 8. Answer: 1, 2, 3, and 6. Rationale: Technology skills (option 4) and intelligence (option 5) are individual, personal characteristics and less

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influenced by one’s culture than valuing of elders (option 1), gender roles (option 2), nonverbal communication (option 3), or diet (option 6). Culture may, however, influence how technologic skills (option 4) and intelligence (option 5) are viewed and valued. Cognitive Level: Understanding. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 18-5. 9. Answer: 4. Rationale: To gather assessment data regarding the client’s heritage, nurses must explore clients’ beliefs and practices. A good beginning would be to ask clients to indicate from the checklist which apply to them. Physical exam (option 1) and medical history (option 2) may suggest some cultural affiliation but the nurse cannot assume that these findings show significant affiliation from the client’s perspective. Blood analysis generally provides little data for a heritage assessment although blood type and some immunologic or genetic data can be relevant (option 3). Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 18-9. 10. Answer: 2. Rationale: If an interpreter is not available at your agency, you must still meet the expectations of providing information in a way the client can comprehend it. Providing written instructions, whether in English or the client’s language, is insufficient since the client may not be able to read and remains unable to have questions answered (option 1). Family members should not be relied on to interpret medical information (option 3). Option 4 is not an appropriate action. ­Cognitive Level: Applying. Client Need: Psychosocial Integrity. ­Nursing Process: Planning. Learning Outcome: 18-7.

Chapter 19: Complementary and Alternative Healing Modalities

1. Answer: 3. Rationale: Although the effectiveness of alternative therapies is sometimes not scientifically established, many people report ­significant benefit from them for a wide variety of conditions. Alternative therapies often cost less, but this is not a primary consideration (option 1). Clients often seek alternative therapies because traditional therapies are ineffective, but this is not the primary difference (option 2). Both traditional and alternative therapies utilize products from nature (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: N/A. Learning Outcome: 19-1. 2. Answer: 1. Rationale: Therapeutic horseback riding, or animalassisted therapy, is the use of the rhythmic movement of the horse to increase sensory processing and improve posture, balance, and mobility in people with movement dysfunctions. Cognitive Level: ­Applying. Client Need: Psychological Integrity. Nursing Process: N/A. ­Learning Outcome: 19-9. 3. Answer: 2. Rationale: Grounding relates to one’s connection with reality. Being grounded suggests stability, security, independence, having a solid foundation, and living in the present. Energy, centering, and sadness or depression (options 1, 3, and 4) does not relate to groundedness. Cognitive Level: Applying. Client Need: Health Promotion/ Maintenance and Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 19-2. 4. Answer: 4. Rationale: Naturopathy focuses on the total person. The primary focus is disease prevention. Naturopathy may be the best choice in decreasing disease rates by empowering and educating people about ways to stay healthy. Belief in a higher being is not a core principle. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: N/A. Learning Outcome: 19-5. 5. Answer: 2. Rationale: Colonics is the procedure for washing the inner wall of the colon by filling it with water or herbal solutions and then draining it. Colon cleansing is a controversial method of detoxification and the issue requires further discussion. Establishing a baseline regarding the client’s knowledge regarding the process is most appropriate. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: N/A. Learning ­Outcome: 19-7.

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6. Answer: 2. Rationale: Thirty percent of current prescription drugs are derived from plants. Herbs and medications are similar in structure and therapeutic value (option 1). Some medications may be more powerful than herbs but not all are (option 3), and herbs tend to be less dangerous than medications (option 4). Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 19-4. 7. Answer: 1. Rationale: Serious interactions can occur between herbs and medications. It is acceptable that people choose herbs as a way to maintain health and treat minor disorders (option 2). Although the knowledge the nurse gains may be helpful, contributing to research is not the primary reason for assessing herb use (option 3). While we hope clients share important information with us, they also have free will about what they choose to share (option 4). Cognitive Level: ­Applying. Client Need: Physiological Integrity. Nursing Process: ­Assessment. Learning Outcome: 19-10. 8. Answer: 4. Rationale: The oils in options 1, 2, and 3 will burn the skin if they are not diluted in a carrier oil. Cognitive Level: Understanding. Client Need: Physiological Integrity. Nursing Process: Planning. ­Learning Outcome: 19-10. 9. Answer: 1, 2, 4, and 5. Rationale: Massage is a way of communicating without words, including the caring intent of the provider. It provides mental and physical relaxation. Massage speeds the removal of metabolic waste products, allowing more oxygen and nutrients to reach the cells and tissues. It lowers blood pressure and slows the heart rate. Passive exercise from massage cannot strengthen muscles (option 3). Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 19-6. 10. Answer: 1. Rationale: There is no evidence that massage (option 2), herbs (option 3), or yoga (option 4) improves pregnancy rates, although relaxation and good physical conditioning are generally encouraged. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 19-10.

Chapter 20: Concepts of Growth and Development

1. Answer: 1, 3, 5. Rationale: Options 2 and 4 are related to development. Development is an increase in the complexity of function and skill progression, and development skills include the ability to adapt to one’s environment. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 20-1. 2. Answer: 4. Rationale: The study of growth (physical) and development (function and skills) is correct because the answer needs to have both components to be complete. Option 1 addresses only the growth aspects. Option 2 addresses only developmental aspects, and option 3 addresses only the environmental factors that might influence growth and development. Cognitive Level: Remembering. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 20-1. 3. Answer: 3. Rationale: Toddlers typically demonstrate negative behavior and are hesitant around strangers, resisting close contact with people they do not know well. They do not have sophisticated language skills and often use crying or fussing to communicate. Older schoolage children and adolescents are likely to cooperate without complaint in many health procedures (option 1). School-age children, engaged in the task of industry versus inferiority, display curiosity about how things work, asking many questions of nurses (option 2). Preschoolage children, who are in the fantasy, curiosity, and exploration stage, like to manipulate objects and play “pretend” (option 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 20-7. 4. Answer: 4. Rationale: Adolescents need to establish identity, which involves developing a more mature sense of independence and

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responsibility. Providing her with schoolwork keeps her connected to her peer group and gives a sense of accomplishment. Also, it prevents the client from “worrying” about getting behind in school assignments. Interaction with peers is very important during this stage, but they are likely to be attending school during the day (option 1); an infant’s sense of trust is reinforced if parents room-in, and older infants and toddlers experience less separation anxiety if parents are nearby (option 2); and preschool and school-age children would benefit from the distraction and social interaction of others in the recreation room (option 3). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 20-5. Answer: 2. Rationale: The client is in Erikson’s stage of integrity versus despair. Finding meaning and purpose in his life after retirement is a sign of achievement. His comments regarding visits to his family and being asked by friends to help with their projects indicate that he is actively involved and purposeful (options 1 and 4). His comment regarding needing medication for knee pain can be expected in many older people, especially those who have been laborers or suffered injury when younger (option 3). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 20-5. Answer: 1. Rationale: School-age children (6–12 years) are in the preadolescent period where the peer group begins to increasingly influence behavior. The nurse must allow time and energy for the school-age child to pursue hobbies and school activities and should recognize and support the child’s achievement. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 20-2. Answer: 2. Rationale: Erikson’s late childhood stage focuses on initiative versus guilt. During this stage, the children are beginning to have the ability to evaluate their own behavior and are learning the degree to which assertiveness and purpose influence the environment. Option 1 is incorrect because Fowler’s focus is spiritual development. Both options 3 and 4 are names of adult theorists. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 20-7. Answer: 1. Rationale: Piaget identifies this phase as the intuitive thought phase with significant behaviors as follows: egocentric thinking diminishes, thinks of one idea at a time, includes others in the environment, words express thoughts. Erikson identifies this developmental stage as industry versus inferiority, and the children are learning the degree to which assertiveness and purpose influence the environment. They begin to have the ability to evaluate their own behavior. Fowler identifies this stage as intuitive-projective, a combination of images and beliefs given by trusted others, mixed with the child’s own experience and imagination. Therefore, the nurse knows that this child has a normal imagination and needs to explore and learn about this new piece of equipment in language appropriate to his age. For option 2, imagination is normal for this age group, and stating that he needs to be “a big boy” is counterproductive. Option 3 is incorrect because his language skills are developing and he needs to understand the world around him. Option 4 is incorrect because adding to his fears will only increase his anxiety level and decrease his trust in you as a nurse. Cognitive Level: Applying. Client Need: Health ­Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 20-11. Answer: 1. Rationale: All of the nursing actions listed here are appropriate, but attachment theory emphasizes the importance of parents being available to their child when the child is experiencing stress. The best action would be to encourage the mother to stay with her child as much as possible. Putting a picture of the mother in the crib (option 2) may provide some comfort, since by 15 months of age, children demonstrate object permanence and people permanence, so

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the child “knows” the mother will return. Holding and cuddling the child (option 3) may also provide comfort, but the child must trust the caregiver, and the nurse’s other responsibilities may restrict the amount of time and when he or she can be with the child. Distraction (option 4) can temporarily refocus the child’s attention, but it does not address the need for emotional and physical contact with the parent. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 20-10. 10. Answer: 4. Rationale: Adulthood, age 25 to 65 years, is characterized by the central task of generativity versus stagnation. Positive resolution is indicated by creativity, productivity, and concern for others. Negative resolution is characterized by self-indulgence, self-concern, and lack of interests and communication. Cognitive Level: Understanding. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 20-7.

Chapter 21: Promoting Health from Conception Through Adolescence

1. Answer: 4. Rationale: Providing opportunities for the parent to express worries and discuss facts about SIDS gives more control over the situation. The nurse can also provide her with information about the Back to Sleep campaign. Option 1: The highest incidence of SIDS occurs between 2 and 4 months of age, but it does occur in older infants. It is not the best response because it provides facts but does not address the parent’s immediate concerns. Option 2: SIDS affects boys more than girls. However, this information is likely to increase anxiety and does not address the concerns of the parent. Option 3: There is no known cause of SIDS, although respiratory problems may be present in some infants. This response is insensitive to the needs of the mother. Cognitive Level: Applying. Client Need: Psychosocial Integrity. ­Nursing Process: Implementation. Learning Outcome: 21-8. 2. Answer: 3. Rationale: Preschool-age children use fantasy and makebelieve to learn about, understand, and master their environment, including their concepts of death. The child’s conceptualization of death is consistent with her cognitive development. The response in option 1 negates the child’s understanding and limits her ability to develop fuller understanding and adapt to the loss. Option 2 negates the child’s attempts to understand and deal with the loss. Option 4 is incorrect because at 4 years of age, children can hear explanations such as “when people get old they will die,” but these children do not have a firm grasp of the meaning of time and age, and probably will not understand. Cognitive Level: Applying. Client Need: Health Promotion/­Maintenance and Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 21-6. 3. Answer: 1. Rationale: It is the responsibility of adults to supervise children constantly and closely when around water. Option 2, learning water safety and how to swim, is important and should be encouraged at an early age, but that still does not ensure a child’s safety. Option 3 is incorrect because young children are at risk near any amount of water that can cover the nose and mouth. Option 4: Infants and toddlers can drown in a very small amount of water, even several inches in a bathtub or “kiddie pool.” Cognitive Level: Applying. Client Need: Safe, Effective Care Environment and Health Promotion/Maintenance. Nursing Process: Planning. Learning Outcome: 21-8. 4. Answer: 2. Rationale: School-age children acquire stereognosis, the ability to identify an unseen object simply by touch. Option 1: Birth weight triples by about 12 months. Children enter school age weighing about 45 pounds and gain about 5 to 7 pounds per year. Option 3: Significant physical change occurs during the school-age years. Option 4: Fat deposits do not normally appear until puberty. Cognitive Level: Understanding. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 21-1.

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5. Answer: 2. Rationale: The nurse must present an open, accepting attitude to the adolescent’s questions while encouraging the adolescent to find relationships that promote discussion of feelings, concerns, and fears. Giving directions and suggesting counseling may turn the student from seeking help (options 1 and 3). Just giving written information on a particular topic will not address the complete situation the student comes seeking assistance with (option 4). Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 21-8. 6. Answer: 2. Rationale: Molding of the head is made possible by the fontanels and occurs during vaginal deliveries as the head comes through the birth canal. Within a week, the newborn’s head usually regains its symmetry. It is normal with vaginal deliveries. Babies born via cesarean section do not experience molding. Molding is not permanent—a fact that makes parents feel more reassured. Option 1 dismisses the parent’s concerns. This condition is not abnormal and does not need to be referred to the doctor but rather the nurse needs to reassure the parents that nothing is wrong (option 3). Option 4 is not necessarily true nor does it adequately answer the parents’ concerns. Cognitive Level: Applying. Client Need: Psychosocial Integrity. ­Nursing Process: Implementation. Learning Outcome: 21-1. 7. Answer: 1. Rationale: Although toddlers like to explore the environment, they always need to have a significant person nearby. Parents need to know that young children experience acute separation anxiety and that abandonment is their greatest fear. Option 2: This is normal toddler development. Option 3: Child is probably not old enough to perform manipulative-type strategies. Option 4: This is normal behavior for this age group. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 21-3. 8. Answer: 2. Rationale: Regression is reverting to an earlier development stage (bed-wetting, using baby talk, etc.) as part of the child’s experiences with separation anxiety. Nurses can assist parents by helping them understand that this behavior is normal and will pass as the child reestablishes herself as part of the family and works through her own frustration with the situation. Regressive behavior is not based on physiology and, unless it lasts, would not have to be further investigated (option 1). Strict discipline may not be the better solution over understanding and caring (option 3). Option 4 does not provide the parents with an understanding of the root of the problem. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 21-2. 9. Answer: 1. Rationale: During the phase of concrete operations, children change from egocentric interactions to cooperative interactions. They also develop an increased understanding of concepts that are associated with specific objects. They learn to add and subtract and understand cause-and-effect relationships. Option 2 action is indicative of the preconceptual phase—an egocentric approach that uses magical thinking. Option 3 action is indicative of the formal operations phase—reasoning is deductive and futuristic. Option 4 is indicative of physical growth. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 21-4. 10. Answer: 1. Rationale: Often the first noticeable sign of puberty in females is the appearance of the breast bud, although the appearance of hair along the labia may precede this. Option 2: The growth spurt in girls is between ages 10 and 14, but is too vague to be noticeable. Option 3: The eccrine glands are found over most of the body and produce sweat. The apocrine glands develop in the axillae, anal and genital areas, external auditory canals, and around the umbilicus and the areola of the breasts. Option 4: Mood swings are not as definitive as physical changes. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 21-2.

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Chapter 22: Promoting Health in Young and Middle-Aged Adults

1. Answer: 3. Rationale: The average age for the onset of menopause in American women is 47 years. Therefore, there is nothing abnormal about ongoing menses in a 45-year-old woman, and gynecologic care is not warranted (option 1). As a woman nears menopause, ovulation may become irregular and difficult to predict. Conception remains a possibility, and the lack of predictable ovulation may actually increase the likelihood of unintended pregnancy (option 2). Many women have no negative symptoms of menopause, and the experience of menopause is highly culturally determined (option 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 22-2. 2. Answer: 2. Rationale: Generation X includes individuals born in the years 1965 to 1978. The Baby Boomers were born in the years 1945 to 1964 (option 1). Generation Y includes people born between the years 1979 and 2000 (option 3). Millennials were born between the years 1979 and 2000 (option 4). Cognitive Level: Remembering. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 22-1. 3. Answer: 3. Rationale: Lung cancer is the most common cause of cancer death in women age 24 to 65 years. Breast cancer is common, but deaths related to breast cancer have declined. Lymphoma and colon cancer are significant diseases for both men and women (options 2, 3, and 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 22-7. 4. Answer: 1, 2, 3, 5. Rationale: Other factors indicating problems include a variety of physical complaints, digestive disorders, increase in isolation, problems with close relationships, and financial failure. Brain tumors are not an indicator for suicide. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 22-7. 5. Answer: 2. Rationale: Kohlberg’s initial work indicated that moral development was completed by adulthood, but more recent research has demonstrated that moral development continues throughout adulthood. Moral development refers to a decision-making process of right and wrong, and proceeds in a series of predictable stages (option 3). Moral development and spirituality are unrelated, and represent very different spheres of human thought and behavior (option 4). Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 22-5. 6. Answer: 2. Rationale: The middle-aged person is generally attempting to relate to adult children and grandchildren as well as assisting aging parents. Hence, continuous efforts to meet the needs of others occur. Selecting a life partner is the developmental task for young adults. Reviewing one’s life course is the task for older adulthood (option 3). Establishing a sense of self is usually achieved during adolescence (option 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 22-3. 7. Answer: 2. Rationale: Hypertension is a major problem for young African American adults, particularly men. The causes for this are unknown. Options 1, 3, and 4 are not evidence-based statements. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Assessment. Learning Outcome: 22-7. 8. Answer: 1, 2, 3, and 5. Rationale: Hypertension (elevated blood pressure) forces the heart to work harder, resulting in decreased function of the heart; the electrocardiogram assesses cardiac rhythm and rate; high cholesterol levels are directly related to a decrease in arterial size, which decreases circulation blood to the cardiac tissue; activity level (e.g., dyspnea on exertion) can indicate cardiovascular disease. While cardiac impairment may decrease sexual performance, which is important to assess, the others would have priority given the limitations for the screening program (option 4). Cognitive Level: Analyzing.

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Appendix A Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 22-9. 9. Answer: 1. Rationale: Asking the individual if she or he is afraid of someone at home, or if someone hurt her or him, is a critical step in a comprehensive assessment. Intimate partner violence is a serious problem for women and men of all ages, cultures, and socioeconomic levels. The nurse should suspect it in people whose injuries are not consistent with the history they give. Referring the individual to a shelter without completing a thorough assessment may lead to inappropriate care (option 2); the nursing process requires assessment before intervention. Collaboration with other health care professionals may be very helpful but an assessment needs to be done first (option 3). Documentation of the assessment does not directly address, reduce, nor solve the concern (option 4). Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Assessment. Learning Outcome: 22-7. 10. Answer: 3. Rationale: Each of these activities indicates achievement of a developmental task, but the nurse must know which task is appropriate for the client’s chronological age. Obtaining and decorating a place to live is an activity that establishes independence from parents, a task for young adults. Creating a scrapbook is an important strategy to enhance ego integrity, a developmental task for older adults (option 1). Working with philanthropic groups is a hallmark of generativity, a developmental task for those in midlife (option 2). Considering career paths is more appropriate to the identity task of adolescence (option 4). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 22-3.

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Chapter 23: Promoting Health in Older Adults

1. Answer: 2. Rationale: Independence established prior to the loss of a mate makes adjustment easier. A person who had meaningful relationships and friendships or economic security, ongoing interests in the community or private hobbies, and a peaceful philosophy of life copes more easily with bereavement. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 23-11. 2. Answer: 3. Rationale: Because the hearing loss occurs in the ability to distinguish high-pitched tones, speaking in a low and distinctive voice tone is the most appropriate method of communicating with the clients. Hearing loss in the older adult includes a loss of the ability to discern higher frequencies, and speaking slowly at a particular volume is not the best way to communicate with the clients (option 1). The stem indicates the clients have noticeable hearing loss, but does not indicate the clients are deaf; large lettering is appropriate if the client has a visual problem (option 2); hearing aids are not usually effective when the problem is related to neural damage (option 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 23-8. 3. Answer: 2. Rationale: This type of conversation is a necessary part of successful aging, and the nurse should support the reminiscence. There is no need for a psychological consult as this is not abnormal behavior for this age group (option 1). It is not necessary to redirect the client to other topics of conversation since reminiscing is not an unhealthy behavior (option 3). Elders generally respond better to familiar caregivers (option 4). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 23-12. 4. Answer: 4. Rationale: It is a myth regarding the aging process that most old people are depressed. By relating that depression is not a normal part of aging, the nurse can further dialogue with the daughter. The older client’s number of losses is less important than how she copes (option 1). A depressed affect may be the older adult’s usual look (option 2). It is yet to be determined if in fact she is depressed (option 3).

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Cognitive Level: Remembering. Client Need: Safe and Effective Care Environment. Nursing Process: Implementation. Learning ­Outcome: 23-15. Answer: 3. Rationale: With the normal aging process, there is a decrease in muscle tone, digestive juices, and intestinal activity. These together may lead to indigestion and constipation in the older adult. It would be premature, as well as outside the scope of nursing practice, for the nurse to consider any other pathology (options 1 and 4) or to tell the client that there is a need for invasive testing (option 2). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 23-8. Answer: 1. Rationale: The client has lost muscle strength. Strengthening exercises will improve his mobility and lessen the possibility of a fall. Option 2: Information indicates the client has difficulty rising from a seating position, not standing after he reaches the position; further assessment is needed before implementing this intervention. Option 3: Praise should come after the proper intervention is implemented and a plan is in place so that the praise is focused toward a goal to resolve the problem. Option 4 resolves the problem immediately but does nothing to resolve the underlying problem. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing ­Process: Implementation. Learning Outcome: 23-8. Answer: 4. Rationale: Sexual activity is possible for older adults although the responses are slower. The clients would need a health history and physical assessment of the cardiovascular system before drawing this conclusion (option 1). With the introduction of Viagra, older men are more able to perform than in the past (option 2). Older men’s interest tends to decline, but it is not known whether it is related to impotence; apparently this older client is interested in sexual activity (option 3). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 23-16. Answer: 3. Rationale: Presbyopia is loss of near vision related to aging. Option 1 is loss of hearing ability related to aging. Option 2 is dry mouth related to a decrease in saliva, and option 4 is a decrease in the motility of the esophagus related to aging. Cognitive Level: Remembering. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 23-8. Answer: 4. Rationale: This response reflects an understanding of the different stages of independence and control an older adult experiences when admitted to the hospital and the need for the nurse to assess the client’s need for control and autonomy. After admission, the client willingly gives up autonomy to the hospital routine because the client wants to get better (option 4). As the client’s health improves and progresses, he or she wants to increase autonomy (option 1). Before discharge the client is thinking about if he or she can go home (option 2). Option 3 is not realistic given the usual hospital routine. Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. Nursing Process: Planning. Learning Outcome: 23-6. Answer: 3. Rationale: The nurse treats the older woman with empathy. Saying the sister is dead may trigger agitation or an argument. It may start the grieving process all over again and be distressing for the woman (option 1). These responses should be avoided. It is more compassionate to focus on the woman’s feelings, and encourage her to talk about her sister and remembered events. Long-term memory remains functional in many clients with dementia compared to short-term memory. By having her reminisce, the nurse can stimulate the woman’s recall of events from a long time ago (option 3). It is deceptive to say the sister won’t visit today or that the woman should wait to see if she does visit today (option 4). Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 23-12.

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Chapter 24: Promoting Family Health

1. Answer: 1. Rationale: Grandparents, aunts, and uncles are considered extended family members. Parents and spouse are considered immediate family members. Children who no longer live at home are considered immediate family members. Roommates and close family friends may be considered extended family members if grandparents, aunts, and uncles do not exist. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 24-2. 2. Answer: 3. Rationale: Tay-Sachs is a neurodegenerative disease that occurs primarily in descendants of Eastern European Jews. Simply because of this family’s race, they are at risk for developing this health problem. The elderly couple is active and so is not at high risk simply because of age (option 1). Just because the family is led by a teenage mother, even though maturity is one of the factors the nurse will ­assess in this situation, does not necessarily indicate that a health risk ­exists (option 2). Although poverty is a major problem that affects the family, the fact that there is health insurance is a positive sociologic factor (­option 4). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 24-4. 3. Answer: 1. Rationale: The health history of the client’s current living partners is critical information since many illnesses are communicable or environmental. Giving this advice, the nurse also validates that family are whoever the client says they are. History of illness data of blood relatives is also extremely valuable and should always be included, whether or not the client lives with them. Neither the history nor the physical exam is more important than the other—both are necessary for a complete plan of care. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 24-4. 4. Answer: A visual representation of family members by gender, age, health status, and lines of relationships through the generations is referred to as a genogram. Cognitive Level: Remembering. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 24-4. 5. Answer: 1, 2, and 4. Rationale: It is essential for the nurse to determine the duration of the illness, the meaning of the illness to the family and its significance to family systems, and the financial impact of the illness in order to completely assess the impact of the illness on the family as a whole. Duration of the illness will determine the degree of disruption and adaptation required. These factors affect the members of the family in addition to the ill client. Option 3: Coping mechanisms used by other families with similar illnesses may not be relevant because families vary greatly in their makeup and function patterns. Option 5: Knowing the incidence of the illness in the community at large is an important factor for the community health nurse in exploring epidemiologic issues such as prevention strategies and public health policies but is not as relevant for assisting the particular family. Cognitive Level: Understanding. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 24-6. 6. Answer: 1. Rationale: Presenting to the clinic indicates the family is probably ready to face the health challenges caused by the previous activities. There is no evidence that the adult child or parent is experiencing disabling coping (option 2). Impaired Parenting applies when the parent is unable to care for a child rather than the reverse. ­Although some strain must be experienced by the child, evidence does not indicate that Caregiver Role Strain is the most important aspect of the situation. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Diagnosis. Learning Outcome: 24-6.

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7. Answer: 1. Rationale: This describes a state in which a family with previous normal functioning experiences a dysfunction. The communication patterns have affected how the family works as a unit. Impaired Verbal Communication means that the members are not able to communicate because of complications with speaking or saying the words, which is not the case in this situation (option 2). Ineffective Family Coping must be related to an etiology, so option 3 is incorrect. Option 4 is incorrect as the family does recognize the problem as members of the family seek assistance from outside sources. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Diagnosis. Learning Outcome: 24-6. 8. Answer: 4. Rationale: The focus of activity on personal purposes does not promote effective family functioning. A family system that functions efficiently focuses primarily on purposes involving the total system, allows input from the outside, has personal boundaries that are well defined, and interdependent family members. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 24-3. 9. Answer: 2. Rationale: A family should provide an environment that supports the growth of the individual members. It is neither possible nor appropriate for the family to try to provide everything each member wants (option 1), nor that members are accepted into society (option 3). Although the family protects its members, a healthy family will share and use appropriate resources with the broader community (option 4). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 24-1. 10. Answer: 2. Rationale: A child who doesn’t speak and is watchful when parents are near would be a significant indicator of a possible abuse situation. The baby may have an untreated condition, but chronic cold symptoms are not evidence of abuse (option 1). Dirty clothes or clothes not meeting the nurse’s standards are not signs of abuse (option 3). Not having a regular physician would be a concern for health promotion and maintenance, but not for abuse (option 4). Cognitive Level: Analyzing. Client Need: Health promotion and maintenance. Nursing Process: Planning. Learning Outcome: 24-5.

Chapter 25: Caring

1. Answer: 1. Rationale: Knowing means understanding the other’s needs and how to respond to those needs. Sensing that a client is withdrawn and sullen, the nurse knows that spending extra time can sometimes allow the client to feel comfortable in talking about what might be bothering him. Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. Nursing Process: Assessment. ­Learning Outcome: 25-2. 2. Answer: 1. Rationale: Teaching the client to make self-care decisions at home empowers him to care for his illness. Empowerment is not the primary goal for options 2, 3, and 4. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: ­Implementation. Learning Outcome: 25-4. 3. Answer: 3. Rationale: Mayeroff defines patience as “allowing the other to grow in his own way and time.” Options 1, 2, and 4 are not clearly the goal. Cognitive Level: Remembering. Client Need: Psychosocial Integrity. Nursing Process: Planning. Learning Outcome: 25-3. 4. Answer: 1. Rationale: In this situation, culture care diversity addresses the differences between Indonesian medical practices and traditional American practices. Universality addresses the similarities among the cultures. Since Leininger’s theory addresses cultural elements relevant to nursing, options 2, 3, and 4 are incorrect. Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. Nursing Process: Evaluation. Learning Outcome: 25-2. 5. Answer: 4. Rationale: Ethical knowing focuses on matters of obligation or what ought to be done and goes beyond simply following the

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ethical codes of the discipline. Cognitive Level: Applying. Client Need: N/A. Nursing Process: N/A. Learning Outcome: 25-3. Answer: 4. Rationale: Caring practice involves connection, mutual recognition, and involvement. It is more than just performing skills adequately or even efficiently. It’s a sense that the nurse has made a difference to someone else. Caring means that people, relationships, and things matter. Explaining a procedure, then seeking permission to begin lets the client know that the nurse respects the client as an individual. All other options are examples of appropriate and professional nursing care, but do not address a caring aspect. Cognitive Level: ­Applying. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 25-4. Answer: 2. Rationale: As depicted in Figure 25–1, this is the model for the theory of bureaucratic caring. Cognitive Level: Remembering. ­Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 25-2. Answer: 1. Rationale: Empirical knowing is gained from studying scientific models and theories. Aesthetic knowing arises from application in practice (option 2). Personal knowing arises from self-examination (option 3). Ethical knowing arises from confronting conflicting values (option 4). Cognitive Level: Applying. Client Need: N/A. Nursing ­Process: N/A. Learning Outcome: 25-3. Answer: 4. Rationale: Meditation involves the described behaviors. Storytelling involves communication with others (option 1). Yoga combines various postures with breathing practices (option 2). Music therapy involves listening to music (option 3). Cognitive Level: Analyzing. Client Need: N/A. Nursing Process: N/A. Learning ­Outcome: 25-5. Answer: 3. Rationale: Twenty-five minutes of vigorous activity 3 days a week is the recommendation for a healthy lifestyle. Ten minutes is an insufficient amount of time for moderate exercise (option 1), as is 20 minutes (option 2). Daily vigorous activity for 30 minutes may be too strenuous (option 4), depending on the client’s level of conditioning. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 25-6.

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Chapter 26: Communicating

1. Answer: 3. Rationale: Nonverbal, gentle touch is an important tool; overstimulation may affect the client in a negative way. Option 1: Written communication requires a higher level of consciousness than verbal. Option 2: The client does not have a hearing problem but lacks the ability to interpret and understand communication. Option 4: Lack of facial expression may increase fear. Cognitive Level: Applying. ­Client Need: Psychosocial Integrity. Nursing Process: Implementation. ­Learning Outcome: 26-9. 2. Answer: 3, 1, 2, 4. Rationale: During the preinteraction phase (option 3), the nurse gathers information about the client before meeting the client. During the introductory phase (option 1), the nurse usually engages in some social interaction to put the client at ease. During the working phase (option 2), the nurse helps the client to explore feelings and helps the client plan a program. During the termination phase (option 4), the nurse summarizes or reviews the process that took place. Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. Nursing Process: Planning. Learning Outcome: 26-6. 3. Answer: 1. Rationale: The client is nonverbal, so speaking en face, ­using an interpreter, or using client’s dominant language does not address the client’s ability to communicate. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 26-4. 4. Answer: 1. Rationale: Respect is correct because the nurse is validating the client’s feeling. It is not genuineness (option 2) because the nurse is

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giving information versus being genuine. Concreteness (option 3) is giving a specific example. The nurse is not confronting (option 4) but supporting through respect for the client’s feelings. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: ­Implementation. Learning Outcome: 26-6. Answer: 2. Rationale: Because anxiety and low self-esteem precede powerlessness, which results in indecisiveness, it is the most correct answer; nursing management always deals with the client’s current display of needs. Options 1 (anxiety) and 3 (low self-esteem) may cause a sense of powerlessness that results in indecisiveness. Option 4: There is no evidence that the client’s social interactions are less than adequate. Cognitive Level: Applying. Client Need: Psychosocial Integrity. ­Nursing Process: Diagnosis. Learning Outcome: 26-9. Answer: 2 and 3. Rationale: Assessing possible visual or hearing problems allows the nurse to provide appropriate interventions (e.g., inserting hearing aid). Communicating what will be occurring at a stressful time helps the client feel more secure and can reduce anxiety. Option 1 is not the best answer as the client could say yes/no or nod the head and the nurse will not know if the client fully understands. It would be better to ask the client to tell you where he or she is. Option 4 is important to do; however, immediately after surgery is not the best time as the client may be in pain and/or groggy from the anesthesia. Option 5 is false reassurance because the nurse does not know if the client is going to feel better. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 26-4. Answer: 4. Rationale: Nonverbal communication, or body language, often tells the nurse more about what a person is feeling than what is actually said. The interpretation of such observations requires validation with the client. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 26-3. Answer: 4. Rationale: Option 4 is a therapeutic technique using an open-ended question that allows the client to elaborate. The other options are barriers to communication. Option 1 is incorrect because the client did not ask about the abilities of the surgeon and the response does not focus on the client. Option 2 is changing the subject, and option 3 is giving advice. Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 26-9. Answer: 4. Rationale: An important characteristic of assertive communication includes the use of “I” statements versus “you” statements. “You” statements place blame and put the listener in a defensive position. “I” statements encourage discussion. Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 26-4. Answer: 1. Rationale: It encourages the client to verbalize and choose the topic of the conversation. Option 2 is used when the nurse is unsure of the message and asks the client to repeat or restate the message. Option 3 is used to help a client differentiate the real from the unreal, and there is no information available to indicate this is a concern in this situation. Option 4 is used at the end of an interview or teaching session. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 26-4.

Chapter 27: Teaching

1. Answer: 2. Rationale: Options 1 and 3 are psychomotor, and 4 is under the cognitive domain. Cognitive Level: Understanding. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 27-3. 2. Answer: 2. Rationale: The NANDA label Deficient Knowledge is used when the client is seeking health information or when the nurse has

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identified a learning need, as in this case. The area of deficiency (diet and medication regimen) should always be included in the diagnosis. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 27-9. Answer: 3. Rationale: Motivation is the desire to learn and influences how quickly and to what extent a person learns. It is generally greatest when a person recognizes a need and believes the need will be met through learning. Clients who struggle with rules or following prescribed courses of treatment are not motivated to learn the best reason for their particular plan of action (option 1). The client who is already waiting to go home may be motivated for that, but not to the extent of being ready to learn how to achieve this end (option 2). Motivation must be experienced by the client, not by someone else, as in being a “coach” for newcomers (option 4). Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 27-5. Answer: 1. Rationale: Individuals learn in various ways, such as visually, group learning, auditory, and participatory. The individual knows how learning has occurred in the past. Option 2 is a component of the implementation phase of teaching, and the question is asking how to assess a client’s style of learning. Options 3 and 4 involve others and it is best to ask the client. Cognitive Level: Remembering. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 27-7. Answer: 3. Rationale: Option 1 is an old diagnosis, which has been changed. Option 2 is a wellness nursing diagnosis; the data would need to address that the client is seeking health information and why in order to be the correct answer. The diagnosis of Noncompliance is ­associated with the intent to comply, but situational factors make it difficult. The data in the question do not support option 4. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Diagnosis. Learning Outcome: 27-9. Answer: 2, 3, and 5. Rationale: Options 2, 3 and 5 are open-ended questions that will give the client the opportunity to provide information that will help the nurse assess level of knowledge and subsequently provide/discuss needed information with the client. Options 1 and 4 are closed-ended (yes/no) questions. A “no” answer may cause a discussion but it will be difficult for the nurse to assess if it is the information the client really wants to know. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 27-7. Answer: 1, 2. Rationale: The inability to identify changes in the skin around the stoma would indicate that instruction has not been effective. The client’s stating he does not want to perform self-care to the ­ostomy or the client’s asking his wife to learn the care would also indicate that effective learning did not occur. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 27-13. Answer: 3. Rationale: All are important factors to assess. The priority, however, would be the potential economic factor because the medications can be very expensive and the client may not take them if he or she cannot afford them. Cognitive Level: Applying. Client Need: ­Physiological Integrity. Nursing Process: Assessment. Learning ­Outcome: 27-7. Answer: 3. Rationale: This option is the easiest for the nurse to evaluate. Option 1 is difficult to evaluate because “understand” is too vague. Option 2 refers more to an affective outcome and the question is asking about a cognitive outcome. Option 4 is telling more about the husband than the client. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 27-13.

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10. Answer: 2. Rationale: This is the only option that clearly reflects the teaching process, evaluation method, and the response of the client indicating evidence of learning. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Evaluation. Learning Outcome: 27-14.

Chapter 28: Leading, Managing, and Delegating

1. Answer: 1. Rationale: This is a situation in which urgent decisions are needed, and one person provides instructions without input from others (autocratic). This is especially appropriate if the rest of the group is not functioning at an appropriate level. Option 2 would be found in shared governance structures when the risks are low and there is time for collaboration. Option 3 is most effective in groups with high levels of professional and personal maturity and where cooperation and coordination are not significant. Option 4 involves the rigid use of rules. Because managing casualties is a highly unpredictable activity, enforcement of rules is not appropriate. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: N/A. Learning Outcome: 28-2. 2. Answer: 1. Rationale: In this situation, the manager needs to verify and clarify the client’s statement with the assigned nurse before taking any direct action. Assigning another nurse to administer the client’s medications (option 2) could be dangerous because it assumes the client is accurate in his statement. It is premature to review proper medication procedures with the nurse before knowing for certain that the procedure has not been followed (option 3). If the manager determines that there is disagreement about whether or not the medications have been given, it might be appropriate for the manager, nurse, and client to discuss the situation together (option 4) but certainly not before the manager has a private conversation about the situation with the nurse. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcome: 28-7. 3. Answer: 4. Rationale: The RN is ultimately responsible for the action, reporting it, and following through on any action. Part of delegation is supervision and evaluation—ultimate responsibilities that belong to the RN. The nurse manager, aide, or client did not delegate the task of vital signs; therefore, are not responsible for the time lapse between discovery and action. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcome: 28-6. 4. Answer: 1, 2, 3, 4. Rationale: Enough time is not one of the five rights of delegation. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcome: 28-8. 5. Answer: 4. Rationale: Interaction between the two groups may lead to a compromise. Option 1: Although explaining the reasons for the desired change is useful, overemphasis on the rationale may not be useful since resistance is often more emotional than rational. Option 2: This situation does not meet the criteria for an autocratic leadership style. There is no urgency and the task primarily involves the staff. Option 3: If the manager were not solidly committed to the new proposal, it should not be introduced, because it will result in unnecessary disturbance. Option 4: The manager should be open to modification of the proposal if justified. Cognitive Level: Applying. Client Need: Safe, Effective Care Planning. Nursing Process: Implementation. Learning Outcome: 28-10. 6. Answer: 2. Rationale: Managers are employees and have been given authority by the institution for which they work. The other options are characteristic of leaders more than managers. Cognitive Level: Understanding. Client Need: Safe, Effective Care Planning. Nursing Process: N/A. Learning Outcome: 28-1.

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Appendix A 7. Answer: 1, 2, 3, 4. Rationale: The nurse as manager is focused on systems. Cognitive Level: Applying. Client Need: Safe, Effective Care Planning. Nursing Process: Evaluation. Learning Outcome: 28-3. 8. Answer: 3. Rationale: Middle managers supervise first-level managers and serve as liaison between first- and upper-level managers. First-level managers supervise nonmanagerial staff (option 1) and report institutional changes to direct-care staff (option 2). Creating institutional goals and strategic plans is the responsibility of upper-level managers (option 4). Cognitive Level: Understanding. Client Need: Safe, Effective Care Planning. Nursing Process: Evaluation. Learning Outcome: 28-4. 9. Answer: 4. Rationale: Evaluating outcomes and effectiveness is part of the coordinating function of management. Cognitive Level: Remembering. Client Need: Safe, Effective Care Planning. Nursing Process: N/A. Learning Outcome: 28-5. 10. Answer: 3. Rationale: In this situation, the UAP was not given the right direction and communication—that the client was not permitted to be out of bed. UAPs commonly weigh clients so it was the right task and right person (options 1 and 2). Although supervision might have prevented the error, it was the nurse’s responsibility to tell the UAP of the client’s mobility status and, if necessary, the proper way to weigh such a client (option 4). Cognitive Level: Analyzing. Client Need: Safe, Effective Care Planning. Nursing Process: Evaluation. Learning Outcome: 28-9.

Chapter 29: Vital Signs

1. Answer: 2. Rationale: Body temperature is frequently measured orally even if the client has eaten or drank something cold or hot. One only needs to wait 30 minutes, and then this site can be used. Axilla is the preferred site for newborns, not adults (option 1). The popliteal site would not be used given the history of heart disease. There could be circulatory issues that might affect accurate reading since this site is much farther away from the heart (option 3). Rectal would be contraindicated in this client given the history of heart disease. With the diagnosis of heart disease, the nurse would need to assess for the presence of hemorrhoids (option 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 29-5. 2. Answer: 3. Rationale: The apical rate would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm; a radial pulse would only reveal the heart rate and suggest an arrhythmia. For clients in shock, use the carotid or femoral pulse (option 1). The radial pulse is adequate for determining a change in the orthostatic heart rate (option 2). The radial pulse is appropriate for routine postoperative vital sign checks for clients with regular pulses (option 4). Cognitive Level: Understanding. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 29-5. 3. Answer: 2. Rationale: Persons in a semi-Fowler’s position will better aid themselves and the nurse to assess their respiratory status. The prone, side-lying, and supine positions increase the volume of blood inside the thoracic cavity and compress the chest, compromising the client’s respirations. Cognitive Level: Understanding. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 29-3d. 4. Answer: 2. Rationale: If the cuff is inflated to about 30 mmHg over previous systolic pressure, that would be 168. To ensure that the diastolic has been determined, the cuff should be released slowly until the mid60s mmHg (and then completely) for someone with a previous reading of 74. The cuff should be deflated at a rate of 2 to 3 mm per second. Thus, a range of 90 mmHg will require 30 to 45 seconds. ­Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 29-3e.

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5. Answer: 1. Rationale: The cardiac catheterization client will need a thorough assessment since she is just returning to the nursing unit. Invasive procedures, such as a catheterization, will need to be closely assessed. More than likely a Doppler will be needed to ensure the pedal pulse is present and stable in the extremity used during the procedure. Unlicensed personnel are not usually delegated Doppler ultrasound device use. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 29-8. 6. Answer: 3, 4, and 5. Rationale: For this client, the nurse could take an axillary, tympanic, or temporal artery temperature. Due to the facial drooping and difficulty swallowing, the oral route is not recommended (option 1). Although the rectal route could be used, it would require unnecessary moving and positioning of a client who cannot assist, and it would not provide a significant advantage over the other routes (option 2). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 29-1. 7. Answer: 4. Rationale: The posterior tibial and pedal pulses in the foot are considered peripheral and at least one of them should be palpable in normal individuals. Option 1: A bounding radial pulse is more indicative that perfusion exists. Options 2 and 3: Apical and carotid pulses are central and not peripheral. Cognitive Level: Analyzing. ­Client Need: Health Promotion and Maintenance. Nursing Process: Diagnosing. Learning Outcome: 29-9. 8. Answer: 3. Rationale: Dyspnea, difficult or labored breathing, is commonly related to inadequate oxygenation. Therefore, the client is likely to experience shortness of breath, that is, a sense that none of the breaths provide enough oxygen and an immediate second breath is needed. Option 1: Shallow respirations are seen in tachypnea (rapid breathing). Option 2: Wheezing is a high-pitched breathing sound that may or may not occur with dyspnea. Option 4: The medical term for coughing up blood is hemoptysis and is unrelated to dyspnea. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 29-7. 9. Answer: This blood pressure should be recorded as 180/105/95 mmHg using the systolic/1st diastolic/2nd diastolic convention. Rationale: Phase 1 first sound is a clear tapping when deflation of the cuff begins. Phase 2 has a muffled, swishing sound. In phase 3, blood is flowing freely via an increasingly open artery; sounds are more crisp and more intense but softer than phase 1. Phase 4 sounds become muffled and have a soft blowing quality. In phase 5 the last sound is heard followed by silence. Cognitive Level: Analyzing. ­Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 29-9. 10. Answer: 4. Rationale: The SpO2 in this case is 97%. Option 1 indicates the systolic blood pressure of 121 mmHg, option 2 the mean arterial pressure of 95 mmHg, option 3 the pulse of 87 beats/min, and option 5 the diastolic blood pressure of 84 mmHg. In addition, the client’s temperature is shown. Cognitive Level: Understanding. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 29-3f.

Chapter 30: Health Assessment

1. Answer: 2. Rationale: Resonance is a normal sound over the lung. Tympany would be heard over the stomach (air filled) (option 1), hyperresonance is never a normal finding (option 3), and dullness would be heard below (not above) the 10th intercostal space (option 4). ­Cognitive Level: Remembering. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcomes: 30-3; 30-4k. 2. Answer: 1, 2, 3. Rationale: Examining the body through use of touch describes palpation (option 4). Striking the body to elicit a sound from a body part describes percussion (option 5).

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Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 30-2. Answer: 1. Rationale: A bruit suggests abnormal turbulence in the aorta, and the primary care provider must be notified. For absence of bowel sounds to be considered abnormal, they must be silent for 3 to 5 minutes (option 2). Continuous bowel sounds are normally heard over the ileocecal valve following meals (option 3). Bowel sounds are more commonly irregular than they are regular (option 4). Cognitive Level: Understanding. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcomes: 30-3; 30-4o; 30-8. Answer: 1. Rationale: If a pedal pulse, which is more distal than the popliteal, is present, then adequate arterial circulation to the leg is present even though the popliteal artery has not been located. Presence of a femoral pulse would not provide confirmation that arterial flow exists below that point (option 2). Taking a thigh BP requires locating the popliteal pulse (option 3). Because the purpose of finding the popliteal pulse is to provide information about arterial circulation to the leg, checking the distal pulse before requesting assistance from another nurse is appropriate (option 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcomes: 30-3; 30-4m. Answer: 2. Rationale: Visual acuity often lessens with age. Facial hair is likely to become coarser, not finer (option 1). The sense of smell becomes less, rather than more acute (option 3). The respiratory rate and rhythm is regular at rest (option 4). However, both may change quickly with activity and be slow to return to the resting level. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluating. Learning Outcome: 30-3. Answers include color, turgor, temperature, moisture, lesions, odor, and edema. Cognitive Level: Remembering. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 30-4b. Answer: 3. Rationale: Recent memory includes events of the current day. Recalling a series of numbers tests immediate recall (option 1). Recalling childhood events tests remote (long-term) memory (option 2), and subtracting backwards from 100 tests attention span and ­calculation skills (option 4). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcomes: 30-3; 30-4q. Answer: 4. Rationale: If the client can only read the first three lines, vision is impaired and could lead to falls or other injuries. This impaired vision is not related to deficient knowledge (option 1) or memory (option 2) and may or may not be related to circulation (option 3). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Diagnosing. Learning Outcomes: 30-3; 30-8. Answer: 1, 2, 3, 4. Rationale: Using a stethoscope to transmit sounds to the ears is done during auscultation, not indirect percussion. ­Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 30-2. Answer: Of the terms listed, only equal, symmetrical, and firm are normal findings. Atrophied, flaccid, contractured, hypertrophied, crepitation, spastic, and tremor are abnormal findings. Review the terms in the glossary to go over their meanings. Cognitive Level: ­Understanding. Client Need: Health Promotion and Maintenance. Nursing ­Process: Evaluation. Learning Outcomes: 30-4p; 30-8.

Chapter 31: Asepsis

1. Answer: 1. Rationale: When a client has an airborne disease and must go elsewhere in the hospital, the client must wear a mask. Cognitive

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Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcome: 31-9. Answer: 1, 2, 3. Rationale: The nurse should instruct the client to minimize exposure to others when recovering from surgery to reduce the risk of infection (option 4). The nurse should instruct the client to get adequate rest and sleep when recovering from surgery to reduce the risk of infection (option 5). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 31-8. Answer: 3. Rationale: Paper towels and a sink for hand washing should be in the client’s room so they can be used before the staff leave the room. A blood pressure cuff is needed in the client’s room to prevent cross contamination. A cabinet stocked with gloves and gowns would be outside the room (option 1). Cards and records should never be taken into an isolation room (option 2). The sign explaining the kind of isolation should be on the outside of the door to alert the staff of what is needed to enter (option 4). Cognitive Level: Applying. ­Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 31-10. Answer: 1. Rationale: Unless overly contaminated by material that has splashed in the nurse’s face and cannot be effectively rinsed off, goggles may be worn repeatedly (option 1). Since gowns are at high risk for contamination, they should be used only once and then discarded or washed (option 2). Surgical masks (option 3) and gloves (option 4) are never washed or reused. Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 31-11b. Answer: 4. Rationale: It should not be necessary to unroll this small edge of the cuff. The most important consideration is the sterility of the fingers and hand that will be used to perform the sterile procedure. The rolled-under portion is now contaminated and should not be unrolled by the nurse or colleague since it would then touch the remaining sterile portion of the glove (option 3). Cognitive Level: ­Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 31-11d. Answer: 2, 3, and 4. Rationale: Flu shots are recommended for all adults over age 50. Only adults at risk need to receive hepatitis B and A vaccine (note that this is different than for children). Options 1 and 5 are incorrect because all adults should receive a tetanus booster every 10 years (or sooner if injured) and adults over age 60 should receive the herpes zoster vaccination. Cognitive Level: Remembering. Client Need: Safe, Effective Care Environment. Nursing Process: Assessment. Learning Outcomes: 31-8; 31-6. Answer: Because a malnourished client with a wound is less able to resist an infection, Risk for Infection is the most likely nursing diagnosis. Others may include Pain or Imbalanced Nutrition but they are less focused on the immediate health risk. Cognitive Level: Applying. ­Client Need: Safe, Effective Care Environment. Nursing Process: Diagnosing. Learning Outcome: 31-7. Answer: 2. Rationale: Raw foods touched by human hands can carry significant infectious organisms and must be washed or peeled. Antimicrobial soap is not indicated for regular use and may lead to resistant organisms. Hand hygiene should occur as needed. Hot water can dry and harm skin, increasing the risk of infection (option 1). Clients should learn all the signs of inflammation and infection (e.g., redness, swelling, pain, heat) and not rely on the presence of pus to indicate this (option 3). People should not share washcloths or towels (option 4). Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Evaluation. Learning Outcomes: 31-8; 31-5. Answer: 1. Rationale: Sterile objects are considered unsterile if placed lower than the waist. Only area 1 in this situation would be considered sterile. Above the neck, higher than 2 inches above the elbow, below

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Appendix A the waist/table, and the back are all considered unsterile. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcomes: 31-1; 31-11c. 10. Answer: 3. Rationale: All items within 1 inch of the edge of the sterile field are considered contaminated because the edge of the field is in contact with unsterile areas. When hands are ungloved, forceps tips are to be held downward to prevent fluid from becoming contaminated by the hands and then returned to the sterile field (option 1). Fields should be established immediately before use to prevent accidental contamination when not observed closely (option 2). Reaching over a sterile field increases the chances of dropping an unsterile item onto or touching the sterile field (option 4). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Evaluation. Learning Outcome: 31-11c.

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Chapter 32: Safety

1. Answer: 3. Rationale: In the event of a fire, the nurse’s priority responsibility is to rescue or protect the clients under his or her care. The next priorities are to report or alert the fire department, contain or confine, and extinguish the fire. Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 32-6. 2. Answer: 4. Rationale: Exposure to x-rays in the first trimester could cause harm to the developing fetus. Banging into objects is what a toddler would be likely to do, not an expectant mother (option 1). Bicycle rides and recreational activities would be good for the developing fetus; the mother should stay as active as possible during the pregnancy. Physical activity promotes good health (options 2 and 3). Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 32-4. 3. Answer: 1, 2, 3. Rationale: The ability to stand in place for a minute before ambulating would be applicable if the client were demonstrating signs of orthostatic hypotension (option 4). The use of alcohol with prescribed medications would be beneficial if the client were prescribed sedatives or hypnotics (option 5). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 32-7. 4. Answer: 3. Rationale: A home that was built prior to 1978 has leadbased paint. The ingestion of lead-based paint chips places that child at risk for elevated serum lead levels and neurologic deficits. The most appropriate nursing diagnosis for this child is Risk for Poisoning. Option 1: The risk for suffocation is greater in infants and is not related to a home with lead-based paint. Options 2 and 4 are not related to leadbased paint. Cognitive Level: Applying. Client Need: Safe, ­Effective Care Environment. Nursing Process: Nursing Diagnosis. Learning Outcome: 32-5. 5. Answer: 4. Rationale: Option 4 is an intervention that can allow the client to feel independent and also alert the nursing and nursing staff when the client needs assistance. It is the most realistic answer that promotes client safety. Option 1 can increase agitation and confusion and removes the client’s independence. Option 2 would help but transfers the responsibility to the family member. Option 3 is inappropriate since the client could fall during the unobserved interval and it is not a realistic answer for the nurse. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcomes: 32-6; 32-12a. 6. Answer: 2 and 5. Rationale: Options 2 and 5 are measures needed to keep the client safe in the event of another seizure. Option 1 is incorrect because the current nursing literature states to not put anything in the client’s mouth during a seizure. Options 3 and 4 are more relevant after the cause of the seizure is known. Seizures are not all classified as epilepsy. Cognitive Level: Applying. Client Need: Safe, Effective Care

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Environment. Nursing Process: Planning. Learning Outcomes: 32-8; 32-12b. Answer: 3. Rationale: Providing adequate lighting will help prevent the client from falling. The environment should be clutter-free because any clutter can cause the client to fall (option 1). Wearing terry cloth slippers would allow the client to fall. The client should have rubber skid-resistant soles (option 3). Noise should be kept to a minimum, but turning off alarms would endanger a client (option 4). Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. ­Nursing Process: Implementation. Learning Outcome: 32-6. Answer: 3, 4, and 5. Rationale: Reviewing near misses could identify flaws in the system or practices that placed the client at risk. Communication among staff and with clients will increase the efficiency and create an atmosphere where nurses are willing to discuss errors openly so that the flaws in the system can be corrected. Options 1 and 2 are inappropriate answers. A competent nurse may make medication errors. Also, evidence is needed to support these conclusions. Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcomes: 32-1; 32-3. Answer: 3. Rationale: Suicide and homicide are two leading causes of death among teenagers. Adolescent males commit suicide at a higher rate than adolescent females. Options 1 and 2 are true; however, neither would be as high a priority as preventing suicide. Option 4 is not true. A driver’s education course does not ensure safe practice. ­Cognitive Level: Analysis. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcome: 32-4. Answer: 1, 3, 4, and 5. Rationale: Standards require documentation of the necessity for restraints. The implementation of range-of-motion exercises prevents joint stiffness and pain from disuse. Orienting the client helps the nurse determine the necessity of the restraint. Option 2 is inappropriate because it may cause injury if the side rail is lowered without untying the restraint. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcomes: 32-9; 32-12c.

Chapter 33: Hygiene

1. Answer: 3. Rationale: The client fits the descriptors for a semidependent functional level (see Table 33–2). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 33-3. 2. Answer: 3. Rationale: The client will be positioned in a side-lying position with the head of the bed lowered because the client is at risk for aspiration. The absence of the gag reflex lets the nurse know that the client has no natural defense (cough) and is at a higher risk for aspiration. All other answers are assessments more appropriate prior to bathing the client. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 33-4. 3. Answer: 3. Rationale: The hair should be smooth in texture and ­neither oily nor dry. Dry or thin hair could be a sign of alopecia, and darkness would depend on hair color through the gene pool (option 1). Skin is assessed as being smooth, taut, or shiny, not hair (option 2). A tender, warm scalp could indicate a problem, so this would not be normal (option 4). Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 33-3. 4. Answer: 1. Rationale: Turn off the hearing aid. Option 2 is incorrect because an in-the-ear hearing aid is cleaned with a damp cloth. ­Option 3 is incorrect; make sure the volume is turned all the way down ­because a too loud volume is distressing. Check that the battery is in the hearing aid; do not remove the batteries (option 4).

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Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: ­Implementation. Learning Outcome: 33-15h. Answer: 3. Rationale: Placing the soiled sheet in the laundry bag reduces the spread of microorganisms, which is a safety measure for both the nurse and client. Beginning at the head and moving toward the foot, loosening the bottom linens, provides maximum work space. Mitering the corners at the head of the bed prevents linens from becoming easily loosened. Preparing the client readies the client for the procedure. ­Cognitive Level: Applying. Client Need: Physiological Integrity. ­Nursing Process: Implementation. Learning Outcome: 33-14. Answer: 1, 2, 3, 5. Rationale: When bathing a client with dementia, the nurse should stop if the client begins to feel distressed (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 33-8. Answer: 4. Rationale: It is important to retract the foreskin to remove the smegma that collects under the foreskin and can cause bacterial growth. Cognitive Level: Analyzing. Client Need: Physiological ­Integrity. Nursing Process: Evaluation. Learning Outcome: 33-1. Answer: 1, 3, and 5. Rationale: The developmental level warrants supervision. If the bottle is given during naps or bedtime, the solution has continuous contact with the toddler’s teeth. The first visit to the dentist should occur between the ages of 2 and 3 (option 2). More than 50% of older adults have their own teeth (option 4). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 33-4. Answer: 2. Rationale: The client needs to avoid walking barefoot because that could cause injury that may result in an infection. Also, neurologic impairment is likely as a result of the diabetes, which may result in decreased sensation. The client would be unaware of an injury. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 33-4. Answer: 1. Rationale: Fowler’s is a semisitting position that should ease the client’s breathing. The head of the bed (HOB) in semi-Fowler’s is lower (option 2). The HOB is lowered in the Trendelenburg position (option 3). Although the HOB is raised in the reverse Trendelenburg position, it is a straight tilt and may not be as comfortable as Fowler’s (option 4). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning ­Outcome: 33-13.

Chapter 34: Diagnostic Testing

1. Answer: 3. Rationale: A nursing procedure or laboratory manual is often available if the nurse is unfamiliar with the procedure. If there is any question about the procedure, the nurse should call the laboratory for directions before collecting the specimen. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 33-3. 2. Answer: 4. Rationale: The test cannot be continued, and it should not be documented that one specimen is missing (option 1). The test is not to be ended immediately, and the specimen should not be sent to the laboratory (option 2). The test is not complete. The nurse should not document that the test cannot be completed. It needs to be restarted (option 3). Cognitive Level: Analyzing Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 34-6. 3. Answer: 2. Rationale: A KUB is an x-ray of the kidneys, ureters, and bladder. This does not require direct visualization. Option 1 is an IVP, an intravenous pyelogram, which requires the injection of a contrast media. Option 3 is a retrograde pyelography, which requires the injection of a contrast media. Option 4 is a cystoscopy, which uses a lighted instrument (cystoscope) inserted through the urethra, resulting in direct visualization. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning ­Outcome: 34-8.

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4. Answer: 4. Rationale: This type of nuclear scan demonstrates the ability of tissues to absorb the chemical to indicate the physiology and function of an organ. Option 1 is an invasive procedure that focuses on blood flow through an organ. Options 2 and 3 provide information about density of tissue to help distinguish between normal and abnormal tissue of an organ. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 34-9. 5. Answer: 3. Rationale: Bone marrow aspiration includes deep penetration into soft tissue and large bones such as the sternum and iliac crest. This penetration can result in bleeding. The client should be observed for bleeding in the days following the procedure. Option 1 is a nursing action during a liver biopsy. Option 2 is a nursing action for a thoracentesis, and Option 4 is a nursing action for a lumbar puncture. ­Cognitive Level: Applying. Client Need: Physiological Integrity. ­Nursing Process: Implementation. Learning Outcome: 34-10. 6. Answer: 1 and 4. Rationale: ALT is an enzyme that contributes to protein and carbohydrate metabolism. An increase in the enzyme indicates damage to the liver. The liver contributes to the metabolism of protein, which results in the production of ammonia. If the liver is damaged, the ammonia level is increased. Options 2, 3, and 5 (myoglobin, cholesterol, and BNP) are relevant for heart disease. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 34-2. 7. Answer: 3. Rationale: A glycosylated hemoglobin will indicate the glucose levels for a period of time, which is indicated by the nurse practitioner. Options 1 and 2 will provide information about the current blood glucose, not the past history. Option 4 is used to assess for liver disease. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Planning. Learning ­Outcome: 34-2. 8. Answer: 2, 3, and 5. Rationale: The nurse should obtain the stool specimen from two different areas of the stool. The nurse should observe for a blue color change, which is indicative of a positive result. The nurse should assess for the ingestion of vitamin C by the client because it is contraindicated for 3 days prior to taking the specimen. Option 1 is incorrect since the reagent is placed on the specimen after it is applied to the testing card. Option 4 is incorrect because a pink color would be considered negative and does not require verification. ­Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 34-5. 9. Answer: 1. Rationale: Lying in the lateral position with the head bent toward the chest and knees flexed onto the abdomen is the correct position for a lumbar puncture. In this position the back is arched, increasing the spaces between the vertebrae so that the spinal needle can be readily inserted. Lying prone with knees down toward the abdomen would position the client too high for the physician and could lead to increased intracranial pressure (option 2). Sitting would not arch the back enough to increase the space between the vertebrae for puncture (option 3). Supine with knees pulled toward the chest does not expose the vertebrae to be punctured (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 34-10. 10. Answer: 2, 4, and 5. Rationale: The sputum specimen should be sent immediately to the laboratory. The client should be provided mouth care before and after the specimen is collected. The sputum specimen should be collected for three consecutive days. Option 1 is incorrect because the sputum specimen is collected in the morning not in the evening. Option 3 is incorrect because the term spit indicates that saliva is being examined. The client needs to cough up or expectorate mucus or sputum. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 34-7.

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Appendix A

Chapter 35: Medications

1. Answer: 2. Rationale: If there is any doubt, the medication administration process should be interrupted until the question is clarified. Listen to the client. Find out any other information the client may have about that certain medication. For example, does he know the dosage of the medication taken at home? Do not administer the medication (option 1). Inform the client that you will check the chart first. Review the chart to make sure there is no discrepancy between the physician’s order and the MAR. Review the physician’s progress notes because the medication may have been increased or reduced as part of the treatment plan (option 3). Check with the pharmacist because sometimes a pill may be a different color or shape based on the pharmaceutical company. Do not leave medications at the bedside. Medications should never be left unattended (option 4). Inform the client of your findings. The client will appreciate that you took the time to make sure that he received the correct medication. While it takes time to check out the client’s statement, you will be glad that you avoided a potential medication error. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 35-11. 2. Answer: 2. Rationale: If the primary care provider cannot be reached, all attempts to contact the primary care provider and the reason for withholding the medication are documented. The nurse should not give the medication as prescribed, since the pharmacy has identified that the dose prescribed is outside of dosing limits (option 1). Giving one half of the medication prescribed is outside the nurse’s licensure (option 3). Administering the medicine through the oral route might not be the best for the medication and changing the route is outside of the nurse’s licensure (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Evaluation. Learning Outcome: 35-6. 3. Answer: 1, 3, and 5. Rationale: Five milliliters is too large an amount to inject into one site. The nurse needs to divide the amount into two 2.5-mL injections. A 3-mL syringe could be used (option 1). The length of the needle will depend on the muscle development of the client. The nurse needs to assess the client. The presumption, based on the information provided, is that this client’s muscle mass is within normal limits. The needle length would need to be 1 1/2 inches because the medication is ordered to be given “deep IM” (option 5). This also suggests that the medication should be given in the preferred site for IM injections—the ventrogluteal site—because it provides the greatest thickness of gluteal muscle. The gauge of the needle for an IM injection into the ventrogluteal muscle can range between #20 and #23 (option 3). The nurse needs to assess the viscosity of the medication. Smaller gauges (e.g., #23) produce less tissue trauma; however, viscous solutions may require a larger gauge (e.g., #20–#21). Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 35-5. 4. Answer: 3. Rationale: The type of syringe for subcutaneous injections depends on the medication to be given. This situation does not indicate that the medication is insulin and, thus, another syringe is needed. Generally a 2-mL syringe is used for most subcutaneous injections. Generally, a #20- to #23-gauge needle is used for IM injections. Needle size and length are based on the client’s body mass, the intended angle of insertion, and the site of the injection. Generally, a #25-gauge, 5/8-inch needle is used for adults of normal weight and the needle is inserted at a 45° angle. Because 2 inches of tissue can be grasped or pinched at the site of the injection, the nurse should administer the medication at a 90° angle to ensure the medication reaches subcutaneous tissue. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 35-18b. 5. Answer: 1. Rationale: A tuberculin test is given by intradermal injection. A tuberculin syringe is used because the dosage will most likely

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be 0.1 mL. A short, fine needle is needed to avoid entering the subcutaneous tissue. The needle should have a short bevel and usually be between #25 and #27 gauge. The needle should be between 1/4 to 5/8 inch long. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 35-18a. Answer: 4. Rationale: If the nurse goes by the amount of the medication (0.5 mL) only, the deltoid muscle would be the site. However, knowing and assessing the client is critical. The muscles of an older, emaciated client will most likely be diminished or atrophied. The nurse should consider the ventrogluteal site because that site will have the most muscle mass. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcomes: 35-17c; 35-12. Answer: 2. Rationale: Altered quality of organ responsiveness, resulting in adverse effects becoming pronounced before therapeutic effects are achieved, is one effect of medications on the older client. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 35-12. Answer: 1. Rationale: There is no need to notify the pharmacy for a new tube of ointment or to have the wastage witnessed by another nurse. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 35-20c. Answer: 0.375 or rounded to 0.38 mL. Rationale: After converting to like numbers, the formula would be set up as follows: 400 micrograms = 1 mL 150 micrograms = X mL Cross multiply (400 X = 150) Divide by 400 X = 0.375 Cognitive Level: Applying. Client Need: Physiological Integrity. ­Nursing Process: Implementation. Learning Outcome: 35-9. Answer: 3, 4, 1, 5, 2, 6, 7, and 8. Rationale: This is the correct order for this skill—first the nurse mixes the insulin, assesses the skin, and cleanses the skin. The nurse would then pinch the skin, insert the needle, inject the medication, count to five, and remove the syringe. ­Cognitive Level: Applying. Client Need: Physiological Integrity. ­Nursing Process: Implementation. Learning Outcome: 35-18b.

Chapter 36: Skin Integrity and Wound Care

1. Answer: 3. Rationale: Cleansing should be done with a mild cleansing agent and warm water, so option 1 is not appropriate. Petroleum-based creams are now thought to offer poor overall skin protection and to interfere with incontinence brief absorption (option 2). Keeping the client in bed to treat this area is not necessary and may lead to problems with immobility (option 4). Cognitive Level: Applying. Client Need: Safe, Effective Care Management. Nursing Process: Implementation. Learning Outcome: 36-2. 2. Answer: 1. Rationale: Wound culture specimens should be obtained from a cleaned area of the wound. Microbes responsible for the infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms. An appropriate specimen can be obtained without causing the client the discomfort of debriding. The nurse does not generally debride the wound to obtain a specimen. Once systemic antibiotics have been begun, the interval ­following a dose will not significantly affect the concentration of wound organisms. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 36-10. 3. Answer: 3. Rationale: Hydrocolloid dressings protect shallow ulcers and maintain an appropriate healing environment. Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2) will stick to new granulation tissue, causing more damage. A dressing is needed to protect the wound and enhance healing. Cognitive

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Level: Applying. Client Need: Physiological Integrity. Nursing ­Process: ­Implementation. Learning Outcome: 36-11. Answer: 3. Rationale: After about 15 minutes of heat application, the thermal receptors adapt to the temperature increase and the sensation of warmth is diminished. Clients often request that the temperature be increased because they do not feel the same amount of heat. This can lead to burns. There is no evidence that this client has increased thermal tolerance or that the rebound effect is occurring. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 36-14. Answer: 3. Rationale: Immobile and dependent persons should be repositioned at least every 2 hours, not every 4, so this client or family member requires further teaching. Warm water and moisturizing damp skin are correct techniques for skin care. Red areas that do not return to normal skin color should be reported. It would also be correct to use a foam pad to help relieve pressure. Cognitive Level: ­Analyzing. Client Need: Physiological Integrity. Nursing Process: Evaluation. Learning Outcome: 36-10. Answer: 3. Rationale: The head of the client’s bed should be kept at less than 30 degrees elevation as much as possible (option 1). Baby powder and cornstarch should not be used because they cause abrasive grit damage to tissues (options 2 and 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 36-10. Answer: 2. Rationale: This client has an actual impairment of the integrity of the skin due to the rash and the scratching so is no longer “at risk.” Because the damage is at the skin level, it is not impaired tissue integrity (option 3) since that would involve deeper tissues. Surface excoriation is also not prone to becoming infected. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: ­Diagnosing. Learning Outcome: 36-9. Answer: 1, 3, and 4. Rationale: Risk factors for pressure ulcers include low-protein diet, lengthy surgical procedures, and fever. Protein is needed for adequate skin health and healing. During surgery, the client is on a hard surface and may not be well protected from pressure on bony prominences. Fever increases skin moisture, which can lead to skin breakdown, plus the stress on the body from the cause of the fever could impair circulation and skin integrity. Insomnia (option 5) would generally involve restless sleeping, which transfers pressure to different parts of the body and would reduce the chances of skin breakdown. A waterbed (option 5) distributes pressure more evenly than a regular mattress and, thus, actually reduces the chances of skin breakdown. Cognitive Level: Remembering. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 36-1. Answer: 1, 2, and 4. Rationale: To irrigate a wound, the nurse uses clean gloves to remove the old dressing and to hold the basin collecting the irrigating fluid plus sterile gloves to apply the new dressing. A ­60-mL syringe is the correct size to hold the volume of irrigating solution plus deliver safe irrigating pressure. The irrigation fluid should be room or body temperature—certainly not refrigerated. Forceps may be used to remove or apply a dressing but are not required for irrigation. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 36-13b. Answer: 2. Rationale: The knot of the triangle sling must be kept off the spinal processes because this would be uncomfortable and put unnecessary pressure on the vertebrae. The elbow should be flexed slightly less than 80° (not >90° as in option 1) so the hand is above the elbow to prevent dependent swelling. The sling must extend past the wrist in order to support the hand. Although the sling must be removed to check for circulation and skin integrity, every 2 hours

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(option 4) is unnecessarily frequent and impractical. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Evaluation. Learning Outcome: 36-13c.

Chapter 37: Perioperative Nursing

1. Answer: 1, 2, 3, 4, 5. Rationale: All options should be obtained when completing a preoperative assessment. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 37-3 2. Answer: 2. Rationale: Grieving is the state in which an individual experiences reactions in response to an expected significant loss. The definition for option 1 is “confusion in mental picture of one’s self ” and is often characterized by negative responses such as shame, embarrassment, guilt, or revulsion. Option 3, fear, is usually characterized by feelings of dread, fright, apprehension, or alarm. Ineffective coping, option 4, is usually characterized by verbalization of inability to cope or ask for help, inappropriate use of defense mechanisms, or inability to meet role expectations. Cognitive Level: Applying. Client Need: ­Psychological Integrity. Nursing Process: Diagnosis. Learning ­Outcome: 37-4. 3. Answer: 1. Rationale: The nurse should provide information including what will happen to the client, when, and what the client will experience. The nurse should clarify any misconceptions the client may have. The nurse should also explain the roles of the client and support people in preoperative preparation, the surgical procedure, and during the postoperative phase. How to perform activities of daily living following surgery is not a part of preoperative teaching. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Evaluation. Learning Outcome: 37-6. 4. Answer: 2. Rationale: The symptoms describe decreased cardiac output and not any of the other listed complications. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: ­Assessment. Learning Outcome: 37-10. 5. Answer: 3. Rationale: Options 1 and 2 are incorrect because the client is still recovering from the anesthesia used during surgery. Option 4 is incorrect because pain usually decreases after the second or third postoperative day. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning ­Outcome: 37-10. 6. Answer: Splinting. Rationale: If the incision is painful when the client coughs, splinting the abdomen may reduce the pain. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 37-6. 7. Answer: 3. Rationale: The unconscious client should be positioned on the side, with the face slightly down. In the supine position, the client could occlude the airway. In the prone position, the client’s operative site may not be readily assessed. A pillow under the head could cause the client’s airway to become obstructed. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 37-9. 8. Answer: 1 and 3. Rationale: Anesthetics, narcotics, fasting, and inactivity all inhibit peristalsis. Oral fluids and food are started after the return of peristalsis. The client may feel hungry but peristalsis may not be present. The other options are important but not related specifically to advancing the client’s diet. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 37-9. 9. Answer: Safety. Rationale: The client’s protective reflexes are compromised, especially with general anesthesia. Thus, the perioperative nurse needs to maintain the client’s safety during surgery. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. ­Nursing Process: Planning. Learning Outcome: 37-5.

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Appendix A 10. Answer: 2, 3, and 5. Rationale: Option 1 is incorrect because sterile technique is used. The suture material that is visible is in contact with bacteria and must not be pulled beneath the skin during removal (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Learning Outcome: 37-12e.

Chapter 38: Sensory Perception

1. Answer: 1, 3, 5. Rationale: Pain, sleeplessness, and worry can contribute to sensory overload. Nocturnal confusion and being easily ­annoyed are manifestations of sensory deprivation (options 2 and 4). Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. Nursing Process: Evaluation. Learning Outcome: 38-3 2. Answer: 4. Rationale: Since the client lives alone and is recovering from cataract surgery, the client’s risk for injury is great. Social Isolation would be appropriate for the client with long-term vision changes but not one with an acute change as in cataract surgery. Risk for Impaired Skin Integrity is used to describe clients who have altered tactile sensation. Disturbed Sensory Perception is used to describe clients whose perception has been altered by physiological factors such as pain, sleep deprivation, immobility, disease states such as CVA, or brain trauma. Cognitive Level: Applying. Client Need: Psychosocial Integrity. ­Nursing Process: Diagnosis. Learning Outcome: 38-6. 3. Answer: 2. Rationale: Because of the paraplegia (paralysis of lower body), the client is unable to feel discomfort. The client will be taught to lift self using chair arms every 10 minutes if possible. Option 1 is an actual problem versus a potential problem. In option 3, the client wears glasses that help correct the poor vision. Option 4 is more of a Risk for Injury diagnosis. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Diagnosis. Learning Outcome: 38-6. 4. Answer: 2. Rationale: This client could use an assistive device that flashes a light when the doorbell rings. Option 1 relates to safety of the environment rather than sensory alteration. Options 3 and 4 reflect how the client adapts to the sensory alteration. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Evaluation. Learning Outcome: 38-7. 5. Answer: 3. Rationale: Spraying the room with a floral spray will add to the sensory overload (option 1). Vinegar is not instilled into wounds (option 2). Burning a candle will add to the sensory overload and ­burning candles is not safe in the hospital environment (option 4). ­Cognitive Level: Applying. Client Need: Psychosocial Integrity. ­Nursing Process: Implementation. Learning Outcome: 38-7. 6. Answer: 1, 3, and 4. Rationale: Options 2 and 5 relate to interventions for a client with a hearing impairment. Cognitive Level: Applying. ­Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 38-7. 7. Answer: 3. Rationale: A disorganized, cluttered environment increases confusion. Option 1: Keeping the room well lit during waking hours promotes adequate sleep at night. It is important to eliminate unnecessary noise (option 2). Client does not meet the standard criteria for restraint application (option 4). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 38-8. 8. Answer: 2, 4, and 5. Rationale: Options 1 and 3 are clinical signs of sensory overload. Cognitive Level: Remembering. Client Need: ­Psychosocial Integrity. Nursing Process: Assessment. Learning ­Outcome: 38-3. 9. Answer: Identifying taste: 5; Stereognosis: 3; Snellen chart: 1; Identifying aromas: 4; Tuning fork: 2. Cognitive Level: Remembering. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 38-4. 10. Answer: 1. Rationale: The amplified telephone helps with hearing and provides a means for communicating with others. Option 2 refers to

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a tactile impairment. Option 3 relates to a visual impairment, and option 4 an olfactory impairment. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Planning. Learning Outcome: 38-7.

Chapter 39: Self-Concept

1. Answer: 1. Rationale: Sally has an inappropriate view of her physical self, which is body image. Personal identity is a sense of uniqueness (option 2); self-expectation consists of those things one believes the self should be able to do (option 3); and core self-concept includes the most vital central beliefs about one’s identity (option 4). Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Diagnosing. Learning Outcome: 39-2. 2. Answer: 3. Rationale: This is role conflict—several different roles are competing for the person’s time, energy, and abilities. Role ambiguity results when there are unclear expectations of the role (option 1). Role strain exists when there are feelings of inadequacy in performing a role (option 2). Role enhancement is a nursing intervention (option 4). Cognitive Level: Understanding. Client Need: Psychosocial Integrity. Nursing Process: Diagnosing. Learning Outcome: 39-2. 3. Answer: 2. Rationale: It is not appropriate to reinforce her feelings by comparing the client to other clients (option 1), or to blame the spouse for the slowness (option 3), or to instil doubt by asking if the client is really trying (option 4). Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 39-2. 4. Answer: 1. Rationale: This response encourages the client to say more and focuses on the positive. Option 2 is condescending and closes the discussion. Both options 3 and 4 ignore the emotional component of the client’s statement and do not address the person’s feelings of worthlessness. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcomes: 39-6; 39-7. 5. Answer: 3. Rationale: The diagnosis Grieving is appropriate, since the client is expressing a feeling related to a change in physical appearance. The client’s feelings of being ugly do not support the diagnosis of ­Powerlessness, Social Isolation, and Hopelessness. Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. Nursing Process: ­Diagnosis. Learning Outcome: 39-1. 6. Answer: 3. Rationale: Self-awareness consists of the relationship between own and others’ perceptions of the person. The other options reflect only how the nurse sees himself or herself. Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. Nursing Process: ­Evaluation. Learning Outcome: 39-2. 7. Answer: 1. Rationale: The first information the nurse gathers when assessing self-concept should focus on the client’s personal identity. Option 2 assesses role performance. Option 3 assesses social role and option 4 assesses work role. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning ­Outcome: 39-6. 8. Answer: 2 and 5. Rationale: A person with chronic low self-esteem often is able to only make negative statements about self. The client would have difficulty confronting authority (option 1). Option 3 relates to role performance. Option 4 is incorrect because the client would have difficulty achieving even common/realistic goals and is not likely to set extremely high goals. Option 6, sleeping, is generally not impaired with low self-esteem. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Diagnosing. Learning Outcome: 39-5. 9. Answer: 2 and 3. Rationale: The client with poor self-concept should be encouraged to say positive self-statements and minimize negative ones. Such clients should not be encouraged to compare themselves with others (option 1). Having them care for others can be a very

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therapeutic intervention for such individuals (option 4). They should be given realistic and normal levels of expectations for their behavior. Cognitive Level: Applying. Client Need: Psychosocial Integrity. ­Nursing Process: Implementation. Learning Outcome: 39-6. 10. Answer: 4. Rationale: The social self is how one is perceived by others and is difficult, if not impossible, to influence since the client does not control the viewpoints of other persons. With planning, the number of the client’s resources can be increased, self-knowledge improved, and core self-concept broadened since these are within the client’s control. Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. ­Nursing Process: Planning. Learning Outcome: 39-3.

Chapter 40: Sexuality

1. Answer: 4. Rationale: Clients still may feel shame and discomfort regarding sexuality. Most people assume that providers have a great deal of information (option 1). Many clients have questions and concerns (option 2). Although talking with someone of the same gender may make it easier for some women, it is not a requirement for assessment and intervention (option 3). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 40-1. 2. Answer: 1. Rationale: Androgyny has nothing to do with gender attraction or with repression of sexual feelings (options 2 and 3). ­Androgynous individuals do not hold rigid stereotyped gender role expectations since androgyny means flexibility in gender roles (option 4). Cognitive Level: Analyzing. Client Need: Health ­Promotion and Maintenance. Nursing Process: Assessment. ­Learning Outcome: 40-3. 3. Answer: 2. Rationale: In this situation, the nurse should quickly and politely leave the room. Masturbation is not harmful to sexual wellbeing (option 1). It is inappropriate to ask the client to stop so that care can be provided (option 3). Masturbation does not indicate sexual concerns that should be discussed (option 4). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 40-5. 4. Answer: 3. Rationale 1: Clients with vaginismus experience involuntary spasm of the outer one-third of the vaginal muscles. This spasm makes internal examination, tampon use, and intercourse difficult. Use of smaller than normal vaginal speculums may make examination easier. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 40-8. 5. Answer: 4 Rationale: More information is needed before intervening. Also, the client needs the opportunity to express her feelings. Option 1 is an unprofessional response and false reassurance. The ANA Code of Ethics indicates that clients are entitled to a timely and appropriate response to their needs. Option 2 suggests postponing the discussion and that the primary care provider is the better person to deal with her concerns, which is untrue. Option 3 represents feeding into her negative self-concept and inappropriate self-disclosure. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 40-4. 6. Answer: 1. Rationale: Dyspareunia is painful intercourse. Knowledge of the partner’s awareness will contribute to resolution. Involuntary vaginal spasms are called vaginismus (option 2). Painful menstruation is called dysmenorrhea (option 3). Breast swelling can occur during portions of the menstrual cycle but is unrelated to painful intercourse (option 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcomes: 40-6; 40-7. 7. Answer: 3. Rationale: Antihypertensive medications are known to affect sexual functioning in several different ways, so some focused history questions would be indicated. There is no evidence of a relationship between sexual functioning and anti-inflammatories,

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hypnotics, or antihistamines (options 1, 2, and 4). However, the underlying condition that leads the client to take other medications could be important. Side effects of any medication could impact sexual interest or energy level, which reinforces the importance of including taking a sexual health history for all clients. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcomes: 40-6; 40-7; 40-8. 8. Answer: 2. Rationale: LI includes instructing clients regarding when sexual activity is safe or unsafe. P involves giving permission to be sexual beings and to discuss issues (option 1). SS includes specific suggestions that help clients promote optimal functioning (option 3). Intensive therapy (IT) requires special skills offered by a nurse specialist or sex therapist (option 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcomes: 40-1; 40-9. 9. Answer: 4. Rationale: A change in sexual frequency is not abnormal but may suggest an opportunity for enhanced knowledge if he desires. It does not suggest pathology or disturbed body image (options 1 and 2). It would be incorrect to assume his lifestyle is sedentary merely because the frequency of his sexual activity has decreased (option 3). Further assessment of the reason for the decrease in sexual activity is indicated. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Diagnosing. Learning Outcomes: 40-1; 40-2; 40-4; 40-8. 10. Answer: 3. Rationale: The key term is ineffective. If the suggestions given by the nurse are ineffective in reaching the desired goals, the client may require intervention from someone with more specialized skills. Verbalizing constructive methods of modifying sexual activity are healthy responses and do not require a more skilled therapist (option 1). The generalist nurse can refer the client to education and support groups (option 2). Experimenting with new sexual activities is probably a healthy direction and does not suggest the need for referral (option 4). Cognitive Level: Understanding. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 40-8.

Chapter 41: Spirituality

1. Answer: 4. Rationale: Options 1 and 2 involve assessment and diagnosis, not planning. Option 3, simply keeping the client busy, does not necessarily contribute to feeling fulfilled or purposeful. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Planning. Learning Outcomes: 41-1; 41-3; 41-6. 2. Answer: 3. Rationale: The client can be asked general questions to elicit information about what beliefs and practices are important to the present health care situation, and what, if anything, the client would like from the health care team to support spiritual health. Offering to pray with the client is over the boundary of professional practice unless the client requests such intervention and the nurse is comfortable with the arrangement (options 1 and 2). At this point, there is no information that indicates the client is in need of referral for counseling. This would occur only if the client demonstrates spiritual distress at the level best handled by a specialist (option 4). Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcomes: 41-5; 41-6. 3. Answer: 3. Rationale: The key term is full. Option 1 would be inadequate; option 2 is only partial presencing; and option 4 is transcendent presencing. Cognitive Level: Remembering. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 41-6. 4. Answer: 3. Rationale: This client portrays no distress (option 1) or risk for distress (option 2), but rather the potential for enhanced spiritual health as a result of the transformative illness experience. Option 4 is not a valid diagnosis. Cognitive Level: Applying. Client Need: ­Psychosocial Integrity. Nursing Process: Diagnosis. Learning ­Outcomes: 41-1; 41-2.

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Appendix A 5. Answer: 4. Rationale: Assessment is always the first step of the process of spiritual caregiving or any nursing activity. Options 1, 2, and 3 may not respect the spiritual beliefs of either the nurse or the client. While an assessment may lead the nurse to share personal beliefs, these are never urged on the client. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcomes: 41-1; 41-4; 41-7. 6. Answer: 4. Rationale: The nurse should wait in the hall until the prayer is over and the client or family gives permission to enter the room. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 41-6. 7. Answer: 3. Rationale: Options 1, 2, and 4 are potentially uncaring or unethical. Jehovah’s Witnesses have a well-developed network of representatives who can be called to explain and explore medical options with their fellow believers and medical staff. Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. Nursing Process: Evaluation. Learning Outcomes: 41-1; 41-4; 41-6. 8. Answer: 2. Rationale: Residing in the SNF likely will curb the client’s participation in her church. Options 1, 3, and 4 are incorrect because it is not known if the relocation or an alteration in religious practice will affect her spiritual well-being in either a negative or positive way. ­Cognitive Level: Applying. Client Need: Psychosocial Integrity. ­Nursing Process: Diagnosis. Learning Outcomes: 41-1; 41-2; 41-5. 9. Answer: 1, 2, 4, 5. Rationale: Option 3 is a question used for identifying significant values. Cognitive Level: Applying. Client Need: ­Psychosocial Integrity. Nursing Process: Assessment Learning ­Outcome: 41-8. 10. Answer: 1. Rationale: Although the mother is arguably angry, it is unknown whether this anger is impairing her religiosity or her coping. More data are needed before determining that either option 2 or 3 is the best diagnosis. The mother is experiencing distress versus being at risk for it (option 4). Cognitive Level: Applying. Client Need: ­Psychosocial Integrity. Nursing Process: Diagnosis. Learning Outcomes: 41-2; 41-5.

Chapter 42: Stress and Coping

1. Answer: 1. Rationale: Short-term coping strategies can reduce stress to a tolerable limit temporarily, but are ineffective ways to deal with reality permanently. They can even have a destructive or detrimental effect on the person. An example of short-term strategies is using alcoholic beverages or drugs. Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 42-6. 2. Answer: 2. Rationale: In this situation, the best alternative is to be certain that the nurses are well prepared for the responsibilities of their jobs, as the frustration of being unprepared leads to burnout. Asking physicians to assume nursing tasks is not appropriate. Counseling and exercise cannot be made requirements for the staff. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: ­Planning. Learning Outcome: 42-9. 3. Answer: 1. Rationale: In the transaction model, stress is a very personal experience and varies widely among individuals. Option 2 represents the stimulus model, and option 3 represents the response model of stress. In option 4, external resources and support are a factor in determining stress levels but omit the key aspects of internal/personal influences. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 42-1. 4. Answer: 3. Rationale: With stress, respirations increase, pupils dilate, peripheral blood vessels constrict, and the heart rate increases. ­Cognitive Level: Applying. Client Need: Psychosocial Integrity. ­Nursing ­Process: Assessment. Learning Outcome: 42-3. 5. Answer: 4. Rationale: Defensive Coping is the repeated projection of falsely positive self-evaluation based on a self-protective pattern that defends against underlying perceived threats to positive self-regard.

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Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. Nursing Process: Diagnosing. Learning Outcome: 42-8. Answer: 1, 3, and 4. Rationale: Common stressors among young adults include marriage, starting a new job, and leaving the parental home. Stressors from aging parents are more common among middleaged adults (option 2); decreased physical abilities is a stressor in older adults (option 5); and changing body structure serves as a stressor in both children and older adults (option 6). Cognitive Level: Understanding. Client Need: Psychosocial Integrity. Nursing Process: Planning. Learning Outcome: 42-7. Answer: 2. Rationale: All four areas of health promotion strategies may be important, but for this client sleep is likely to be the most adversely affected by travel in which changing time zones and unfamiliar sleeping quarters are common. It is easier for clients to adapt to modifying exercise (option 1), nutrition (option 3), and time management (option 4) during travel than it is to control sleep. Thus, it becomes the most important area requiring intervention to avoid worsening the existing stress. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 42-9. Answer: 4. Rationale: Unless the nurse feels in physical danger, it is important to remain with the client, allow the anger to dissipate, and then begin assessing the cause. Leaving the room provides no therapeutic action (option 1). Option 2 may be considered setting limits, which can be helpful, but cannot occur until the client is calmer. All behavior is meaningful; it is inappropriate to ignore the client’s behavior (option 3). Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 42-9. Answer: 1. Rationale: This client is exhibiting severe anxiety and, therefore, learning is impaired but not impossible (see Table 42–2). Therefore, it is most appropriate for the nurse to teach only those things that are critical for the client to learn at this time. The nurse also recognizes that learning may not be retained at this level of anxiety and plans to reinforce the teaching when the client is less anxious. ­Cognitive Level: Applying. Client Need: Psychosocial Integrity. ­Nursing Process: Planning. Learning Outcome: 42-4. Answer: 1, 2, and 4. Rationale: Compensation (option 1) may allow the client to overcome a weakness. Displacement (option 2) allows the client to express feelings safely. Repression (option 4) protects the client from further emotional trauma until able to cope. Minimization (option 3) prevents the client from accepting responsibility for actions. Regression (option 5) returns the client to a lower/previous developmental level. Note: Each of these may be more or less effective defenses depending on the exact context of the situation. Cognitive Level: Understanding. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 42-5.

Chapter 43: Loss, Grieving, and Death

1. Answer: 1, 2, and 3. Rationale: Correct answers include abbreviated (normal grief that is briefly experienced), anticipatory grief (experienced before the loss/death but appropriate), and disenfranchised grief (the emotions are felt privately, just not expressed in public). Unhealthy/abnormal types of grief include complicated grief (option 4) in several different forms: Unresolved grief is extended in length and severity (option 5). With inhibited grief, symptoms are suppressed, and other effects, including somatic, are experienced instead (option 6). Cognitive Level: Remembering. Client Need: Psychosocial Integrity. Nursing Process: Diagnosing. Learning Outcome: 43-2. 2. Answer: 1, 2, 4, 5. Rationale: The nurse should not permit the family to view the client before cleaning and care are provided. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing ­Process: Implementation. Learning Outcome: 43-8. 3. Answer: 1. Rationale: This statement acknowledges the family’s grief simply. Avoid statements that may be interpreted as overly impersonal

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(option 2), false support (option 3), or harsh (option 4). Cognitive Level: Application. Client Need: Psychosocial Integrity. Nursing ­Process: Implementation. Learning Outcome: 43-8. Answer: 3. Rationale: Until children are about 5 years old, they believe that death is reversible. Between ages 5 and 9, the child knows death is irreversible but believes it can be avoided (option 2). Between 9 and 12 years of age, the child recognizes that he, too, will someday die (option 3). At 12 to 18 years old, the child builds on previous beliefs and may fear death, but often pretends not to care about it (option 4). Cognitive Level: Remembering. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 43-4. Answer: 4. Rationale: Adaptive responses indicate the client can put the loss into perspective and begin to develop strategies for coping with the loss. Although the other options are responses the client might likely give and feel, and are not pathologic, they do not demonstrate movement toward a goal of adaptation nor problem solving. Cognitive Level: Application. Client Need: Psychosocial Integrity. Nursing Process: Evaluation. Learning Outcome: 40-3. Answer: 1. Rationale: The nurse needs to assess and explore the meaning of the client’s crying. Options 2 and 4 leap to assumptions about the meaning of the tears and ignore the possibility of the client’s distress. Option 3 suggests that the client has the same feelings as the nurse, which may not be correct. Cognitive Level: Application. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 43-3. Answer: 1. Rationale: The nurse must be certain that the advance directive is a legal document. In some states, relatives, heirs, and physicians cannot witness an advance directive. This is to prevent potential abuse of power. Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. Nursing Process: Planning. Learning Outcome: 43-5. Answer: 4. Rationale: To plan with and assist the family, the nurse needs more data regarding the family’s reactions to their loss. Information on issues such as insurance coverage (option 1) can wait until later and may be more appropriately the responsibility of social services rather than the nurse. It is important for the nurse to determine their understanding of their injuries but they are stated as minor (option 2). Once the nurse has assessed the family’s responses it will be important to determine availability of outside resources to assist them (option 3). Cognitive Level: Analyzing. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 43-1. Answer: 2. Rationale: If the client feels that his terminal state is a reflection of failure of the medical system, this fear of abandonment is common. It may not be totally unfounded because failing to cure a client is frustrating and may reflect in the care provided to the client. While nurses do provide much of the care given to terminal clients, physicians continue to be an integral part of care. Cognitive Level: Application. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 40-3. Answer: 1. Rationale: Assisting the client to die with dignity involves allowing the client to participate in and choose the direction of the remainder of his or her life. Sharing the nurse’s own views about life after death (option 2) does not enhance client dignity. The nurse should not assume that avoiding talking about dying and emphasizing the present (option 3) is therapeutic for the client. Only if the client wishes to have someone else perform care is doing so supporting death with dignity (option 4). Otherwise, it may have the opposite effect. Cognitive Level: Application. Client Need: Psychological Integrity. Nursing Process: Planning. Learning Outcome: 43-7.

Chapter 44: Activity and Exercise

1. Answer: 4. Rationale: Research has shown that the only option that has any influence on frequency of back injury is a policy prohibiting solo lifting. Wearing a back belt, body mechanisms training, and

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physical fitness do not prevent injury. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 44-7. Answer: 1. Rationale: Weight bearing helps to move calcium back into the bone, thereby strengthening them. A standard intervention for those attempting to prevent or reverse osteoporosis is beginning an exercise plan that includes weight-bearing activities. Additional calcium in the diet after osteoporosis has begun is not thought to be effective (option 2). Strict bed rest may well make the osteoporosis worse because there is no weight-bearing activity (option 3). Assisted range of motion exercises are not weight-bearing and do not help delay or reverse osteoporosis (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 44-2. Answer: 1. Rationale: Vital signs that do not return to baseline 5 minutes after exercising indicate intolerance of exercise at that time. This is a real problem, not “at risk for,” as in option 2. There is no evidence that the client requires assistance (impaired mobility, option 3), or is immobile (disuse syndrome, option 4). Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Diagnosis. Learning Outcome: 44-6. Answer: 3. Rationale: Although the crutches (or cane) are always used along with the weaker leg, the weaker leg should go down the stairs first. The stronger leg can support the body as the weaker leg moves forward. All of the other statements are correct. Cognitive Level: ­Analyzing. Client Need: Physiological Integrity. Nursing Process: Evaluation. Learning Outcome: 44-9. Answer: 3. Rationale: Range-of-motion exercising should never cause discomfort. In this case, the best action is to reduce the movement of the joint just until the point of slight resistance is felt and evaluate the pain response at that level. If there is no pain, the exercise can be continued. Stopping the treatment is not justified until an ­assessment occurs (options 1 and 2). Continuing at the same level of intensity may cause damage to the joint as well as cause the client pain (option 4). Cognitive Level: Applying. Client Need: ­Physiological ­Integrity. ­Nursing Process: Implementation. Learning Outcome: 44-8. Answer: 1. Rationale: Normal gait involves a level gaze, an initial ­rotation beginning in the spine, heel strike with follow-through to the toes, and opposite arm and leg swinging forward. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing ­Process: Assessment. Learning Outcome: 44-5. Answer: 1, 4, and 5. Rationale: Eating and bathing will flex the elbow joint, and grasping and manipulating utensils to eat and write will take the thumb through its normal ROM. Walking flexes the hip. Shaving and eating require elbow flexion, not extension (option 2). Writing brings the fingers toward the inner aspect of the forearm, thus flexing the wrist joint (option 3). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 44-1. Answer: 3. Rationale: It is prudent for nurses to understand and use proper body mechanics at all times to decrease risk, while keeping in mind the importance of assistive devices and help from other staff. While it is generally accepted that proper body mechanics alone will not prevent injury, many work settings do not yet have “no manual lift” and “no solo lift” policies and resources in place. Cognitive Level: ­Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 44-7. Answer: 4. Rationale: Placing the client in a safe position is the best maneuver. Leaving the client creates unsafe conditions because the client may faint before being able to return to her room (options 1 and 2). Rapid, shallow breathing (hyperventilation) may increase the dizziness (option 3). Cognitive Level: Applying. Client Need: Safe, Effective

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Appendix A Care Environment. Nursing Process: Implementation. Learning Outcome: 44-10g. 10. Answer: 2. Rationale: The reddened area of the skin can lead to skin breakdown. The other options are within normal limits. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 44-3g.

Chapter 45: Sleep

1. Answer: 2. Rationale: This is the brainstem where the reticular formation (and RAS) is located and which integrates sensory information from the peripheral nervous system and relays the information to the cerebral cortex. An intact cerebral cortex and reticular formation are necessary for the regulation of sleep and waking states. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 45-1. 2. Answer: 1. Rationale: When the client is critically ill or being ­admitted for an outpatient procedure, sleep history can be omitted or deferred. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 45-6. 3. Answer: 3. Rationale: The best outcome statement for this client is to report getting sufficient sleep to provide energy for daily activities. The client may require more than 8 hours of sleep to feel rested and have sufficient energy (option 1). Simply listing coping mechanisms for anxiety relief is not as helpful as actually getting sleep (option 2). Antianxiety medications are probably not the most important factor for this client (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process:Planning. Learning Outcome: 45-7. 4. Answer: 4. Rationale: Suddenly stopping barbiturate sleeping pills can precipitate a dangerous withdrawal. Doses should be tapered gradually and the tapering process supervised by the client’s primary care provider. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 45-4. 5. Answer: 1. Rationale: Preschool children require 10 to 12 hours of sleep per night. Young children often rise early, so it is more appropriate to put the child to bed earlier in the evening. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 45-3. 6. Answer: 1. Rationale: Daytime hypersomnia is often due to medical conditions such as kidney, liver, or metabolic disturbances. The nurse should suggest that the client be evaluated by a physician. Daytime hypersomnia is rarely caused by psychologic issues. An over-thecounter sleep aid is not a good choice as the man already sleeps well at night and sleep aids can sometimes cause future sleep disturbances. Caffeinated beverages may increase daytime wakefulness, but will not help any underlying problem that may be present. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 45-6. 7. Answer: 4. Rationale: The client’s symptoms, combined with his weight, suggest that he has obstructive sleep apnea and should be referred to a sleep disorders specialist for further evaluation. It would not be wrong to refer him to a dietitian for weight loss counseling (option 2), but being evaluated by a sleep disorders specialist is more critical. Drinking alcohol or taking sleeping pills is not advised in clients with sleep apnea because they disrupt the client’s sleep patterns (option 3). Cognitive Level: Analyzing. Client Needs: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 45-5. 8. Answer: 1. Rationale: Reducing exposure to bright light in the morning, when driving home, and when going to sleep will make it easier to fall asleep after work. Exercising before going to bed will increase arousal (option 2). Caffeine consumed at the beginning of a 12-hour shift will not assist the nurse in remaining awake during the latter

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part of the shift (option 3). Although working in a brightly lit area will reduce drowsiness, this strategy is rarely available to nurses working the night shift; lights are often dimmed in hospital corridors and client rooms (option 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 45-7. 9. Answer: 3. Rationale: Napping frequently reappears in older adults. Unless the person has difficulty falling asleep at night, there is no reason an individual should not be allowed to take a 15- to 20-minute nap in the early afternoon. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 45-3. 10. Answer: 1, 3, and 4. Rationale: Reducing environmental noise, as well as the number of times she is disturbed for medications and vital signs, will reduce the likelihood that she will awaken during the night. Delivering necessary care at 1.5- or 3-hour intervals is consistent with multiples of the 90-minute sleep cycle. Since it is unlikely that all of the noise in the environment can be eliminated, using a fan to generate a steady background noise may help mask sounds of people talking, carts being moved through the halls, and other noise. Music is not usually recommended because it can be interesting to listen to, thus encouraging wakefulness (option 2). The room temperature needs to be satisfactory for the client. A room that is too warm is not usually conducive for sleep (option 5). Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 45-8.

Chapter 46: Pain Management

1. Answer: 1. Rationale: During the transduction phase, noxious stimuli trigger the release of biochemical mediators, such as prostaglandins, bradykinin, serotonin, histamine, and substance P, that sensitize nociceptors. Noxious or painful stimulation also causes movement of ions across cell membranes, which excites nociceptors. Pain medications such as ibuprofen or aspirin can work during this phase by blocking the production of prostaglandin or by decreasing the movement of ions across the cell membrane. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 46-2. 2. Answer: 2. Rationale: The client’s pain intensity needs to be assessed first for effective pain management. In a postoperative client it is important to assess pain intensity frequently to manage the acute pain experience. Option 1: The most pain a person is willing to tolerate before taking action can be discussed with the client after the pain intensity has been assessed. Option 3, location of pain, is important, but it is not the priority. Option 4: This information is important but not for a client in acute pain. The priority would be to assess the pain intensity. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Assessment. Learning Outcome: 46-5. 3. Answer: 2. Rationale: Referred pain appears to arise in different areas of the body, as may occur with cardiac pain. Phantom pain is that which is experienced in a limb after an amputation (option 1). Visceral pain originates in an organ (option 3). Chronic pain is that which is felt for months after the pain experience should have ended (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 46-1. 4. Answer: 1. Rationale: This indicates an increasing level of sedation, which can be an early sign of impending respiratory depression. ­Option 2 is normal. Option 3 can indicate increasing sedation; however, option 1 describes a higher level of sedation and an intervention such as notifying the primary care provider. Option 4 indicates pain management that may be tolerable for the client. Cognitive Level: ­Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 46-7.

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Answers to Test Your Knowledge

5. Answer: 3. Rationale: Opioids may depress the respiratory system, so the nurse should assess the respiratory rate before administering opioids. Options 1 and 2 are subjective data. Option 4 is not applicable to assess prior to administering an opioid medication to a client. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Assessment. Learning Outcome: 46-5. 6. Answer: 4. Rationale: Options 2 and 3 are subcategories of physiological pain (option 1). A clue to the answer is that the client has diabetes, which often leads to diabetic peripheral neuropathy. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 46-1. 7. Answer: 2, 4, and 5. Rationale: Massage, heat and cold, and acupressure are cutaneous stimulation techniques that can “close” the gates and inhibit the transmission of further pain. Options 1 and 3 are pharmacologic interventions, which are important; however, they inhibit the pain during the transmission phase of nociception. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 46-3. 8. Answer: 2. Rationale: The words pain or complain may have emotional or sociocultural meanings (options 1 and 4). It is better to ask clients if they are having any discomfort—they can then elaborate in their own words. Option 3 is too general and expects clients to report their pain without being asked. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Assessment. Learning Outcome: 46-5. 9. Answer: 3 and 5. Rationale: Older clients may deny complaints of pain because it may indicate a worsening of their condition that may threaten their independence. Older adults may use words other than pain. Although many perceive pain as a natural outcome of aging, it is not a natural part of aging (option 1). Pain perception may decrease (option 2) and narcotics can be used with careful monitoring by the nurse (option 4). Cognitive Level: Understanding. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 46-7. 10. Answer: 1. Rationale: Based on the information provided, the nurse needs to determine the client’s understanding of the effects of pain on recovery and if the client has misconceptions about pain. Option 2 usually pertains more to chronic pain and fatigue. Options 3 and 4 could be true, but the priority is option 1. Movement enhances respiratory, cardiovascular, and GI recovery from general anesthesia and the outcomes associated with a surgical procedure. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: ­Diagnosis. Learning Outcome: 46-6.

Chapter 47: Nutrition

1. Answer: 4. Rationale: Fluid intake for each feeding is not entered on the graphic sheet. The amount of fluid for a 24-hour period would be documented on this sheet (option 1). Fluid intake for tube feedings is not documented in the dietary consultation notes or the vital signs record (options 3 and 4). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 47-13. 2. Answer: 4. Rationale: This client needs more grains in the diet. The client should have 6 to 7 oz grains per day, 3 cups/week dark green vegetables, 2 cups/week orange vegetables, 3 cups/week legumes, 3 cups/ week starchy vegetables, 1.5 to 2 cups fruit per day, 5 to 6 oz meat and beans per day, and 3 cups milk, yogurt, and cheese per day. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 47-5. 3. Answer: 4. Rationale: Anthropometric measurements such as triceps skinfold measurement provide the most meaningful data when monitored over longer periods of time such as several months to years. The changes in this measurement occur so slowly that remeasuring in 2 days to one month, would not provide significant data. Cognitive

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Level: Applying. Client Need: Physiological Integrity. Nursing ­Process: Implementation. Learning Outcome: 47-9. Answer: 2. Rationale: Swallowing ice or water may help calm the gag reflex and also facilitate the “swallowing” of the tube. This is a common response to the presence of a tube in the oropharynx, so removal of the tube is not necessary (option 1). The nurse should not use pressure to pass the tube (option 3). The client’s head should be tilted forward at this point. Tilting the head back will open the airway, not the esophagus (option 4). Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Evaluation. Learning Outcome: 47-10a. Answer: 1. Rationale: For proper flow, the feeding container hangs 1 foot above the tube insertion. Feedings may be administered if there is less than 90 to 100 mL of residual volume (unless agency policy specifies otherwise) (option 2). To prevent or reduce the risk of aspiration, the client should be placed in Fowler’s position during feeding (option 3). The feeding should be warmed to room temperature before administration to decrease cramping and diarrhea (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 47-10c. Answer: 1. Rationale: The Dietary Guidelines recommend 30 minutes of physical activity on most days of the week to achieve optimal weight. Some individuals benefit from a low-carbohydrate diet, but no particular diet is the solution for all individuals (option 2). A reasonable diet emphasizes balance and portion control rather than forbidding or requiring any specific foods (option 3). Fresh and chemical-free foods may be healthier than preserved foods but do not automatically assist with weight loss (option 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 47-8. Answer: 3. Rationale: Always inquire into the client’s favorite foods when planning a diet. Dairy may not be indicated for this client due to the high incidence of lactose intolerance in individuals of Asian heritage (option 1). Beer can be a source of calories and, in moderation, is not harmful, and may maintain the client’s satisfaction with the dietary changes. The nurse will need to assess the ability to swallow beer safely, however (option 2). Calories from lipid sources should be kept below 35% and, when enhanced wound healing is indicated (not so with a stroke), increased protein and carbohydrates are needed rather than fats (option 4). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 47-9. Answer: This client has lost 13 pounds which is 6.7%: (195 – 182)/195. If the weight loss has been steady during the past 2 months, that would indicate a 3.3% loss per month. Less than 5% loss in 1 month is not significant, but if this loss continues, the client will reach a 10% loss in 3 months, which is a severe loss. A more detailed assessment is indicated to determine the client’s nutritional status. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 47-6; 47-7; 47-8. Answer: 2. Rationale: A small-bore nasal feeding tube tip is most commonly placed in the stomach. Option 1 indicates the esophagus. A tube tip placed there can lead to aspiration. Option 3 indicates the postpyloric duodenum. Small-bore nasal tubes can be advanced to this location if desired but such a placement is less common than gastric placement. Option 4 indicates the jejunum where feeding tubes can be placed but usually not from a nasally placed tube. Cognitive Level: Understanding. Client Need: Physiological Integrity. Nursing Process: Evaluation. Learning Outcome: 47-10a. Answer: 4. Rationale: 3 ounces tuna + 2 slices whole wheat bread = 3.1 mg Fe; 1 ounce cheese = ˜200 mg Ca2+; pear = 4.2 g fiber. Option 1: 1/3 cup raisins = 1.75 mg Fe; 3 ounces cottage cheese = 90 mg Ca2+; 1 banana = 2.1 g fiber. Option 3: 1/2 cup spaghetti + 2 ounces

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Appendix A ground beef = 2.3 mg Fe; 1/2 cup ice cream = 97 mg Ca2+; 1/2 cup lima beans = 3.2 g fiber. Option 2: 3 ounces chicken + 1/2 cup peanuts = 2.9 mg Fe; 1/2 cup broccoli ˜158 mg Ca2+; 1/2 cup broccoli = 2.4 g fiber. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning ­Outcome: 47-1.

Chapter 48: Urinary Elimination

1. Answer: 3. Rationale: 1: When aldosterone is released from the adrenal cortex, sodium and water are reabsorbed in greater quantities, increasing the blood volume and decreasing urinary output. Elevated aldosterone levels will not increase the urine output, urinary incontinence, or urinary retention (options 1, 2, and 4). Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: ­Assessment. Learning Outcome: 48-2. 2. Answer: 3, 4. Rationale: Residual urine is not measured to evaluate glomerular filtration rate, to determine the extent of renal failure, or to evaluate fluid volume status. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 48-4. 3. Answer: 4. Rationale: The nurse should make sure that the tip of the penis is not touching the condom and that the condom is not twisted, because a twisted condom could obstruct the flow of urine. The nurse should wash her hands before and after the procedure (option 1). The nurse should document after the procedure is completed (option 2). The nurse should instruct the client about the drainage system after attaching the bag to the device (option 3). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 48-10a. 4. Answer: 1. Rationale: The catheter in the vagina is contaminated and cannot be reused. If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus does not indicate that another nurse is needed although sometimes a second nurse can assist in visualizing the meatus (option 2). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning ­Outcome: 48-10b. 5. Answer: 3. Rationale: Soaking in a bathtub can increase the risk of exposure to bacteria. The bag should be below the level of the bladder to promote proper drainage (option 1). Intake of cranberry juice creates an environment that inhibits infection (option 2). Clean technique is appropriate for touching the exterior portions of the system (option 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 48-7. 6. Answer: 4. Rationale: The key phrase is “the urge to void.” Option 1 occurs when the client coughs, sneezes, or jars the body, resulting in accidental loss of urine. Option 2 occurs with involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Option 3 is involuntary loss of urine related to impaired function. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Diagnosis. Learning Outcome: 48-6. 7. Answer: 2 and 4. Rationale: Option 2 validates the diagnosis. Cotton underwear promotes appropriate exposure to air, resulting in decreased bacterial growth (option 4). Increased fluids decrease concentration and irritation (option 1). The client should wipe the perineal area from front to back to prevent spread of bacteria from the rectal area to the urethra (option 3). Showers reduce exposure of area to bacteria (option 5). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 48-7. 8. Answer: 2. Rationale: The ileal conduit and vesicostomy (options 1 and 4) are incontinent urinary diversions, and clients are required to use an external ostomy appliance to contain the urine. Clients with

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a neobladder can control their voiding (option 3). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 48-9. 9. Answer: 3. Rationale: Because the bladder muscles will not contract to increase the intrabladder pressure to promote urination, the process is initiated manually. Options 1, 2, and 4: To promote continence, bladder contractions are required for habit training, bladder training, and increasing the tone of the pelvic muscles. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 48-9. 10. Answer: 2 and 5. Rationale: It is important for the client to inhibit the urge-to-void sensation when a premature urge is experienced. Some clients may need diapers; this is not the BEST indicator of a successful program (option 3). Citrus juices may irritate the bladder (option 4). Carbonated beverages increase diuresis and the risk of incontinence (option 4). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 48-6.

Chapter 49: Fecal Elimination

1. Answer: 2. Rationale: Normal defecation is facilitated by thigh flexion, which increases the pressure within the abdomen, and a sitting position, which increases the downward pressure on the rectum. Expulsion of the feces is assisted by contraction of the abdominal muscles and the diaphragm, which increases abdominal pressure, and by contraction of the muscles of the pelvic floor, which moves the feces through the anal canal. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 49-1. 2. Answer: 1, 2, 3, 5. Rationale: Older adults should be advised that normal patterns of bowel elimination vary considerably. For some, a normal pattern might be every other day; for others, twice a day. Constipation can be relieved by increasing the fiber intake to 20–35 grams per day. Adequate exercise is a preventative measure for constipation. Daily fluid intake of 6–8 glasses is an essential preventive measure for constipation. Responding to the gastrocolic reflex, and not ignoring it, also helps with constipation. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 49-3. 3. Answer: 1. Rationale: Oil retention enemas take effect within 1–3 hours. Enemas using a hypertonic solution take effect in 5–10 minutes. Soapsuds enemas take effect in 10–15 minutes. Enemas using hypotonic or isotonic solutions take effect in 10–20 minutes. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 49-8. 4. Answer: 3. Rationale: An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. The skin under the appliance may remain pink/red for a while after the adhesive is pulled off. Feces from an ascending ostomy are very liquid, less so from a transverse ostomy, and more solid from a descending or sigmoid stoma. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning ­Outcome: 49-9. 5. Answer: 2. Rationale: Once the cause of diarrhea has been identified and corrected, the client should return to his or her previous elimination pattern. This is not an example of an allergy to the antibiotic but a common consequence of overgrowth of bowel organisms not killed by the drug (option 1). Antidiarrheal medications are usually prescribed according to the number of stools, not routinely around the clock ­(option 3). Increasing intake of soluble fiber such as oatmeal or potatoes may help absorb excess liquid and decrease the diarrhea, but insoluble fiber will not (option 4). Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 49-6.

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6. Answer: 2. Rationale: The client has assessment findings consistent with complications of surgery. Option 1: Irrigating the stoma is a dependent nursing action, and is also intervention without appropriate assessment. Option 3: Assessing the peristomal skin area is an independent action, but administering an antiemetic is an intervention without appropriate assessment. Antiemetics are generally ordered to treat immediate postoperative nausea, not several days postoperative. Option 4: Administering a bulk-forming laxative to a nauseated postoperative client is contraindicated. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 49-6. 7. Answer: 3. Rationale: This provides relief of postoperative flatus, stimulating bowel motility. Options 1, 2, and 4 manage constipation and do not provide flatus relief. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 49-8. 8. Answer: 3. Rationale: Blood in the upper GI tract is black and tarry. Option 1 can be a sign of malabsorption in an infant, option 2 is normal stool, and option 4 is characteristic of an obstructive condition of the rectum. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 49-2. 9. Answer: 1, 3, 4, and 5. Rationale: Option 1 is the most appropriate. The client is unable to decide when stool evacuation will occur. In option 3, client thoughts about self may be altered if unable to control stool evacuation. In option 4, client may not feel as comfortable around others. In option 5, increased tissue contact with fecal material may result in impairment. Option 2 is more appropriate for a client with diarrhea. Incontinence is the inability to control feces of normal consistency. Cognitive Level: Analyzing. Client Need: Physiological Integrity. ­Nursing Process: Diagnosis. Learning Outcome: 49-6. 10. Answer: 5. Rationale: Option 5 is a sigmoidostomy site. Option 1 is an ileostomy site, option 2 is ascending colostomy, option 3 is transverse colostomy, and option 4 is descending colostomy. Cognitive Level: ­Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 49-9.

Chapter 50: Oxygenation

1. Answer: 2. Rationale: The cough reflex depends upon nerve impulse transmission via the vagus nerve to the medulla. The nurse must monitor clients with vagus nerve impairment (through spinal cord injury, trauma, CNS depression, or other means) for a decreased or absent cough reflex. This decreased or absent reflex places the client at high risk for aspiration or development of pneumonia or other respiratory infections. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 50-5. 2. Answer: 3. Rationale: 1: In a client with chronic obstructive lung disease, the drive to breathe is often dependent upon low oxygen concentration. Increasing oxygen delivery by increasing the oxygen from 1.5 Lpm to 3 Lpm may be dangerous to this client (option 1). Lowering the head of the bed makes it more difficult to breathe (option 2). This client should have the head of the bed elevated to Fowler’s position or should be assisted to lean over the overbed table to increase chest excursion. Chronic obstructive lung disease makes it difficult for the client to breathe out, so increasing rate of respirations will not be helpful (option 4). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 50-8. 3. Answer: 1. Rationale: Prior to starting the procedure, it is important to develop a means of communication by which the client can express pain or discomfort. The twill tape is not changed until after performing tracheostomy care (option 2). Cleaning the incision should be done ­after cleaning the inner cannula (option 3). Checking the tightness of the ties and knot is done after applying new twill tape (option 4).

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Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 50-11d. Answer: 3. Rationale: The nurse should turn the client’s head to the side to allow drainage of oral secretions. The airway should not be taped in place as it would then act as an airway obstruction if dislodged (option 1). Although suctioning the client is possible with the airway in place, the client should be suctioned only when it is necessary (option 2). Insertion of a nasal trumpet or nasopharyngeal airway is not necessary when the oropharyngeal airway is in place (option 4). Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 50-9. Answer: 2. Rationale: Proper use of an SMI requires the client to take slow, steady inhalations, every hour or two, 5 to 10 breaths each time. Only the mouthpiece can be successfully rinsed or wiped clean. The device should not be submerged in water (option 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 50-8. Answer: 2. Rationale: The tube should be reconnected to the water seal as quickly as possible. Assisting the client back to bed (option 1) and assessing the client’s lung (option 3) are possible actions after the system is reconnected. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. ­Learning Outcome: 50-9. Answer: 1. Rationale: Anemia is a condition of decreased red blood cells and decreased hemoglobin. Hemoglobin is how the oxygen molecules are transported to the tissues. Option 2 would depend on where the infection is located. Option 3: A fractured rib would interrupt transport of oxygen from the atmosphere to the airways. Option 4: Damage to the medulla would interfere with neural stimulation of the respiratory system. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Assessment. Learning Outcome: 50-7. Answer: 3. Rationale: Respiratory difficulty related to a reclining position without other physical alterations is defined as orthopnea. Cognitive Level: Remembering. Client Need: Safe, Effective Care Environment. Nursing Process: Diagnosis. Learning Outcome: 50-5. Answer: 4. Rationale: Glucocorticoids are prescribed because of their anti-inflammatory effect. Options 1, 2, and 3 are not achieved with glucocorticoids. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 50-9. Answer: 1. Rationale: Postural drainage results in expectoration of large amounts of mucus. Clients sometimes ingest part of the secretions. The secretions may also produce an unpleasant taste in the oral cavity, which could result in nausea/vomiting. This procedure should be done on an empty stomach to decrease client discomfort. ­Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. ­Nursing Process: Planning. Learning Outcome: 50-8.

Chapter 51: Circulation

1. Answer: 3. Rationale: The nurse should advise the client to avoid exercise in hot or cold weather as these extremes of temperature increase the workload on the heart. Cold temperatures increase peripheral blood vessel contraction and therefore peripheral vascular resistance, making it more difficult for the heart to circulate blood. Hot temperatures decrease systemic vascular resistance by dilating peripheral vessels. This decrease makes the heart rate increase, thereby increasing the heart’s workload. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 51-4. 2. Answer: 3, 1, 4, 2, and 5. Rationale: See sequence described on page 1290. Cognitive Level: Remembering. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 51-1.

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Appendix A 3. Answer: 3. Rationale: Capillary refill is an assessment of capillary blood flow and thus tissue perfusion. Symmetrical chest expansion (option 1) is an assessment of respiratory function; pursed-lip breathing (option 2) is a technique used to assist clients with obstructive lung diseases to keep alveoli open during respirations. Activity intolerance (option 4) can occur because of low cardiac output (e.g., heart failure). Activity tolerance would indicate adequate tissue perfusion. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 51-4. 4. Answer: 2. Rationale: Hemoglobin is the oxygen-carrying portion of the blood, and anemia (decrease in hemoglobin and hematocrit) is often associated with client complaint of being tired, listless, and unable to tolerate normal activities. The client’s symptoms may or may not be associated with the blood urea nitrogen level, an alteration in the blood sugar level, and an altered serum potassium level. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: ­Assessment. Learning Outcome: 51-4. 5. Answer: 4. Rationale: Cardiac output equals stroke volume heart rate. Since this client has a sustained rapid heart rate, the ventricles are most likely not having sufficient time to relax and refill between contractions, so the stroke volume will decrease. At the rate of 170, the compensatory increase in heart rate is no longer helpful in increasing cardiac output. This leads to a decrease in cardiac output. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 51-4. 6. Answer: 3. Rationale: Because the clients would experience impaired tissue perfusion resulting in respiratory compensation, they are most likely to experience the sign/symptom of shortness of breath. The client with the MI will experience cardiac impairment resulting in decreased cardiac output as well as severe chest pain resulting in increased oxygen demand with decreased availability. Clients with heart failure will have decreased pumping ability of the cardiac muscle resulting in pulmonary congestion and decreased cardiac output. Clients with anemia have fewer RBCs to carry the oxygen to the tissues, resulting in hypoxia. Options 1 and 4 would be signs for the client with the MI. Option 2 is seen in heart failure. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 51-3. 7. Answer: 4. Rationale: The three cardinal signs of cardiac arrest are apnea, absence of a carotid or femoral pulse, and dilated pupils. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 51-5. 8. Answer: 1, 3, and 5. Rationale: Option 1: An example of Ineffective Tissue Perfusion is a decrease in arterial circulation in the legs related to atherosclerosis. Option 3: Examples of Decreased Cardiac Output are clients with MI, heart failure, or tachycardia. Option 5: Not enough blood is being pumped by the heart to meet the demands of the body. Activity Intolerance is when the client doesn’t have physiological energy for ADLs. Common reasons can be anemias and heart failure. Options 2 and 4: Acute Confusion and Sleep Pattern Disturbance are not directly related to cardiovascular disease. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Diagnosing. Learning Outcome: 51-4. 9. Answer: 2. Rationale: SCDs promote venous return from the legs to the heart. They inflate and deflate plastic sleeves wrapped around the legs to promote venous flow. The sequential inflation and deflation counteract blood stasis in the lower extremities. Option 1: Arterial flow is from the heart to the general circulation. Option 3: Afterload is related to the ventricles’ ability to eject blood forward. These devices affect peripheral circulation. Option 4: There is no relationship between pain and the purpose of the devices. Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 51-6.

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Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 51-1.

Chapter 52: Fluid, Electrolyte, and Acid–Base Balance

1. Answer: 3. Rationale: A client who is fasting is at risk for development of metabolic acidosis. The body recognizes fasting as starvation and begins to metabolize its own proteins into ketones, which are metabolic acids. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcomes: 52-4; 52-5. 2. Answer: 2. Rationale: The priority intervention is to discontinue the transfusion. If this client is having a transfusion reaction, it will be better to limit the amount of blood transfused. The nurse would also contact the physician to collaborate on further treatment, but this action should be after the transfusion is discontinued. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: ­Assessment. Learning Outcome: 52-8. 3. Answer: Hypertonic. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 52-1. 4. Answer: 2. Rationale: Because of the retention of CO2, the clinical profile of respiratory acidosis includes decreased pH < 7.35, PaCO2 > 42 mmHg, with varying levels of HCO3 related to hypoventilation. Option 1 is respiratory alkalosis, which occurs because of blowing off of CO2 resulting in a decreased level of acid and retention or production of bicarbonate, which in turn results in pH >7.45, PaCO2 < 38 mmHg, HCO3 > 26 mEq/L related to hyperventilation. Option 3: Metabolic acidosis occurs because of a gain of hydrogen ions or a loss of HCO3 with a pH < 7.35, normal PaCO2 of 35–45 mmHg, and HCO3 < 22 mEq/L, often caused by diarrhea, bicarbonate infusion, or retention related to kidney failure. Option 4: Metabolic alkalosis is caused by gain of bicarbonate or loss of hydrogen ions related to vomiting, gastric suction, or loss of upper gastrointestinal secretions by various other methods. Cognitive Level: Applying. Client Need: ­Physiological Integrity. Nursing Process: Assessment. Learning ­Outcomes: 52-2; 52-5. 5. Answer: 1, 3, and 5. Rationale: Options 1, 3, and 5 relate to fluid volume deficit. The data indicate an actual problem, which excludes ­option 2. Option 4 relates more to fluid volume excess. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing ­Process: Diagnosis. Learning Outcome: 52-6. 6. Answer: 4. Rationale: Salt substitutes contain potassium. The client can still use it within reason. Option 1: Avocado is higher in potassium than most foods. Option 2: Hypokalemia can potentiate digoxin toxicity and checking the pulse will help the client avoid this. Option 3: It is important to take potassium with food to avoid gastric upset. ­Cognitive Level: Applying. Client Need: Physiological Integrity. ­Nursing Process: Evaluation. Learning Outcomes: 52-7; 52-8. 7. Answer: 2. Rationale: Because insertion of a subclavian central venous catheter may result in hemothorax, pneumothorax, cardiac perforation, thrombosis, or infection, the priority finding for planning

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care is tachycardia. Bibasilar crackles may develop secondary to fluid overload or to the disease process, but would not be particularly evident just after placement of the subclavian catheter (option 1). ­Decrease in pedal pulses and headache would not be associated with the placement of a subclavian catheter (options 3 and 4). Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing ­Process: ­Assessment. Learning Outcome: 52-5. 8. Answer: 2. Rationale: Because of CO2 retention the PaCO2 is ­elevated. CO2 is involved in production of acid, which will result in a decreased pH. HCO3 will vary. Option 1: Metabolic acidosis involves a loss of bicarbonate, but no retention of CO2. Option 3: Metabolic alkalosis involves a loss of acid or retention of HCO3,

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but no retention of CO2. Option 4: Respiratory alkalosis involves a loss of CO2 resulting in an increased pH. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning ­Outcome: 52-5. 9. Answer: 4. Rationale: The major clinical signs and symptoms of hypocalcemia are due to increased neuromuscular activity and not the renal, cardiac, or GI systems. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 52-8. 10. Answer: 2, 4, and 5. Rationale: Options 1 and 3 relate to hypermagnesemia. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcomes: 52-4; 52-5.

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Appendix B

 Single Measurement Scales Used in NOC

Scale Code* 01

Serverely compromised

Substantially compromised

Moderately compromised

Mildly compromised

Not compromised

02

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

06

Not adequate

Slightly adequate

Moderately adequate

Substantially adequate

Totally adequate

07

10 and over

7–9

4–6

1–3

None

09

None

Limited

Moderate

Substantial

Extensive

11

Never positive

Rarely positive

Sometimes positive

Often positive

Consistently positive

12

Very weak

Weak

Moderate

Strong

Very strong

13

Never demonstrated

Rarely demonstrated

Sometimes demonstrated

Often demonstrated

Consistently demonstrated

14

Severe

Substantial

Moderate

Mild

None

17

Poor

Fair

Good

Very good

Excellent

18

Not at all satisfied

Somewhat satisfied

Moderately satisfied

Very satisfied

Completely satisfied

19

Consistently demonstrated

Often demonstrated

Sometimes demonstrated

Rarely demonstrated

Never demonstrated

20

No knowledge

Limited knowledge

Moderate knowledge

Substantial knowledge

Extensive knowledge

*Scale numbers are not continuous due to retirement of previous scales. From Nursing Outcomes Classification (NOC): Measurement of Health Outcomes, 5th ed., by S. Moorhead, M. Johnson, M. L. Maas, and E. Swanson, Eds., St. Louis, MO: Mosby, 2012, pp. 12–17. Used with permission.

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Appendix C NANDA-Approved Nursing Diagnoses 2015–2017

Activity, Deficient Diversional Activity Intolerance Activity Intolerance, Risk for Activity Planning, Ineffective Activity Planning, Risk for Ineffective Adaptive Capacity: Intracranial, Decreased Adverse Reaction to Iodinated Contrast Media, Risk for Airway Clearance, Ineffective Allergy Response, Risk for Allergy Response, Latex Allergy Response, Latex, Risk for Anxiety Anxiety, Death Aspiration, Risk for Attachment, Risk for Impaired Bleeding, Risk for Blood Glucose Level, Risk for Unstable Body Image, Disturbed Body Temperature: Imbalanced, Risk for Bowel Incontinence Breast Milk, Insufficient Breastfeeding, Ineffective Breastfeeding, Interrupted Breastfeeding, Readiness for Enhanced Breathing Pattern, Ineffective Cardiac Output, Decreased Cardiac Output, Decreased, Risk for Cardiovascular Function, Impaired, Risk for Caregiver Role Strain Caregiver Role Strain, Risk for Childbearing Process, Ineffective Childbearing Process, Readiness for Enhanced Childbearing Process, Risk for Ineffective Chronic Pain Syndrome Comfort, Impaired Comfort, Readiness for Enhanced Communication, Readiness for Enhanced Communication: Verbal, Impaired Confusion, Acute Confusion, Chronic Confusion, Risk for Acute Constipation Constipation, Perceived Constipation, Risk for Contamination Contamination, Risk for Coping: Community, Ineffective Coping: Community, Readiness for Enhanced Coping, Defensive

Coping: Family, Compromised Coping: Family, Disabled Coping: Family, Readiness for Enhanced Coping: Readiness for Enhanced Coping, Ineffective Corneal Injury, Risk for Decision Making, Readiness for Enhanced Decisional Conflict Denial, Ineffective Dentition, Impaired Development: Delayed, Risk for Diarrhea Disuse Syndrome, Risk for Dry Eye, Risk for Dysreflexia, Autonomic Dysreflexia, Autonomic, Risk for Electrolyte Imbalance, Risk for Emancipated Decision-Making, Impaired Emancipated Decision-Making, Impaired, Risk for Emancipated Decision-Making, Readiness for Enhanced Emotional Control, Labile Falls, Risk for Family Processes, Dysfunctional Family Processes, Interrupted Family Processes, Readiness for Enhanced Fatigue Fear Fluid Balance, Readiness for Enhanced Fluid Volume: Deficient Fluid Volume: Deficient, Risk for Fluid Volume: Excess Fluid Volume: Imbalanced, Risk for Frail Elderly Syndrome Frail Elderly Syndrome, Risk for Functional Constipation, Chronic Gas Exchange, Impaired Gastrointestinal Motility, Risk for Dysfunctional Gastrointestinal Motility, Dysfunctional Grieving Grieving, Complicated Grieving, Risk for Complicated Growth: Disproportionate, Risk for Health: Community, Deficient Health Behavior, Risk-Prone Health Maintenance, Ineffective Health Management, Family, Ineffective Health Management, Ineffective Health Management, Ineffective Family Health Management, Readiness for Advanced 1

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NANDA-Approved Nursing Diagnoses 2015–2017

Health Management, Readiness for Enhanced Home Maintenance, Impaired Hope, Readiness for Enhanced Hopelessness Human Dignity, Risk for Compromised Hyperthermia Hypothermia Hypothermia, Risk for Impulse Control, Ineffective Infant Behavior: Disorganized Infant Behavior: Disorganized, Risk for Infant Behavior: Organized, Readiness for Enhanced Infant Feeding Pattern, Ineffective Infection, Risk for Injury, Risk for Insomnia Jaundice, Neonatal Jaundice, Neonatal, Risk for Knowledge, Deficient Knowledge, Readiness for Enhanced Labor Pain Lifestyle, Sedentary Liver Function, Risk for Impaired Loneliness, Risk for Maternal/Fetal Dyad, Risk for Disturbed Memory, Impaired Mobility: Bed, Impaired Mobility: Physical, Impaired Mobility: Wheelchair, Impaired Mood Regulation, Impaired Moral Distress Mucous Membrane: Oral, Impaired Mucous Membrane: Oral, Impaired, Risk for Nausea Neglect, Unilateral Neurovascular Dysfunction: Peripheral, Risk for Noncompliance Nutrition, Imbalanced: Less than Body Requirements Nutrition, Readiness for Enhanced Obesity Overweight Overweight, Risk for Pain, Acute Pain, Chronic Parenting, Impaired Parenting, Readiness for Enhanced Parenting, Risk for Impaired Perfusion: Gastrointestinal, Risk for Ineffective Perfusion: Renal, Risk for Ineffective Perioperative Hypothermia, Risk for Perioperative Positioning Injury, Risk for Personal Identity: Disturbed Personal Identity: Disturbed, Risk for Poisoning, Risk for Post-Trauma Syndrome Post-Trauma Syndrome, Risk for Power, Readiness for Enhanced Powerlessness

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Powerlessness, Risk for Pressure Ulcer, Risk for Protection, Ineffective Rape-Trauma Syndrome Relationship, Ineffective Relationship, Readiness for Enhanced Relationship, Risk for Ineffective Religiosity, Impaired Religiosity, Readiness for Enhanced Religiosity, Risk for Impaired Relocation Stress Syndrome Relocation Stress Syndrome, Risk for Resilience: Individual Resilience, Impaired Resilience, Readiness for Enhanced Resilience, Risk for Impaired Role Conflict, Parental Role Performance, Ineffective Self-Care, Readiness for Enhanced Self-Care Deficit: Bathing Self-Care Deficit: Dressing Self-Care Deficit: Feeding Self-Care Deficit: Toileting Self-Concept, Readiness for Enhanced Self-Esteem, Chronic Low Self-Esteem, Chronic Low, Risk for Self-Esteem, Situational Low Self-Esteem, Situational Low, Risk for Self-Mutilation Self-Mutilation, Risk for Self Neglect Sexual Dysfunction Sexuality Pattern, Ineffective Shock, Risk for Sitting, Impaired Skin Integrity, Impaired Skin Integrity, Risk for Impaired Sleep Deprivation Sleep Pattern, Disturbed Sleep, Readiness for Enhanced Social Interaction, Impaired Social Isolation Sorrow, Chronic Spiritual Distress Spiritual Distress, Risk for Spiritual Well-Being, Readiness for Enhanced Standing, Impaired Stress Overload Sudden Infant Death Syndrome, Risk for Suffocation, Risk for Suicide, Risk for Surgical Recovery, Delayed Surgical Recovery, Delayed, Risk for Swallowing, Impaired Thermal Injury, Risk for Thermoregulation, Ineffective Tissue Integrity, Impaired Tissue Integrity, Impaired, Risk for

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Appendix C

Tissue Perfusion: Cardiac, Risk for Decreased Tissue Perfusion: Cerebral, Risk for Ineffective Tissue Perfusion: Peripheral, Ineffective Tissue Perfusion: Peripheral, Risk for Ineffective Transfer Ability, Impaired Trauma, Risk for Trauma: Vascular, Risk for Urinary Elimination, Impaired Urinary Elimination, Readiness for Enhanced Urinary Incontinence, Functional Urinary Incontinence, Overflow Urinary Incontinence, Reflex

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Urinary Incontinence, Stress Urinary Incontinence, Urge Urinary Incontinence, Urge, Risk for Urinary Retention Urinary Tract Injury, Risk for Ventilation: Spontaneous, Impaired Ventilatory Weaning Response, Dysfunctional Violence: Other-Directed, Risk for Violence: Self-Directed, Risk for Walking, Impaired Wandering

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Answers to Anatomy & Physiology Review, Critical Thinking Checkpoints, and Applying Critical Thinking, and End-of-Unit Meeting the Standards Questions Chapter 1 N/A.

Chapter 2: Critical Thinking Possibilities

1. The nurse needs to know what types of clients were involved in the research, e.g., medical diagnoses, age, and other health risk factors. Similarly, what are the characteristics of the research setting? Was it in a hospital or long-term care? How many clients participated in the study? What other standards or care were in place at the agency? The more different these are from your own population and setting, the greater the chance that different outcomes could result from the intervention. Also, did this research build on previous studies or is it the first of its kind? 2. How will the expertise of your clinicians affect this situation? Do they have the skill to use the overlay as compared to other possible interventions? How many clients in your setting are at risk for skin breakdown? Consider also the clients’ values and preferences. What would be the cost to the client, if any? Are there related considerations such as the comfort of the overlay, any restrictions on positioning for its optimal use, etc.?

Chapter 3: Critical Thinking Possibilities

1. Some of the many concepts that can be identified are illness, disease, wellness, and nutrition. 2. The physician seems to view Tony as someone who has some choices in his own care. He also appears to be making a statement related to quality of life (wellness) that reflects a belief that the client would not be getting better and intravenous nutrition was, therefore, not indicated. The nurse appears to have expanded the definition of client to include family and friends and has a different prognosis in mind. 3. Florence Nightingale would focus Tony’s care on the need for a clean environment, good water, and light as necessary for his health. 4. All of the nursing models recognize an interdependence of systems and relationships that would make controlling diarrhea a top priority. None of the nursing models is any more powerful than the others as a foundation for the nurse’s plan of care.

Chapter 4: Critical Thinking Possibilities

1. The nurse needs to verify that the client received information from the primary care provider and that she understands the information. Can the client explain in her own words what the doctor told her? Does she have any questions? 2. The three exceptions of people who cannot provide consent are minors, individuals who are unconscious or injured in such a way that they are unable to give consent, and individuals with mental illness who have been judged to be incompetent. If this client is an alert, competent adult, she can provide consent. 3. The nurse will need to read the form to the client. 4. Unless the husband is the appointed guardian or has power of attorney for health care decisions, the client should sign the form. The client will need assistance as to where to sign the form. The client could even mark an “X.” Remember, the nurse witnesses that the client gave her consent voluntarily and that the signature is authentic. 5. The nurse needs to include the following: • The consent form was read to the client before she signed it.

• A reference to the client’s understanding of the procedure (e.g., “able to state reasons for surgery, pros and cons of surgery. Stated she had no questions. Aware that she can change her mind”). • If the husband helped the client sign (e.g., guided her hand), this information should be documented. • Record any teaching as a result of nursing-related questions by the client (e.g., “discussed and demonstrated techniques for coughing and deep breathing after surgery”).

Chapter 5: Critical Thinking Possibilities

1. Personal values are often based on family, cultural, religious, or other beliefs and attitudes. The nurse must not assume any particular values based on these characteristics, however. They must be validated with the individual. What appear to be the client’s values must be confirmed with him through open and supportive discussion. 2. The nurse needs to review the variety of factors influencing the client’s values and decisions such as family support, previous experience with health care situations, the meaning of illness (and of the foot) to the person, and his personal goals. The surgeon has information about the client’s overall health status, possibly previous experiences with this client, and personal values and beliefs about the impact of an amputation. 3. The nurse’s responsibility is to ensure that the client has all of the information required for him to make an informed decision and that the information is accurate. This may include information beyond his physiological condition such as facts about his health insurance coverage for acute and rehabilitative care. The nurse’s personal beliefs about what the client should do or what the surgeon should recommend must not influence the nurse in carrying out this responsibility. 4. It is sometimes difficult to find the middle ground between advocating for the client and interfering in the client–primary care provider relationship. Also, the client’s informed decision may be counter to standard or recommended medical practice. 5. The ANA’s Code of Ethics or a patient bill of rights can help the nurse recall the standards that apply in guiding nurse decision making during possible ethical dilemmas. The nurse’s actions should be based on ethical theory and standards, not on personal opinion.

Chapter 6: Critical Thinking Possibilities

1. It does not seem as though the client has used many health promotion or prevention services. He would have used secondary prevention services extensively in seeing the primary care provider for his blood pressure and joint problems and having surgery. His time at the skilled nursing facility, with the home health nurse, and the physical therapist visits were tertiary preventive care. 2. He has visited the primary care provider’s office, which is useful for monitoring existing problems and screening for new ones; the hospital has the expert staff for performing his surgery and the nursing personnel for caring for him during the perioperative period. They have laboratories, therapeutic services (e.g., physical therapy), and nutrition services to meet his needs. Examples of other agencies would include the skilled nursing facility and home health care. 3. This client has health care needs in a variety of areas. His age and health problems suggest that he will continue to need health care for the foreseeable future. The case manager can become very familiar with the client and family situation so that the appropriate levels of care

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can be provided when he needs them and within his insurance coverage. He would have Medicare but may also have supplemental coverage. Should he become unable to continue living in the current house, the case manager may assist with determining the type of living facility most appropriate. If the client needs to be readmitted to the hospital, the case manager serves as an excellent facilitator in the communication needed among the physician, hospital, rehabilitative setting, and home health care personnel. 4. Examples include these: Pharmacist—older adults often take many different medications. During an acute illness, there is a particular need to ensure that newly ordered medications that may be required for the current condition do not interfere with medications used for chronic conditions. Spiritual support—although we do not know Mr. Mendel’s religious preference, he may be experiencing some spiritual concerns, for example, about dying. If he and his wife have a relationship with a church or other similar institution, it would be important to include this aspect in his care. Many other professionals may be included on the team.

Chapter 7: Critical Thinking Possibilities

There can be no traditional answers to these questions. What follow below are aspects to consider. 1. Overall, decreasing the time clients spend in dependent situations such as being in acute care hospitals is consistent with the agenda’s aims at health care reform. However, the nurse must also consider the culture of the client and the environment. Active decision making by the client is a Western view that may not be shared by clients from Asian, African American, or Latino backgrounds. In European health care systems, clients often spend as much as five times longer in a hospital than do American clients. The client may not be accustomed to community-based care and have very different views of the health care professionals who provide community-based care. Also, the scenario does not address outcomes. A primary concern would be to measure the incidence of complications, need for rehospitalization, and client satisfaction with the short stays. 2. Individuals will have unique responses to this question. Answers should reflect consideration of the views and skills of nurses, clients, and systems. 3. In an integrated health care system, the client would move easily from the diagnostic phase through treatment and rehabilitation— possibly using a case manager to assess the client and family and follow her though the entire episode. A community coalition would focus more on the risk factors leading to the health problem and initiatives to educate the population on wellness, prevention, and early detection. 4. Communication with the client, family, and other health care providers would be key to determining that a particular client is appropriate for this “fast-track” approach to the surgery. If the parties disagree, shared decision making should be used in establishing the details of how the care will actually be provided. Mutual respect and trust are key—that the health care providers are skilled and knowledgeable about the procedure and that the client and family can carry out their respective roles once the decisions have been made and communicated. Collaboration with third-party payers can be more complex. Investigate their chain of command and try to find nurses with whom to discuss the cases.

Chapter 8: Critical Thinking Possibilities

1. Many aspects of the nurse’s role will be the same. The techniques such as intravenous medication administration will have the same steps, but they may need to be modified to apply in situations where not all usual supplies or equipment are available (e.g., using a door hook for an IV pole). More so than in the acute care setting, the nurse needs to consider the client’s family as a client in addition to the client.

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2. The client has the same rights as any client but, in addition, has the right to direct that care be administered in a way that is acceptable within his or her environment, to decline to accept the nurse’s recommendations, and to decline the nurse’s assistance and care. 3. Safety issues: any aspects of his home or daily activities that could worsen his diabetes (e.g., inadequate heating/cooling) or potentially cause injury (unsafe railings). Infection control issues: lack of access to needed hygiene facilities; inability to participate in dressing changes and wound care due to poor vision, reduced dexterity, or other factors; lack of adequate caregiver support. 4. In addition to the intangible savings of emotional comfort provided by being in one’s own home, the client is able to maintain many of his personal contacts and activities—including such important tasks as paying bills and caring for pets. While home, the client avoids large hospital room charges and does not incur the extra costs of having someone care for things at home.

Chapter 9: Critical Thinking Possibilities

1. Consider the uses of the computer in the following areas: searching the Internet and literature for research or case studies that might relate; sending queries to experts identified through university medical centers of excellence; e-mailing colleagues from relevant professional nursing organizations. 2. Ask the client to share exactly the nature of the concern. Discuss with the client whether any unique identifiers will be associated with the photos or query, for example, name, address. Suggest that your colleagues will be asked to delete the photo files as soon as the consultation is complete. Would the client find fax or hard copies more acceptable? 3. Use one of the documents available to critique the website yourself. Share with the client the criteria for determining the usefulness of the information found on health websites and discuss how they apply to the specific site. Also, provide the client with other reliable sources of health information such as printed pamphlets or referenced articles. 4. Consider issues such as the ability to do your studying and assignments at a time (and place) of your choosing rather than in a classroom on specific days and times; whether you prefer to work alone or in “real place” groups (online programs also use groups that may do synchronous or asynchronous work); how self-directed you are; the availability of local quality education programs; concern about privacy regarding your academic records and financial aid information; and so on.

Chapter 10: Critical Thinking Possibilities

1. Examples include the following: What evidence supports the assumption? What other explanations for his condition are possible? What might another nurse who sees the situation think? What evidence would suggest a different assumption? 2. This attitude says that critical thinking will lead to appropriate conclusions. It requires that you trust yourself, examine the influence of emotions on your thinking, and use logic to reach conclusions. Suggest how you can show that you have considered these things. 3. If your conclusion is correct and acted on, you have helped keep the client’s problems at a minimum through early intervention. He can receive proper treatment and the nurse can develop a plan of care to assist the client and family with the impact of the condition. If you are incorrect in your assumption and do not consider other potential causes of the client’s discomfort, time may be wasted and the real condition could worsen. Increased cost, emotional frustration, and other negative outcomes may result. 4. How does the client feel about his recent retirement? What is the impact of his retirement while his wife continues to work? Do the coming holidays play a role in his illness?

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Chapter 11: Critical Thinking Possibilities

1. Extremely important areas to include are allergies, comorbidities (other health problems or diseases), and previous experience with surgery. 2. Because the musculoskeletal system is the reason she is in the hospital, it would be given priority. Due to her age and the immobility that will follow surgery, other priority systems would be cardiopulmonary and integumentary. 3. Many answers may be correct. The question should be open ended and prompt for the desired information (for example, it would not be helpful to ask her where she lives). One example would be “It may not be possible for you to be alone when you go home from the hospital. Tell me about who might be available to assist you?” 4. Consider family, friends, clergy, and her old charts.

Chapter 12: Critical Thinking Possibilities

1. Examples would include insomnia; fidgeting; dry mouth; increased pulse, blood pressure, and respirations; and poor attention span. 2. Examples include the uncertainty of the prognosis, lack of knowledge about the condition and its treatment, and fear of pain. 3. Ineffective Airway Clearance or Breathing Patterns, Ineffective Coping, Spiritual Distress, Hopelessness, Readiness for Enhanced Comfort, Grieving. 4. Although this may be a true statement, lung cancer is a medical ­diagnosis—not a nursing diagnosis, which is a response to health status or a health problem. In addition, the stressor (related to) should be something the nurse can treat independently.

Chapter 13: Critical Thinking Possibilities

1. The nurse assumes that the standardized care plan is comprehensive enough for this client with the individualization that is applied to it. 2. The last outcome for Anxiety, “Freely expressing concerns and possible solutions about work and parenting roles,” and the associated interventions are examples because the roles described occur between the client and her family in the home rather than in the hospital setting. 3. Several possibilities exist. The nurse needs to set aside time to discuss the plan with the client, alone or with other family and health care team members. The plan can be presented verbally or in writing. It can be initiated by the nurse who seeks validation from the client. Or the problem list, nursing diagnoses, goals, outcomes, and interventions can be decided on by the client and nurse together after the nurse presents assessment data. 4. If agency guidelines delineate the frequency of nursing interventions and the care plan does not require these more often than specified, no time frame is required. Also, if the intervention is performed during every interaction (e.g., the nurse remains calm and appears confident), no frequency need be written. 5. Nursing diagnoses related to airway are often the highest priority because they represent life-threatening conditions. In reassessing priorities, the nurse considers new problems as well as progress toward meeting existing goals. If the airway problem is in the process of improving, other diagnoses may become higher priority

Chapter 14: Critical Thinking Possibilities

1. For Ineffective Airway Clearance, the overall outcome has not been met. Although the client is able to cough productively, the care plan requires modification and continuation in order to achieve all of the goals. For Anxiety, the overall outcome has been met for the most part. Ongoing assessment and data collection are indicated. 2. Some possibilities are that the interventions have not been adequately implemented (and still are needed) or more time is needed for their effects to be apparent. 3. It might be good to keep the diagnosis so it can be followed in case it reoccurs. On the other hand, the outcomes remaining may be

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accomplished through plans for other nursing diagnoses (such as ­respiratory rate) or are ongoing (teaching). 4. Data collected are recorded in the chart on graphic records and nurses’ notes (see Chapter 15 ).

Chapter 15: Critical Thinking Possibilities

1. No date. Do not know if the hospital policy requires military time. Showed assumption and bias with use of the term “complainer.” Not complete (e.g., what did the nurse listen to . . . would that information be helpful in the care of the client? Were the BPs taken in two different positions or at two different times?). No information as to why the client refused lunch. Another assumption that client fell out of bed . . . did the nurse see it or walk in and find the client lying on the floor? No evidence of using the nursing process as a framework for documentation. 2. Use the nursing process as a framework. Document assessment findings that relate to the defining characteristics of pain. Chart those interventions that were done to help relieve the pain. Document the client’s response to those interventions. If any teaching was done, be sure to document what the teaching was and the client’s response. 1. 6/6/15 #1 Pain 2. S: “sharp, stabbing pain in lower back that radiates to left leg” 3. States pain is 8 out of 10 4. “I didn’t sleep last night” 5. “I feel better” (after interventions) 6. O: BP 210/90 mmHg, P 72 beats/min, R 18/min 7. Last medicated 5 hours previously 8. Medicated with ordered analgesic 9. Heating pad applied to lower back 10. Positioned on side with pillows behind back 11. A: Continues to need narcotic medication to progress toward goal of pain relief 12. P: Add to plan of care to offer analgesic around the clock q4h versus prn 13. 6/6/15 Pain 14. D: “sharp, stabbing pain in lower back that radiates to left leg” 15. States pain is 8 out of 10 16. “I didn’t sleep last night” 17. BP 210/90, P. 72, R. 18 18. Last medicated 5 hours previously 19. Continues to need narcotic medication to progress toward goal of pain relief 20. A: Medicated with ordered analgesic 21. Heating pad applied to lower back 22. Positioned on side with pillows behind back 23. Add to plan of care to offer analgesic around the clock q4h versus prn 24. R: “I feel better” (after interventions)

Chapter 16: Critical Thinking Possibilities

1. Key points to remember include, but are not limited to, the following: • Active listening is very important because it strengthens the rapport between the client and nurse. Careful listening can help check your understanding of what the client is saying or meaning with the responses. • It is important to emphasize that the client has personal choice and control. The client should decide what behavior, if any, to focus on. • Readiness to change, including importance and confidence, needs to be continually assessed. • It is not unusual for individuals to recycle through the stages of change. 2. Questions to consider include these: • “Take me through a typical day in your life and tell me where your [behavior] fits in.” • “You have mentioned smoking, exercise, food, and losing weight. Would you like to talk about one of these topics or is there

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something else you would prefer to talk about?” (This gives clients the opportunity to choose the topic most important to them at the time.) • “Which of these behaviors do you feel most ready to think about changing?” • “Sometimes it can be helpful to examine the pros and cons of [behavior]—would this be helpful?” • “What concerns you the most about [behavior]?” • “Would you like to know more about [behavior]?” • “How do you see the connection between [behavior] and [behavior]?” 3. Mr. W. is in the contemplation stage, because he wonders about changing and is willing to discuss it. Contemplators want to change; however, at the same time, they have a resistance to change. Consciousness raising is important during this stage. Find out if the client wants more information. Assist the client to increase his awareness of the behavior— why he wants to change, the pros and cons of changing, and so on.

Chapter 17: Critical Thinking Possibilities

1. Jerry has a positive outlook and views himself as “well,” whereas Joe has a negative outlook and views himself as “ill.” Identify and compare data indicating the psychological dimension (self-concept, mind–body interactions, and emotional response to health) for both clients. Speculate about how their differences in perception may affect their continuing recovery process. 2. Jerry is most likely an “internal” because he has taken charge of his own health by changing his diet, initiating an exercise program, and attempting to lower his stress. Joe is more likely an “external” because he has been unable to take control of his health. Joe may believe that his health is largely controlled by outside forces and is beyond his control. 3. At least one external factor is Jerry’s physician’s advice. Another may come from his work environment colleagues. 4. Joe’s perception of his illness, and thus his ability to respond in a positive manner, may be affected by a family history of heart disease and his perception that he is at high risk and there is nothing he can do to change his pattern of health. a. Joe’s perceived barriers to action (cost, time, lack of social support) b. Perhaps the benefit of assuming the sick role outweighs the benefit of recovery. 5. Verifying that Joe values the planned outcome achieved from smoking cessation; verifying Joe’s knowledge about the effects of smoking and providing needed information or correcting misconceptions; demonstrating genuine concern for Joe and reinforcing positive changes that he does make; allowing Joe to make his own decisions, thereby demonstrating trust and respect. Many other interventions are possible.

Chapter 18: Critical Thinking Possibilities

1. Rachel’s culture (values, beliefs, norms, and life practices that guide thinking, decisions, and actions) is mixed and can be referred to as ­bicultural because she has integrated practices and values from both her mother and father who were of different backgrounds. 2. Rachel’s ethnicity (consciousness of belonging to a group that is differentiated from others by symbolic markers) is most strongly associated with her Jewish background as evidenced by her return to the Jewish religion as an adult and by her obvious connection with this group. 3. Cultural values often determine the roles of family members, their interactions, who has authority to make decisions on the client’s behalf, and family involvement in the client’s care. Without clear guidelines on the cultural practices Rachel adheres to, it may be difficult to provide culturally sensitive care. 4. Rachel’s beliefs and values will strongly affect her approach to death and the way her family reacts toward her before and during the death process. a. Rachel’s culture may dictate her choice of dying with family members present, rites, or rituals to be performed, and the degree of knowledge she wishes to have about the dying process.

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b. Rachel’s religion is likely to strongly influence the care of her body after death and burial procedures. 5. A cultural assessment is particularly important at this time in Rachel’s life so that her death can be congruent with her beliefs and traditions. It is also important to determine her primary support systems, to preserve her preferences, and to offer support to Rachel and her family in culturally acceptable ways.

Chapter 19: Critical Thinking Possibilities

1. Tim’s name suggests that he may be of Asian descent (and cancer of the stomach is more common in Asian populations than in some other ethnic groups). Tim’s parents do not speak English and this suggests that they are not from a North American culture. Many Asian people use CAM as a regular part of their health activities. Tim’s gastric cancer appears to be quite serious. Often, cancer clients whose disease is not responding to conventional therapy seek CAM to treat the disease or to cope with symptoms. 2. Certainly, touch, biofeedback, prayer, music, meditation, and similar CAM therapies might help Tim’s ability to cope with his pain and even increase his nutritional intake. There may also be herbs, homeopathic, and TCM products that are safe to use with his Western therapy ­although the nurse must investigate these carefully. Where would you look for this information? 3. The nurse may ignore finding the bags of “tea,” but there is a risk that the substance could be contraindicated with other medications Tim currently takes. The nurse can ask Tim or his wife what is in the bags and determine the safety of their use. 4. If the nurse is strongly in favor of or opposed to CAM, this may color interactions with the client and family. The nurse should review these biases and ensure that he or she can still provide professional care considering personal perspectives. The nurse should be open minded to hearing the client’s beliefs and supporting the client’s right to act in accordance with his beliefs.

Chapter 20: Critical Thinking Possibilities

1. Finnegan is in Erikson’s early childhood stage, where the task of ­developing “autonomy versus shame and doubt” is paramount. Through successful achievement of this task, the child will learn to express himself, cooperate with others, and self-regulate emotions and behaviors (demonstrate self-control). Unsuccessful mastery of this stage leads to a child who is unsure of the self, unable to limit behaviors, and is willful, resistant, or defiant. 2. Because Finnegan is not able to cognitively understand the implications of his condition, his parents should provide clear, simple statements of what is expected of him (e.g., “You will need to wear the eye patch every day”) and why the treatment is necessary (e.g., “Wearing the eye patch will help your eye learn to see better”). Their approach should be matter-of-fact and supportive, acknowledging his feelings and giving him specific praise and comfort (e.g., “Sometimes it is hard to wear glasses, isn’t it? You don’t complain much at all. That’s a good lesson to learn and a hard one. Come here, let’s have a hug together.”), without emotional drama (e.g., “Oh, you poor little thing! I am so sorry you have problems with your eyes! Here, let Mama hold you!”). His parents should also encourage Finnegan’s active decision making in his care, fostering his sense of control over the situation (e.g., “Finn, you need to wear the patch for two hours each day. Do you want to put it on after breakfast or after your nap? You get to decide.”). Parents should be counseled that Finnegan is in the midst of learning self-control; they should expect some resistance and defiance, but should use distraction and active support (above) when it occurs, not engage in a power struggle with the child. 3. Finnegan is in Piaget’s early preconceptual stage, where he is curious about the environment, exploring, learning language and concepts, and very self-focused. From a social learning perspective, he is

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Answers becoming increasingly aware of his relationship with others and is learning by observation and imitation. Use explanations with simple language and concepts the child understands; allow him to look at, manipulate, and explore the patch and glasses; provide play objects so he can express his feelings tactilely (e.g., dolls, puppets, drawing, or painting); read books about and encourage him to notice and talk with you about other people who wear glasses or eye patches; give him explicit praise and encouragement for success.

Chapter 21: Critical Thinking Possibilities

1. Eight-year-old children are in Piaget’s stage of concrete cognitive thinking. They tend to see things as “right” and “wrong” and emphasize following rules, usually because doing so means they will be perceived as “good” and they will be rewarded. 2. A first step in talking with Shireena and her mother is to find out how the child understands her condition. Ask Shireena to tell you what she thinks has happened and what caused her problem. As you listen to her answer, validate those things that are accurate (e.g., “Yes, when you get water from a lake in your ears, it can cause an infection.”) and add new knowledge (e.g., “But not everyone gets an infection from lake water; sometimes it just seems to happen.”). Ensure that she does not feel at fault (e.g., “I know you tried hard not to put your head under water, but sometimes water splashes up no matter how hard you try.”). Encourage Shireena to ask questions and explain to her what has happened. Drawing a picture of the ear can be a useful tool for both the child and her mother. Use words that are age appropriate and if a new word seems to confuse the child, explain what it means in simple, concrete terms. The mother should participate in the discussion, but the nurse should actively solicit input from both. 3. Provide clear, concrete directions on what is expected in the treatment plan. Ask for ideas from both mother and child about how they will implement the plan (e.g., When will the drops be put in? Where will the medicine be stored? How will they remember to put the drops in? Are there any activities pending that might disrupt the treatment plan [travel, sleep-overs, etc.]?). Again, validate those ideas that sound workable, and make other suggestions as appropriate (e.g., “Some of my patients find that making a 10-day calendar with three spots for each day helps. They cross off each spot after the drops are put in, and at the end of 10 days, they have a special treat planned.”). Shireena is entering Erikson’s stage of industry vs. inferiority and this experience could be an opportunity for her to take an active, creative role in her self-care. The nurse should point this out to her mother and make every effort to ensure that Shireena gains new skills at the same time she is recovering from her external ear infection.

Chapter 22: Critical Thinking Possibilities

1. Health promotion for the young, or emerging, adult should include a comprehensive health assessment (including physical exam) at least every 5 years. Mr. Jones stated he had not seen a health care provider since high school. The nurse should attempt to get the name of the previous provider, and ask if Mr. Jones has participated in any workplace health fairs or screenings, such as blood pressure, hearing, or blood glucose. Young adults need regular dental care, so the nurse should ask Mr. Jones when he last saw a dentist, what took place at the visit, and if he has another visit scheduled. If he does not, the nurse can suggest that he set up dental appointments for every 6 months, and may supply him with the names and phone numbers of local dentists if Mr. Jones does not have a regular source of dental care.   Several aspects of Mr. Jones’s occupation put him at risk for injury or illness, so it is important to ask how he manages these threats. Particularly, his work exposes him to noise, sun, and falls. He should be asked about use of sunscreen, ear protection, and a hard hat. Exercise is not a major concern if he is engaged in strenuous physical labor on his job, but he should be asked about nutrient and water intake. It is

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important that he take in adequate amounts of protein, iron, fruits, and vegetables. His fluid intake should be at least 64 ounces per day; more if he is perspiring heavily.   Mr. Jones has made several comments that bear further discussion in relation to his health promotion. His intake of alcohol should be investigated for the amount and frequency of intake, as well as signs of alcohol abuse. He should also be asked about the use of a designated driver, or other strategy for travel, when he has been using alcohol. His statement about “chasing women” should also be followed up on. He may be at risk for STIs (see below) and should be referred for STI testing and treatment. His ability to form mature and intimate relationships should also be investigated. 2. Sexual activity is a risk factor for STIs. If Mr. Jones is sexually active, the nurse should explain the rationale for asking questions that he may find embarrassing or intrusive. In a nonjudgmental manner, the nurse should ask the age at which Mr. Jones became sexually active, how many sexual partners he has had, and whether the partners have been men, women, or both. He should also be asked how many partners he currently has, and if he has engaged in oral or anal sex. Mr. Jones should be asked if he uses condoms with every sexual activity. The nurse should be careful not to lead Mr. Jones into a politically correct answer, so might ask “How often do you use condoms?” The nurse should then ask him to explain how he applies the condom, and instruct him on correct technique, if needed.   The nurse is promoting safe sexual practices. If the nurse identifies high-risk sexual behaviors that place Mr. Jones at risk for having an STI, the nurse needs to refer him for testing and possible treatment. 3. Young adults are typically very healthy, and the health risks they are exposed to are primarily from behavior. In addition, health problems in middle and old age may be prevented by health habits started now, and Mr. Jones should be advised of this fact.   Violence and substance abuse are major threats to the health of young adults. Mr. Jones should be asked if he feels safe at work and home, and if he has firearms in his possession. The presence of a gun in the home is strongly correlated with accidental injury and suicide. The risk of injury increases if alcohol or other substances are abused, so these practices are important to query. Tobacco, although not usually a cause of imminent injury, may precipitate health problems, particularly respiratory ones, later in life. Risks for STI and alcohol-related motor vehicle crashes were discussed in answers 1 and 2 above. Finally, Mr. Jones should be apprised of the heightened risk for suicide in young adults. He should be asked about suicidal ideation (particularly given his accident at work) and be given the telephone number of a suicide prevention hotline, if appropriate. 4. Young adults should have a comprehensive physical exam at least every 5 years, with testicular exam, hearing and vision assessment, blood pressure and cholesterol measurement, tuberculin test, and administration of needed immunizations. Monthly testicular self-exam is no longer recommended by the American Cancer Society unless the man has specific testicular cancer risk factors. Some primary care providers, however, believe that a monthly testicular self-exam is a factor in helping men seek early treatment. Each man needs to decide whether or not to do a monthly self-exam. As a result, nurses need to know how to teach men how to perform this self-exam. Because Mr. Jones has not seen a health care provider in several years, by his report, it is important to conduct all of these assessments today, including the testicular examination. The American Cancer Society recommends that a testicular exam be a part of the annual physical exam. His work-related risks of noise and sun exposure indicate a need for a careful hearing screening and examination of the skin for sun damage. The purpose for conducting these exams is to identify signs of developing disease or dysfunction, as well as to reveal any areas where health promotion or protection is needed.

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5. The developmental milestones of psychosocial function in young adults are feeling independent, having a realistic self-image, having positive regard for self and life direction, coping with stress, interacting well with one’s family, being responsible for one’s self, and developing lasting relationships with others. Mr. Jones has displayed some bravado about drinking with friends and interacting with women, but it is difficult to ascertain the quality of the relationships. The nurse should ask more about these friendships, as well as if Mr. Jones has close friends, either male or female. Furthermore, although Mr. Jones has a job, there is no information about its adequacy to meet his financial needs, or how responsibly Mr. Jones manages his employment. No information is given about how Mr. Jones interacts with his family. He should be asked about the use of alcohol or other substances as coping mechanisms. He should also be asked if he is satisfied with his life and occupation. If he is not, the nurse should ask if Mr. Jones has the plans and resources needed to make a change.

Chapter 23: Critical Thinking Possibilities

1. Osteoporosis means “porous bone,” or bone that has gotten thinner and greatly increases the risk of fractures, particularly in older women. Pictures or actual x-rays can be shown to the client to facilitate learning the basics of osteoporosis. The seriousness of the condition should be stressed. At the same time, it should be stressed that following preventive measures and participating in treatment regimes, if this is indicated, will help to maintain bone health. 2. Risk factors should include physical factors such as early menopause, small thin frame, use of steroids, history of rheumatoid arthritis, family history of disease, or history of fractures. 3. Some risk factors are considered to be modifiable, including smoking, diet low in calcium, lack of exposure to sun (sunlight helps to increase vitamin D), increased intake of caffeine and alcohol, and lack of exercise. 4. Most of the medications used to treat osteoporosis help to reduce bone resorption, which means that bone mass is at least maintained. Some of these medications have serious gastrointestinal side effects and some increase the risk of formation of blood clots. It is essential for the client to know the possible side effects and call the physician if any unusual symptoms are experienced. If the medication is an experimental medication, bone density scans may be done at regular intervals to determine effectiveness of the treatment. 5. Measures to discuss for a decreased risk of fractures include the following: assessment of home environment to see what safety measures need to be instituted, making sure that hallways and stairwells are well lit, wearing well-fitting shoes with nonskid soles, removing loose rugs in the house, and keeping the floor free of cords (electrical and telephone) to prevent tripping over them. Measures to maintain bone mass include increasing calcium in the diet and taking a calcium supplement, increasing the amount of weight-bearing exercise, and taking medications to prevent further bone loss.

Chapter 24: Critical Thinking Possibilities

1. Many illnesses can be affected by the client’s emotional state. If her arthritis is the type called rheumatoid, it can flare when the client is under stress. Also, some medications used to treat arthritis can cause mood changes and other distressing adverse effects. Any aspect of the illness that interferes with daily functioning of a family member will affect the coping of all members. 2. The family is affected because Linda’s role functioning is impaired such that others might need to take on tasks that Linda would normally perform. In addition, Linda’s emotional response to her illness can ­interfere with her ability to provide psychological support to her children and spouse and thus cause them severe distress. 3. Facing illness as a family often draws the members, including those normally at some physical or emotional distance, closer together. A disadvantage of facing an illness with the family is the additional

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stress, cost, and responsibilities members may have to take on. The ill member may feel great guilt about the extra work that falls to others. Members may become fatigued and be unable or unwilling to support the ill person. 4. Each family member exists as a part of the whole. They interact with each other and with their human and nonhuman environment. The family has become a more closed system (with thicker boundaries) than usual due to the parents’ desire to avoid assistance or interference from previous spouses. Linda’s biological systems may be malfunctioning, leading to altered function of her other systems and those of the family. For example, feedback in the form of pain will serve as input to her in deciding how much and what types of physical activity she can perform.

Chapter 25: Critical Thinking Possibilities

1. Possible examples describing which aspect of the nurse’s approach relates to each of the following “Six C’s of Caring in Nursing” as outlined by Roach: • Compassion: The nurse prioritizes care to alleviate pain before continuing to other tasks. • Competence: The nurse draws up the correct dose of morphine and administers it safely. • Confidence: The nurse does not hesitate to provide essential care, and expresses her belief in this treatment to the client. • Conscience: The nurse follows safety procedures and protocols at all times, putting the welfare of the client first. • Commitment: The nurse has made arrangements in her personal life (for her own child), so that she can focus on her professional role. • Comportment: The nurse dresses and acts in a professional manner, communicating who she is to the child and mother. 2. Possibilities for descriptions of how each type of knowing prepared the nurse, Megan, for her caring approach: • Personal knowing: The nurse is aware of her own strengths and limitations. She has made arrangements for her own child’s care so that she can focus on her clients. • Empirical knowing: The nurse combines knowledge of growth and development, pathophysiology, medical treatments, and the nursing process to provide competent nursing care. • Aesthetic knowing: By knowing this client and what motivates him, the nurse can plan activities that he understands and appreciates, and that lead to healing and comfort. • Ethical knowing: The nurse appreciates the need to “do no harm” to the client and to promote health and healing. 3. Possible descriptions of how each of the following aspects from Ray’s theory influences the nurse’s care: • Spiritual-ethical-caring: the importance of providing holistic, respectful, safe care that maintains the client’s integrity and promotes healing • Physical: the client’s acute illness (ruptured appendix) and his physical deviations from health • Technologic: the skills involved in nursing care, such as intravenous (IV) therapy, nasogastric tube to suction, IV medications • Social-cultural: the child’s developmental level, family and peer relationships, and cultural background • Educational: the child’s level of understanding as well as individual factors that motivate him to ambulate and participate in other aspects of care • Legal: practice guidelines that serve as standards of care for this medical diagnosis, as well as nursing policies and procedures that guide the nurse’s actions.

Chapter 26: Critical Thinking Possibilities

1. Mrs. Manasovitz’s nonverbal behavior may include changes in posture, facial expression, lack of verbal expression, and so on. Mrs. Manasovitz’s nonverbal communication most likely represents fear, disappointment, loss, anxiety, devastation, and so on.

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Answers 2. The nurse conveyed the following caring actions: sitting with Mrs. Manasovitz, listening to her, and giving her undivided attention. The nurse also conveyed comforting actions: using a soothing voice, reassuring, touching, offering presence, and offering a cup of coffee. The nurse’s actions did communicate caring and comforting as evidenced by Mrs. Manasovitz’s willingness to share her feelings. 3. It is important to provide essential information and establish a trusting relationship during emotionally stressful times. Other advantages of effective communication are helping families with stress reduction, helping them understand treatment options, and helping them with decision making. 4. The nurse conveyed attentive listening by sitting with Mrs. Manasovitz, paying attention to both her verbal and nonverbal language, remaining silent, and focusing solely on Mrs. Manasovitz. Other examples may include not interrupting the client, noting the congruency between verbal and nonverbal language, encouraging the client to talk, and thinking before responding.

Chapter 27: Critical Thinking Possibilities

1. Mrs. Yorty seems preoccupied, so this may not be the ideal time to proceed with teaching. She needs time to adjust to the news that she has received and to come to terms with how her heart condition is going to affect her life. When she is ready to learn, she will give you her full attention, ask questions, talk to others, and show interest. 2. A needs assessment provides information about numerous factors that affect learning, not just cognitive ability. Do not assume that well-­educated individuals have all the information they need to make decisions about their health, or that individuals who are not as well educated do not have the capacity to understand. • A needs assessment would provide such information as Mrs. Yorty’s baseline knowledge of cardiac disease, any health beliefs or cultural factors that may impact her acceptance or rejection of needed changes, the method of learning she prefers to use, and the support systems available to her. 3. Using your learning needs assessment, consider how Mrs. Yorty prefers to learn. • Consider leaving material for Mrs. Yorty to read or videos for her to view. • Schedule short learning sessions rather than overwhelmingly long sessions, use teaching aids, repeat information often, and allow ­active learning. Allow Mrs. Yorty to set the pace. 4. If Mrs. Yorty is able to accurately select foods in accordance with her prescribed diet, is able to accurately plan an exercise program, and can offer suggestions for stress reduction, your teaching has most likely been effective. • Do not confuse the client’s lack of compliance with ineffective teaching. Clients may choose not to follow a prescribed regimen even though they have thorough knowledge of the regimen. 5. Teaching strategies may differ depending on the availability of ­equipment; however, the principles of teaching would be similar. • A learning needs assessment would still be useful. The person’s learning readiness and motivation remain important, and learning objectives would continue to serve as evaluation criteria.

Chapter 28: Critical Thinking Possibilities

1. Mr. Caruso has characteristics of democratic or participative leadership. He is complimentary of his staff ’s ability to set goals and make decisions. He encourages your input and ideas. Mrs. Turner has characteristics of the autocratic leader. She explains her expectations and speaks of implementing her programs. 2. Not sure which characteristics of your admired manager/leader you might want for yourself? If you didn’t already, consider how they influence people; their interest in exploring new ideas; their ability to relate to others; how much freedom they allow or control they exert over

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others; their use of authoritarian, democratic, or laissez-faire style; their energy level; and their creativity. 3. Strategies for dealing with change may include acknowledging that some resistance to change is normal, examining the reasons for the change, focusing on the positive impact of the change, forming a ­support group, and examining the steps of the change process. Review Boxes 28–4 and 28–5 for more ideas. 4. In both primary care and team nursing, registered nurses may delegate tasks to other nurses or to UAPs. However, in primary nursing, the nurse generally provides as much direct care as possible while present, accepts supervisory responsibility for the client’s 24-hour care, and, by definition, delegates care to the other shifts. In team nursing, a designated set or pair of providers is assigned to care for a group of clients. These members will share care for the clients according to agreed-on assignments that include delegation of appropriate tasks by the nurse.

Chapter 29: Critical Thinking Possibilities

1. You need to determine the source of the client’s concern. Is this just a bad time for her? Inquire if she has ever had her blood pressure taken previously. If so, what was the experience like for her? What does she imagine will happen if you take her blood pressure? • Discuss factors that influence clients’ views of having vital signs ­measured—especially factors such as setting: long-term care, ­hospitals, clinics, primary care providers’ offices. 2. Each nurse develops his or her own style for addressing problems such as this with clients. You need to develop yours or it will sound insincere. As a rule, however, explain the situation without assigning fault. For example, you might say, “I wasn’t able to hear your blood pressure that time,” rather than “I’m really new at this and not very good yet.” • If you are confident that your equipment is functioning properly, you may wish to retake the pressure using palpation rather than auscultation since you will be able to establish the presence of the peripheral pulse before you begin. • If you are very new at taking blood pressures, you may wish to ask another nurse to take the blood pressure for you this time. If a ­teaching stethoscope is available, use it so both of you can listen at the same time. • Role-play this situation with fellow students or friends. Try several different responses until you feel comfortable and the “client” ­expresses trust in your approach. 3. When you take a client’s blood pressure for the first time, you need to relate it to previous or expected values. Determine the client’s most recent BP—although this reading is elevated, it might actually be lower than previous readings. Also, assess for any stressors or medications that might currently be influencing the reading. 4. The oxygen saturation value is inconsistent with her other vital signs. Begin by determining if the pulse oximeter equipment is functioning properly and you have applied it correctly to an appropriate location.

Chapter 30: Critical Thinking Possibilities

1. A focused neurologic system assessment must be conducted, including determining her mental status, motor and sensory function, and pupillary reactions. The client may have had a stroke or have injured her head when/if she fell. The musculoskeletal system is also a priority since she may have injured herself or broken a hip either before or after falling. In an older adult who has apparently been injured, the integumentary system is a priority because of the high risk for skin damage, bruising, and skin breakdown. Assessment of other systems may also be justifiable. 2. Be sure that you are asking open-ended questions that cannot be answered with yes or no. Open-ended questions often begin with the words “how” or “what” or “tell me about.” Use good nonverbal communication skills such as being at her level when you speak and making eye contact.

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3. Although you should still use the head-to-toe approach, it may be best to do all of the anterior assessment first and then turn her to perform posterior assessments. You can assess her upper extremities and much of her lower extremities without turning her at all. Do not omit the posterior assessment, however, just to reduce her discomfort. It is extremely important to determine if abnormal findings are there such as lung consolidation or skin breakdown. 4. Begin with family members. Although she lives alone, there may be children, grandchildren, or other relatives who are in contact with her regularly. Also, ask about the source of her regular health care. Other community sources may be neighbors or organizations with which she is affiliated (e.g., church, social groups). If she has a primary care provider, ensure that he or she has been notified of the client’s admission and determine if she was seen recently or if the office can provide pertinent medical history data.

Chapter 31: Critical Thinking Possibilities

1. Examples include age (reduced immune defenses), dehydration, ­nutritional deficit (decreased ability to synthesize antibodies), and the chronic respiratory problem. 2. A full history and physical assessment are indicated. a. In particular, explore her immunization status, chronic illnesses, exposure to others who may have had an infection, medications that could increase susceptibility to infection, stress level, and ­history of previous infections of any kind. b. Assess her skin and mucous membranes and check vital signs that could indicate infection. c. Determine spiritual, cultural, and educational characteristics that may influence her beliefs and understandings, care preferences, and practices. 3. Use of standard precautions (SP) alone will not prevent transmission of her respiratory infection (if contagious) to others since SP are designed to prevent the transmission of bloodborne pathogens. As such, SP do not apply to sputum, nasal secretions, or urine unless contaminated with blood. 4. Depending on the type of organism infecting Mrs. Cortez’s respiratory tract, she may need to be placed on specific precautions. Identification of the organism will determine the type of mask and other precautions needed. a. Interventions that protect all clients from the spread of disease include consistent and thorough hand cleansing, encouraging clients to cover their mouths with tissues when coughing or sneezing, disposal of soiled tissues in an appropriate bedside receptacle, making sure that reusable equipment is cleaned or sterilized appropriately, and handling soiled linens to prevent cross-contamination. 5. The assistant should be complimented on knowing the need to wash/cleanse her hands after contact with the client. However, her technique could be improved through the use of paper towels on the faucet handles and increasing the time spent washing to at least 10 seconds. Also, remind the assistant that the use of an alcohol-based rub is actually the preferred method of hand hygiene between clients.

Chapter 32: Critical Thinking Possibilities

1. Restraints should only be used as a last resort. Some of the reasons include, but are not limited to, the following: Research has not proven that restraining clients prevents falls or injury; they lessen the client’s movement and independence, which infringes on their rights; restraints can increase agitation of the client; the restraints can cause injury (pressure ulcers, skin tears, or death); restraints can interfere with the client’s treatment; restraints can potentially cause health problems such as poor circulation; and restraints can be embarrassing to both client and family members.

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2. Several factors that could affect Mr. Moore’s safety include, but are not limited to, the following: a. He is older than age 65; he has a history of falls; recent surgery for a hip fracture may impair his mobility; he may be weaker now than before his surgery; and his medications may affect his safety (e.g., antihypertensives, diuretics, analgesics). b. Mr. Moore may resume normal activities before he is strong enough. c. Mr. Moore may not be able to meet his nutritional needs because he will need to prepare all but one meal per day. He is at greater risk for injury while preparing his own food. d. Mr. Moore may not understand the precautions necessary to ­protect his own safety. 3. You need to perform a home hazard appraisal. Suggestions for safety enhancement include the following: a. Because the majority of adult injuries stem from falls, caution Mr. Moore about using area rugs and to be aware of where his pets are when he is up moving about. b. Use grip handles in the bathtub and toilet. c. All rooms should be well lighted. Use night-lights. d. Carpets should be in good condition and hardwood floors should not be waxed. e. The house should have smoke alarms; telephones should be easily accessible in case of emergency. 4. He has been physically and socially active and independent; he has a strong family support system (his son will visit daily); he has access to community resources; his rooms are on one level and his house is small; he has pets to decrease his loneliness; he has no other chronic illnesses that would interfere with his healing process.

Chapter 33: Critical Thinking Possibilities

1. After reviewing the defining characteristics and related factors, there is little data to support that the client actually has an impaired ability to perform her own bathing and hygiene. She has been providing for her own needs, has been ambulating, and has no physical impairments. a. The following factors influence an individual’s hygienic practices: culture, religion, environment, developmental level, health and energy, and personal preference. 2. Assess the client for discomfort/pain, fatigue, embarrassment, cultural beliefs, or personal preferences that may affect her decision to omit her personal care. a. Suggested questions for the client: “Are you uncomfortable?” “Are you more tired today than yesterday?” “Do you want to wait until you go home?” 3. In general, bathing and personal care are essential for maintenance of skin integrity and mucous membranes, decreasing potential for infections, enhancing comfort, fostering a feeling of well-being, enhancing relaxation, minimizing odor, and increasing circulation. a. Benefits of personal care to the client include, but are not limited to, decreasing her risk of surgical wound infection and enhancing her comfort and ability to relax. Cleaning her teeth decreases the risk for infection and enables her to enjoy her food. 4. Offer the client several explanations regarding the benefits of proceeding with her bath and personal care, emphasizing the need to prevent infections. a. Offer to assist her and seek her input on where she wants to bathe (e.g., at the bedside or in the bathroom); gather her toiletries and provide for privacy. b. Make sure she has warm water and clean linens. c. Provide intervention (e.g., pain medication), if appropriate, depending on her reason for not wanting to perform personal care. 5. You can gather information and perform assessments during the ­bathing process. a. You can convey to clients that you have the time and the interest to make them feel better.

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Chapter 34: Critical Thinking Possibilities

1. Consider the possible causes. Is the finger vasoconstricted because of decreased blood volume? Would warming it with a warm cloth and having the client hold her hand in a dependent position help? Check the equipment (e.g., lancet injector) to see that it is operating correctly. Was it poor technique? Frequently, a novice nurse does not use enough force to press the injector firmly against the skin or does not have the injector in a perpendicular position relative to the skin. Both are needed to obtain a deep, clean puncture. After you have ascertained the cause, you will need to do another finger-stick to obtain a large enough drop of blood to obtain an accurate reading. 2. The laboratory results suggest that an infection and dehydration are present. Having a previous HCT for comparison would be helpful. Nursing interventions would relate to both infection and dehydration: VS TPR, check for orthostatic hypotension, obtain urine for C&S, interventions to promote hydration. 3. Consider that the client has had no fluids for 3 days. There is no information about the antibiotic (e.g., route and classification), which can also be a factor. Some antibiotics can be nephrotoxic. It is important to obtain a specimen for C&S before starting antibiotics; otherwise the results may not be accurate. Therefore, priorities would be to first start the IV fluids, because this will begin rehydrating her and may also help with obtaining the urine specimen. Second, obtain the urine specimen. You will need to assess how much assistance she may need with providing the clean-catch urine specimen because of expected weakness as a result of not eating or drinking for 3 days. Assistance may include placing her on a bedpan with the nurse doing the cleansing of the perineal area and collecting the sample. Finally, the third priority would be administration of the antibiotic. All of these priorities would take place quickly because they are all important as is the order of the priorities. 4. The reduction in HCT reflects that she was dehydrated and the first HCT was elevated due to hemoconcentration. After being rehydrated, this HCT is more accurate. The WBC indicates that the infectious process is subsiding. 5. Assess her knowledge about an MRI and explain, if necessary, the purpose, procedure, benefits, and risks. Sedation is provided if the client is claustrophobic or unable to lie still during the procedure. Assure her that two-way communication is provided so that the client can provide feedback and be monitored. Inform her that there is a loud knocking noise during the procedure and earplugs are available if she desires. Document her concerns and the teaching you provided. If she continues to be anxious, inform the primary care provider.

Chapter 35: Critical Thinking Possibilities

1. Differences between an allergic reaction and a drug side effect can include these: a. Side effects are not related to an allergic reaction and do not produce the same symptoms as are produced by allergies. Allergic reactions have a distinct pattern of reaction (e.g., skin rash, pruritus, angioedema, rhinitis, tearing, nausea, vomiting, wheezing, dyspnea, or diarrhea). b. A severe reaction is called anaphylaxis and can produce respiratory collapse if emergency treatment is not immediately instituted. c. Drug hypersensitivity or drug allergy is often listed as a systemic side effect in drug handbooks. 2. Mr. Ketron may have allergies to either of the drugs; he may be on another prescribed drug, tobacco, alcohol, or nonprescription drug that interferes with or potentiates one of the prescribed drugs; he may have a medical condition that limits the kinds of drugs he can take safely; he could be allergic to penicillin; and so on. 3. Make the following assessments: a. Inspect and palpate the IV insertion site for signs of infection, infiltration, or a dislocated catheter. b. Inspect the surrounding skin for redness, pallor, or swelling.

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c. Palpate the surrounding tissues for coldness and the presence of edema, which could indicate leakage of the IV fluid into the tissues. d. Take vital signs for baseline data, especially respiratory rate. e. Determine if the client has allergies to the medication. f. Check the compatibility of the medication and IV fluid. g. Determine specific drug action, side effects, normal dosage, recommended administration time, and peak action time of the morphine. h. Check patency of the IV line by assessing flow rate. 4. All of the same precautions should be taken with intravenous medications as with other medications: correct client, correct dose, correct route, and so on. Additional precautions include, but are not limited to, confirming that the antibiotic is compatible with the intravenous fluid infusing, verifying sterility of the system and integrity of the medication bag, verifying that there is no air in the system, cleaning the port prior to placing a needle, and reviewing Mr. Ketron’s medication history for possible allergies. 5. Some drugs are better absorbed when given on an empty stomach, whereas others cause gastrointestinal irritation and should be given with meals or after meals.

Chapter 35: Anatomy & Physiology Review GI System

1. A liquid medication is absorbed faster because it does not need to dissolve. 2. Diarrhea may decrease absorption because the drug is moving too ­rapidly through the small intestine to be absorbed. 3. The presence of food in the stomach will slow the rate of absorption and may decrease the amount of drug absorbed.

Cardiovascular System

1. The distribution of the drug depends on cardiac output and adequate blood flow to the organs and tissues of the body. The distribution of the oral medication may be hindered with a low cardiac output.

Liver

1. Age, especially the very young (immature organ) and the very old (diminished function); history of liver disease; chronic alcohol consumption. 2. If it is a hepatotoxic drug, the nurse would need to be vigilant about a­ssessing the client and the client’s lab values (e.g., liver enzymes) to avoid further organ dysfunction.

Kidneys

1. The very young have immature kidney function, and older adults have diminished organ function. 2. Monitor urine output, check lab values (e.g., bun and creatinine levels), and assess for signs of edema or fluid overload.

Chapter 36: Critical Thinking Possibilities

1. Mr. Johns’ age, his decreased activity and mobility, his decreased sensation on the right, his incontinence, and his nutritional status (thin for his height) suggest he is vulnerable. In fact, he has evidence of possible stage I pressure ulcers over his hips, coccyx, and perineum. 2. You should assess the degree of his loss of sensation, his ability to recognize if he is incontinent, the frequency of his incontinence, how often he ambulates and his capacity for ambulation, his serum protein as an indicator of his nutritional status, and his ability to attend to his own needs. 3. You should undertake measures that include, but are not limited to, providing nutritious meals and snacks, assisting him if necessary, changing his position every 2 hours, avoiding shearing or friction when moving and positioning him, keeping his skin clean and dry, using pressure-relieving support devices, and encouraging activity. Ongoing skin assessment and evaluation of the effectiveness of his

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overall treatment plan are also essential. Discuss the benefit of each of these measures. Consider their cost and the amount of caregiver time required. Prioritize the measures and include rationales. 4. Although the skin is not yet broken, he meets the description of having a stage I ulcer and will progress to further stages (and probably more areas of breakdown) if interventions are not initiated.

Chapter 37: Critical Thinking Possibilities

1. Factors that may increase Mr. Teng’s risk include, but are not limited to, the following: He is 77 years old, placing him at greater risk than younger adults; his respiratory status is compromised and he runs a greater risk for developing postoperative atelectasis or lung infection; and he may be taking medications that will slow healing, such as corticosteroids. 2. A major disadvantage of general anesthesia is that it depresses the respiratory and circulatory systems, so the surgeon and anesthesiologist probably chose not to further complicate Mr. Teng’s respiratory status. A client’s preference for a particular anesthesia is also considered when selecting the type of anesthesia to use. 3. Mr. Teng’s preoperative preparation most likely included, but was not limited to, preoperative teaching regarding preparation for surgery; what to expect following surgery; deep-breathing, coughing, and leg exercises; how to splint his abdomen when moving or coughing; fluid and nutritional support; a bath or shower; antiemboli stockings; and medications to enhance rest the night prior to the scheduled surgery. 4. Even though Mr. Teng had spinal anesthesia and is awake, the same general assessments will be made to detect actual or potential problems. He will not go through the stages of anesthesia arousal or experience altered gag reflexes. He will be assessed for return of feeling to his lower extremities to evaluate remaining spinal anesthesia effect. His postoperative monitoring will not differ from that of other clients. 5. Specific precautions may include, but are not limited to, promoting adequate hydration to replace fluids lost during surgery or fluid limitations prior to surgery, early movement and ambulation to foster maximum lung expansion and prevent lung infection, deep-breathing exercises to remove mucus and prevent stasis of lung secretions, pain control so that he can ambulate and cough more effectively, and leg exercises to prevent thrombophlebitis.

Chapter 37: Anatomy & Physiology Review

1. Assess skin integrity and the presence or absence of any breakdown or bruises. Assess the musculoskeletal, neurologic, and circulatory systems for previous injury or limitations. Assessment for positioning needs is done before the client is transferred to the operating table. 2. The potential pressure areas are the occiput, scapula, olecranon, sacrum, coccyx, and calcaneus. Special attention is paid to previously damaged tissues and diseased joints to prevent breakdown or deterioration due to positioning during the surgical procedure. 3. The priority nursing diagnosis is Risk for Injury related to sustained pressure and misalignment of specific body areas during surgery. Outcome: Client will be free from injury related to positioning.

Chapter 38: Critical Thinking Possibilities

1. Mrs. Dodd is at greatly increased risk for sensory overload due to her environment (critical care unit). She is being bombarded by the noise of her monitors and ventilator, which may be distorted and meaningless due to the sedation she is receiving. Her pain and inability to communicate also contribute to her sensory overload because they contribute to her feelings of being overwhelmed and out of control. 2. Signs of sensory overload may include, but are not limited to, restlessness, agitation, confusion, disorientation, hallucinations, or inability to sleep or rest. Signs of sensory deprivation may include apathy, emotional detachment, and depression. Many times the signs of sensory deprivation and overload are the same; consequently, the nurse must assess the client for factors that may be contributing to one problem over the other.

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3. Interventions include, but are not limited to, reducing and dimming lights; decreasing noise to the degree possible (close doors or curtains); providing comfort measures; explaining all procedures; orienting the client to person, place, and time; speaking in a soft, unhurried manner; and limiting visitors. 4. Clients cared for at home may experience either sensory deprivation or overload depending on the environment. If it is a busy, active environment with several family members, they may experience overload. If clients live alone, have few supportive family members, or are seldom contacted, they are more likely to experience social isolation and become withdrawn or uncommunicative, or lose interest in their usual activities. Interventions for home care or ICU clients are similar and adapted to the specific needs of the client, regardless of setting.

Chapter 38: Anatomy & Physiology Review 1. 2. 3. 4. 5.

Open Closed Figure 38–3B Figure 38–3C Optic nerve (review Figure 38–3)

Chapter 39: Critical Thinking Possibilities

1. Because of his age, Craig’s basic self-concept should be fairly well set and is not likely to be negatively affected. Body image and self-esteem, however, may be altered by his amputation. Body image is at risk because the amputation will change the way he views his body. Personal identity is at risk because he sees himself as an athlete. 2. If Craig’s mood, inability to look at the stump, and unwillingness to discuss rehabilitation continue or new negative responses develop, a negative change in his self-esteem may be occurring. Because his father is also having difficulty with the loss, a strong source of support is unavailable to Craig. 3. There are many possibilities, including his nurses’ attitudes; rehabilitation team and primary caregiver abilities; family and friends’ support; and his internal ability to be adaptable, revise his goals, and use his resources. Craig’s mother’s presence is likely to be supportive unless she offers assistance while encouraging dependency. 4. Adapting to change may be more difficult for older clients. Older adults fear dependence more than younger clients; therefore, a large loss such as this puts them at greater risk for altered self-esteem. In addition, older adults do not heal and progress as quickly as younger ­clients—the ­additional time required may seem to them a negative factor. Much care, however, will be similar: encouragement and support, participation in their own care, identifying personal strengths, and so on. 5. Clients with chronic mental illnesses, cancer, socially stigmatized diseases (AIDS, TB, obesity, sexually transmitted infections), and other sources of disfigurement.

Chapter 40: Critical Thinking Possibilities

1. Many people are uncomfortable discussing such a private matter with strangers (such as their nurses) unless they are made to feel that sexuality is normal and okay. They need to be given permission to openly discuss their concerns without fear of being belittled or made fun. Discuss the benefits of “permission giving.” How would you feel about discussing your sexuality with a stranger? 2. Factors include nurses’ knowledge and comfort with their own sexuality, recognition and acceptance of sexuality as a normal and important human function, understanding of how health impacts sexuality, and nurses’ ability to communicate in general. 3. There is a direct relationship between health and ability to function sexually in that the healthier you are the more likely you are to have the desire and ability to function sexually. • Both physical and mental status affect the ability to function sexually.

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Answers • Diseases such as heart disease, hypertension, diabetes, renal failure, spinal cord injury, or pain can lessen both sexual desire and ability. Mental disorders such as depression can lessen desire. 4. You will need to perform a complete sexual health assessment to provide baseline data. • Two primary problems need to be addressed: his fear of resuming sexual activity and the effects of his antihypertensive medication. • Specific interventions may include providing information, correcting misconceptions, reassurance that resuming sexual activity is safe, and suggesting alternative positions for sex that require less energy than other positions if sexual activity causes him fatigue. • Consult with Mr. Curry’s primary care provider regarding antihypertensive medications that are less likely to produce sexual dysfunction.

2.

3.

Chapter 41: Critical Thinking Possibilities

1. Being religious means being part of an organized system of worship such as a church or synagogue. Terry may mean that he no longer attends the Methodist church or participates in organized religion. Spirituality refers to belief in or a relationship with some higher power, creative force, divine being, or infinite source of energy, such as God or Allah. Clients can be deeply spiritual without belonging to an organized system of worship. Terry admits that he is not very religious; however, there are no data to suggest that he is not spiritual. In fact, Terry’s statement that he is being punished is evidence that he believes in a higher power who is punishing him for not going to church. 2. He states, “I can’t see any reason for going on,” “I know I’m not going to get well,” “I guess I’m being punished.” Terry’s spiritual distress is related to both his physiological situation as well as his concern over not being religious. 3. Spiritual beliefs and religious beliefs can assume greater importance during times of illness. Many individuals will return to their religious roots during times of illness in hopes that they will be cured through divine intervention. 4. A spiritual assessment will help both you and Terry by providing information relative to his spirituality, his religion, and his degree of spiritual distress, so that appropriate interventions can be planned and implemented. Possible benefits may include, but are not limited to, helping Terry draw on inner resources more effectively to deal with his present physical and emotional situation, helping him find meaning in living and hope for the future even though he is presently very ill, and providing appropriate spiritual resources such as a minister or priest. 5. What is taking away the reasons for going on? (That may lead to a need to probe deeper: What reasons kept you going before? For you, what has given life purpose? What has changed that?) Another line of questions can address the possible guilt Terry is experiencing, for example, “Tell me more about your thinking that you are being punished,” which is a better question than “For what do you think you are being punished?” Again, this may open up the concept of forgiveness: What beliefs about taking away punishment or guilt do you have? How do you think one should go about finding forgiveness? (Notice the emphasis on asking about Terry’s thoughts, instead of feelings—a more difficult topic for most.) How does the religion of your parents influence you now? 6. “It seems like you feel like throwing in the towel now.” “I’d venture that it’s hard to see a purpose for living when it is as painful as it has been lately for you.” “If I’m getting the picture right, there’s a question inside you about being guilty of something; and I’m guessing that question is making you feel very uncomfortable inside.”

Chapter 42: Critical Thinking Possibilities

1. It is difficult to know whether Ruby’s coping would differ if only a portion of the breast were going to be removed or whether this is merely the focus of her difficulty in coping with the diagnosis and need for surgery. It might depend on how large her breasts are and if the lump

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represented a significant portion of the breast. Individuals may have very different emotional reactions to situations in which they can or cannot hide their condition or if the impact is directly linked to their role (such as the fact that she is a dress designer). Ruby’s situation fits with a stimulus-based model since the stressors of diagnosis, surgery, and implications of having cancer serve as stress stimuli causing physical and emotional outcomes (such as her ineffective mothering). However, her situation would also fit the response model since the surgery and any further cancer treatment required plus her alcohol use would create stress reactions in the mind and body. The nurse will validate that she cannot know exactly what Ruby is experiencing (assuming the nurse has not actually had a mastectomy), but has worked with many clients undergoing extremely distressful and possibly life-threatening conditions. One of the interventions will include making a connection with other women who have had breast cancer, but that is a response to the content of her message. The nurse first needs to respond to the emotional part of the message—Ruby’s anger, frustration, and lack of control. The suddenness of this diagnosis and Ruby’s extreme reaction of alcohol abuse and neglecting her children certainly may qualify the situation as a crisis. Her inability to discuss her feelings or plans supports the presence of a crisis situation. Under these circumstances, caregivers may need to be more assertive in providing her care and making decisions. She may benefit from referral for psychological therapy/counseling. Many answers may be correct. She does not appear to be using denial. She might use projection in attempting to find a cause of her cancer, which could be maladaptive since, most commonly, the cause of breast cancer is unknown.

Chapter 43: Critical Thinking Possibilities

1. The eldest son most nearly approximates the “awareness of loss” phase. He is experiencing the loss but is able to resume normal activities. The middle son has characteristics of the “conservation/ withdrawal” phase. He has a need to be alone, and is experiencing both physical and psychological symptoms of bereavement. The younger son is experiencing “shock.” He is having difficulty believing that his mother is dead and is experiencing several physical symptoms. 2. Factors include amount of conflict or closeness each brother felt to the mother, amount of time/caring each was able to provide, significance/ meaning of the mother to each, spiritual beliefs and practices, and the amount of guilt each felt related to meeting the mother’s needs during her later years or illness. 3. Cues might include wanting to talk about death, reminiscing or reviewing one’s life, emotional withdrawal or becoming quiet and pensive, allowing others to take over physical care, voicing a sense of urgency about seeing loved ones, and so on. 4. One significant need she may have is for relief of shortness of breath. Both from the pneumonia and the dying process, normal respirations are impaired and she may feel as though she cannot get enough air. In addition, shortness of breath may instill fear—an important need the nurse must attend to. Although this client was not diagnosed as terminally ill, as she approached death, many of the physiological needs identified in Table 43–5 would occur. 5. If you have had mostly positive experiences, or ones similar to those the client is experiencing, these can be shared with others. Consider characteristics of the losses (e.g., if they were expected or unexpected, your age and that of the deceased) and effectiveness of sources of support during grieving.

Chapter 44: Critical Thinking Possibilities

1. His dyspnea on mild exertion is a worrisome sign, and his activity intolerance will worsen if he remains immobile. His edema indicates inadequate venous return, especially with his amount of time spent sitting, and will lead to other problems.

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2. Check environment for possible safety hazards, get a walker light enough to handle easily and be sure it has been adjusted for proper height, keep the tips in good shape, do exercises to keep strength in the hands and arms. 3. Being overweight certainly contributes to his difficulties and should be addressed. More assessment is needed regarding how long he has been overweight and his eating patterns. 4. There is a relationship between physical and emotional health; that the client “wants” to be healthier. 5. With chronic illness, because the condition has existed for a longer time, the outcomes may require more time to achieve than with acute illnesses. Outcomes should be in smaller increments. Lower levels of expectations are often appropriate because full return to earlier levels of health is unlikely.

Chapter 44: Anatomy & Physiology Review

1. Because the upper and lower body are connected, any change in gait such as a limp will affect general alignment, and therefore affect musculoskeletal functioning in the back. Improper alignment throughout the body can lead to discomfort and injury. 2. When the right arm swings forward at the same time as the left leg swings through, a natural rotation of the hips and shoulders is demonstrated. This is a more energy-efficient gait, and makes use of the natural movement in the low back for locomotion. When people hold themselves “stiffly” as they walk, either not moving their shoulders or hips in a rhythmic, swinging fashion, they are interrupting the normal flow of energy through the spine and into the legs, and will likely become tired more quickly, or develop various discomforts throughout their body.

Chapter 45: Critical Thinking Possibilities

1. Other data that may be helpful include, but are not limited to, activities and bedtime habits, degree of noise in the environment, what foods or drinks he consumes just prior to bedtime, if he uses over-the-counter medications to help him sleep, if he has a regular pattern of arising, and whether he is a smoker. 2. Suggest that he read a book or other quiet activity (not watching TV or exercising) before going to sleep, maintain regular sleep and waking hours, explore nonpharmacologic sleep remedies, and so on. 3. Common causes of difficulty in sleeping are physical distress, noisy environment, severe fatigue, changing work shifts, emotional distress, alcohol and other stimulants, weight loss, and smoking.

Chapter 45: Anatomy & Physiology Review

1. When preparing for sleep, people close their eyes, place themselves into a relaxing position, turn out the lights, and so on. This decreases the amount of sensory stimuli to the RAS, which, in turn, relays few stimuli to the cerebral cortex, which promotes sleep. 2. The sensory stimuli (auditory from the noise of the alarm clock and light in the room) activate the RAS, which sends stimuli to the cerebral cortex and causes wakefulness. 3. Brainstem (location of reticular formation and RAS), cerebral cortex (an intact cerebral cortex is necessary for the regulation of sleep and waking states), and the hypothalamus. Injury to the hypothalamus may cause a person to sleep for abnormally long periods.

Chapter 46: Critical Thinking Possibilities

1. There are subjective data (rating her pain as 5) and objective data (vital signs, position, holding abdomen, lying in rigid position) to support that Mrs. Lundahl is experiencing pain; however, no conclusions can be drawn about the intensity, location, quality, or pattern of Mrs. Lundahl’s pain. 2. It would be incorrect to assume that Mrs. Lundahl needs no interventions for her pain. People rate their pain differently based on their past pain experiences, their pain tolerance, their ethnic/cultural values, and so on. Mrs. Lundahl should be asked if she needs pain intervention.

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3. Mrs. Lundahl is most likely experiencing acute pain from her surgery. Depending on the amount of manipulation of bowel, blood vessels, and so on, within her abdomen, she may also be experiencing visceral pain. 4. Numerous interventions may be helpful, such as changing her body position, giving a back massage, or providing a distraction (e.g., soft music). 5. The most reliable method of determining that Mrs. Lundahl’s pain has been relieved is for her to tell you that her pain has been relieved. Objective data may include decreased pulse, blood pressure, and respirations when compared to preintervention values; Mrs. Lundahl resting quietly or sleeping; pink color; absence of nausea or perspiration; and relaxed facial expression.

Chapter 46: Critical Thinking Possibilities

1. Obtaining information regarding factors that affect a person’s pain experience. For example, previous hospitalizations, previous pain experiences, cultural values regarding pain, support people, effect of the environment, and anxiety and stress levels. 2. Consider ATC analgesia the first few days postoperatively. Make his pain assessment the fifth vital sign—assess each time you take vital signs. Assess his sense of control over his pain management. 3. Breakthrough pain even with ATC, and Mr. C. needing to have more of a sense of control over his pain management.

Chapter 47: Critical Thinking Possibilities

1. Being a woman means that her distribution of fat is generally higher than a man’s. At age 59, she is beginning to enter the age range when the body configuration changes somewhat, fewer calories are needed to maintain weight, but nutrients are still very important. Being alone contributes to poor eating habits since meals are often a social event. We do not know her ethnicity but this can influence her view of nutrition and weight. 2. What were her eating patterns before her husband died? What foods does she like and dislike most? What kinds of snacks is she eating? Does she have the financial means to buy food? Does her living situation allow her to make and store food? 3. Suggestions may be many, such as keeping busy with her hands while watching TV (e.g., folding laundry), choosing healthy snacks like ­carrot and celery sticks, and not buying snacks at the store. 4. Although there are many ways to determine her ideal weight from tables, charts, and calculators, her best weight is influenced by many other factors that are difficult to include in these (specific activity level, BMR, body configuration). Since she states she formerly was “petite,” she may wish to return to this state—as much as is possible as she ages. It is important that the nurse not tell her a specific weight that she should achieve. Goal setting must be collaborative.

Chapter 47: Anatomy & Physiology Review

1. Salivary glands secrete enzymes that begin the digestion of carbohydrates. 2. If the pyloric sphincter is obstructed, food cannot move from the stomach into the small intestine. 3. If the gallbladder has been removed, bile is not stored, although it is still made by the liver. The client may have difficulty digesting fats. 4. If the colon is removed, most of the water and many minerals will not be reabsorbed from the chyme into the body. What is eliminated from the small intestine will be very liquid and still contain many enzymes.

Chapter 48: Critical Thinking Possibilities

1. Urinary frequency could be a sign of infection due to causes other than prostate hypertrophy. No other data are given about his other health problems including medications that might be contributing factors. A thorough assessment is indicated. 2. The nurse needs to ensure that the client completely understands the proposed and intended outcomes. There is always a balance between

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Answers the expected positive result and the risk of the intervention. Is this surgery considered culturally appropriate? Although you may not know a great deal about the actual surgery, you realize that not every procedure is completely successful. How would the client react if he continued to have some incontinence following the operation? 3. Often, a medical standard of care is followed unless there are contraindications. If the physician determines that the hypertrophy is severe, and knows that this is not a reversible condition, surgery may be the only logical option. Investigate what other treatments may be used in this situation and propose why they may be seen as less desirable than surgery. 4. The nurse should fully explore the client’s understanding of his condition and what measures can be taken to diminish impact on his ADLs and quality of life if the client truly understands and makes this ­informed choice. It is the nurse’s responsibility to support the client.

Chapter 48: Anatomy & Physiology Review

1. Yes. They are under voluntary control and they are just like any other muscles. Exercise can strengthen them. 2. Urine can leak from the bladder when the pelvic floor muscles are weak. The pelvic floor muscles help control the external urethral sphincter, which closes the urethra to prevent leakage. Exercise can strengthen the pelvic muscles and decrease bladder control problems. See the Managing Urinary Incontinence section in this chapter.

Chapter 49: Critical Thinking Possibilities

1. Ask her about the number and amount of stool she has in order to determine if she is actually having diarrhea or has an impaction. Assess her usual diet, daily fluid intake, amount of fiber in the diet, daily activities, medications, or other factors that could be contributing to constipation and possible impaction. 2. A digital examination may be performed to verify or rule out the presence of a fecal impaction. Other interventions may include administering an oil retention enema followed by a cleansing enema, suppositories, or stool softeners. If all else fails, manual removal of the fecal impaction may be necessary. 3. Consider interventions to promote regular defecation such as increasing intake of fluids, maintaining a regular schedule for defecation, paying attention to the urge to defecate, encouraging warm liquids with breakfast to stimulate the gastrocolic reflex, and so on. To add more fiber to the diet, teach the client about foods that are high in fiber; go through her kitchen with her pointing out what foods qualify. Suggest she interface with others in her complex to plan good menus, eat together, and so on. Also consider referral to physical therapy or other resources to increase activity appropriate for older adults, such as water exercises. 4. The chronic use of laxatives will actually make her more prone to constipation and impaction because she loses muscle tone. Increased intake of fiber, fruits, and vegetables and other ways of naturally dealing with constipation are safer and more appropriate.

Chapter 49: Anatomy & Physiology Review

1. The primary functions of the small intestine are the chemical breakdown of food (digestion) and the absorption of digested foods. 2. The primary functions of the large intestine are absorbing water from indigestible food residue and eliminating the residue in the form of feces. 3. Ileum. The ileocecal valve is between the ileum and the beginning of the large intestine. 4. The stool would be liquid because it has not entered the large intestine and the water has not been reabsorbed. 5. The transverse colostomy would discharge mushy, paste-like stool. The descending colostomy would have semisolid feces because more water has been reabsorbed. 6. Solid, formed feces.

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Chapter 50: Critical Thinking Possibilities

1. The physical assessment reveals fever, use of accessory muscles, adventitious lung sounds, and yellow sputum, all of which suggest more than an average cold. The nurse certainly would have suspected a more significant underlying condition. 2. Ms. Singh has quite a stressful lifestyle with work and school plus her physical stressors of a poor diet and smoking for more than 20 years. The nurse should perform discharge teaching that includes examination of which of these modifiable risk factors may be addressed in both short- and long-term plans. 3. Alteration in mental status may be a very useful sign that the client is hypoxic. Also, increased respiratory and cardiac rates and substantial shortness of breath would be negative signs. If not already in place, continuous oxygen saturation monitoring should be initiated. Frequent assessments and notification of the primary care provider are required. The nurse should have nasotracheal suction equipment available. The client may require transfer to a higher acuity nursing station. 4. Standard precautions must always be in place. The nurse should be careful to glove whenever coming into direct contact with the client’s secretions. The nurse should also wear a mask if the client is unable to control her secretions and may cough or spit in the nurse’s face. 5. A face mask may be uncomfortable or cause the client to feel confined or claustrophobic. If she is not wearing it, it cannot help her. Discuss the face mask with her and determine why she is taking it off. Reassure her and provide measures to decrease her anxiety. If the mask cannot be modified to address these reasons, consider contacting the primary care provider for assistance (e.g., arranging for her to have oxygen by nasal cannula instead, with an appropriate change in the flow rate).

Chapter 50: Anatomy & Physiology Review

1. (a) Hairs in the nose filter the air as it enters and traps particles to prevent them from traveling to the lower respiratory tract; (b) the sneeze reflex clears nasal passages; (c) lymph tissue in the nasopharynx and oropharynx traps and destroys pathogens entering with the inhaled air; (d) the epiglottis closes when swallowing to prevent food particles from entering the lungs. 2. Defense mechanisms present in the lower respiratory tract include the thin layer of mucus (the “mucous blanket”) that traps pathogens. The cilia on the epithelial cells then “sweep” the foreign particles toward the throat. The cough reflex helps dislodge the mucus and foreign particles and propel them out. 3. Because the alveoli are filled with fluid, the gases (oxygen and carbon dioxide) cannot diffuse across the respiratory membrane. The client will have less oxygen in his blood and will experience symptoms of hypoxemia. One of the medical interventions will include administration of oxygen to increase the diffusion gradient from the alveoli so the oxygen molecules will diffuse faster, and hopefully improve oxygenation in the blood.

Chapter 51: Critical Thinking Possibilities

1. This client has decreased arterial circulation to her feet. When the tissues become ischemic, lactic acid builds up and causes the discomfort. The pain she describes is consistent with the medical condition of intermittent claudication. Risk factors for peripheral vascular disease include cigarette smoking, high fat intake, obesity, sedentary lifestyle, hypertension, and diabetes. 2. Ineffective Peripheral Tissue Perfusion and Activity Intolerance are two likely diagnoses. Of these two, activity intolerance may be of highest priority for the nurse since there is a greater likelihood of developing a nursing care plan that can substantially affect her desired level of function and quality of life. Desired outcomes and interventions for the Ineffective Peripheral Tissue Perfusion nursing diagnosis will focus on implementing the medical treatment plan and protection from injury. However, remember that for a care plan to be effective, the client must

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be an active participant in the process. Thus, the diagnoses of highest priority can only be suggested without her input. 3. The physiological impact of the plan must be weighed against the psychological impact—always a difficult thing to do. The nurse must explore the client’s response to the recommendation. If it is unacceptable to her, consider whether any compromises such as fewer visits or use of a wheelchair are more agreeable. 4. Support stockings help increase venous return. This client has impaired arterial circulation. If the stockings are tight, they could actually interfere with the flow of arterial blood to her extremities. She requires client teaching explaining the differences at a level she can comprehend.

Chapter 51: Anatomy & Physiology Review

1. Right side of the heart. 2. Exercise, hypervolemia, mitral valve regurgitation, or insufficiency. 3. It has a positive effect or outcome when it increases cardiac output. For example, during exercise there is an increase in venous return, which causes the heart to contract more forcefully, with the result that stroke volume and cardiac output increase to supply the body with needed oxygen and nutrients. 4. The increase in the “stretch” of the heart muscle increases the contractility of the heart but only to a certain point (Frank-Starling law of the heart). Once it reaches that point, contractility and cardiac output decrease. 5. Diuretics decrease circulating volume, which decreases preload (the volume returning to the heart). 6. The left ventricle. 7. High blood pressure (hypertension)—the left ventricle has to create a pressure above the client’s diastolic pressure to pump blood into the circulation. Arterial vasoconstriction—the left ventricle works harder

when it has to pump blood through narrowed vessels as opposed to wide or dilated vessels. 8. Decrease blood pressure (e.g., antihypertensives). Decrease peripheral resistance or vasoconstriction (e.g., vasodilators).

Chapter 52: Critical Thinking Possibilities

1. Suggestions may be many, such as finding a fluid that she likes or that helps her nausea, making sure fluids are served at the appropriate temperature, using a straw, and starting with small amounts. Administering an antiemetic medication as ordered may also help improve her oral intake. 2. Although there are many indicators of fluid balance, daily weights are an important way to provide more data about fluid. You can explain that a loss of 1 kg (2.2 lb) indicates a fluid loss of approximately 1 liter. It is an easy, quick way to get more information about fluid balance.

Chapter 52: Anatomy & Physiology Review

1. Respiratory problems such as pneumonia, atelectasis, narcotic overdose, and central nervous system depression due to anesthesia. 2. With shallow respirations, the CO2 is not eliminated by the lungs, which causes two results: an increase in PaCO2 and an increase in CO2 in the blood, which reacts with H2O to form carbonic acid, which ­increases the number of hydrogen ions causing a decrease in pH. 3. Respiratory acidosis. 4. Anxiety, fear, fever, respiratory infections. 5. The increase in respirations causes more carbon dioxide than normal to be exhaled. This results in a loss of CO2 in the blood causing a low PaCO2. Because of the low CO in the blood, the amount of carbonic acid in the blood is reduced, resulting in an increased pH. 6. Respiratory alkalosis.

Suggested Answers to End-of-Unit Meeting the Standards Questions Unit 1 Suggested Answers:

1. Megan is an adult so the nurse cannot share any health information with her mother unless Megan gives permission. 2. The nurse will explain that Megan is legally an adult and competent to make her own health care decisions and cannot be forced to comply. The nurse’s responsibility is to provide Megan with any information she needs to make an informed decision. Then Megan’s choice must be respected. 3. The nurse must prevent Megan from harm (right not to be harmed), ensure that she is adequately informed about her role in the research study (right to full disclosure), confirm that her decision to participate or not participate is her own and she has not been coerced (right to self-determination), and that her privacy is maintained (right to privacy). 4. The nurse needs to make sure that Megan is familiar with the details of data collection protocols to maintain the integrity of data collected and with all aspects of care delivery requirements under the study plan. 5. The nurse should conduct a review of research journals to determine assessment techniques that have been validated through research that was conducted in settings that are similar to the nurse’s own setting. This information should be taken to the standards and practice committee so they can update current facility policy.

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Unit 2 Suggested Answers:

1. Rhett’s situation has elements of more than one level of prevention but the nurse will most likely focus on the primary level because this emphasizes staying healthy and avoiding illness. He is already doing some of these things through his diet and exercise. He also has some secondary prevention in that he requires prescription medication for his cholesterol and blood pressure. 2. Community-based health resources for Rhett may include wellness classes sponsored by the HMO or public events offered by community health services and focused classes or support groups for individuals with diabetes or high blood pressure. You can also assist him in finding reputable web-based resources. 3. Visits from home care nurses are only appropriate for clients who are unable to care for themselves or not mobile enough to go to a health care facility. Neither is true for Rhett and that is a good thing! 4. Advantages of using technology to track his blood pressure include that the record will be easy to read and the data may be imported into a visual depiction such as a timeline or trend chart. The data can be sent and shared electronically with his primary care provider(s) or be uploaded into his personal health record. However, there is also a concern for privacy anytime personal data is sent electronically. Because Rhett uses computers extensively, if there is a way to share electronically, it may enhance his adherence to the regimen.

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Answers 5. There will be many situations in nursing in which the client is a rich source of knowledge even beyond that of the nurse. Admit your knowledge limits and express your openness to learning from the client. If you cannot answer his question, be certain that you clearly understand what he wants to know and then use critical-thinking strategies to find out the answers for him. Most policies are written to promote consistent achievement of goals and avoid pitfalls. However, situations vary over time and policies need to be reviewed and revised at regular intervals. Consider whether there is a way to meet the requirement for the signature with the modern forms of electronic validation. Use your employer’s administrative structure to determine who has responsibility for this policy and whether it can be modified. You should also consider how great an inconvenience the current policy is, and if it is a very important policy to change. Since there are so many policies, some will rank as higher priority than others.

Unit 3 Suggested Answers:

1. The orthopedist will perform a thorough history and physical examination as required for surgery. The nurse needs to focus assessment on baseline physiological parameters that will be reevaluated during the postoperative period, including a complete list of all current medications and possible allergies. In addition, the nurse gathers preoperative data to assist in the discharge plan areas of functional abilities, support systems, and psychological needs. Although no system would be inappropriate to assess, the nurse’s time with Benjamin will be limited and a systematic head-to-toe examination should provide adequate physical data. The admission history will be very useful in guiding the interview because it ensures that the nurse obtains information about the physical environment at home (e.g., stairs, safety issues such as carpeting and bathrooms); who will be available to help at home; whether his employment provides disability insurance, sick leave, and physical therapy coverage; fears and concerns about functioning; previous experience with surgery; and so on. 2. A risk diagnosis implies that the problem is not current but factors are present that could lead to the diagnosis if the nurse does not intervene. Using critical thinking, the nurse considers how to obtain information about Benjamin’s parenting responsibilities. We know that he is married but have no details regarding his spouse’s role. Who is the primary caretaker? Do both parents work? Although the nurse may expect certain gender roles, those may not exist in this family. The best source of this data is Benjamin himself although the nurse may also discuss caretaking of the children with the spouse if available. Once the data is obtained, the nurse clusters the cues, examines all the real and potential problems concurrently, and then writes the diagnoses. 3. The standardized care plan will contain an estimate of the degree of mobility expected at each time point in the recovery. Benjamin is a young, athletic man whose employment is likely to play a significant role in the family’s resources but this must be validated. Does he have sick leave benefits? How anxious is he to return to work? Since his job is primarily desk work, is it possible for him to work from home while in recovery? Does the 16-year-old child have a driver’s license that might make it possible for the child to assist with transportation or chores? Also, consider the possible impact of the surgery on Benjamin’s view of his role in the family. The plan may need to address ways he can continue to feel he is contributing.   Depending on whether Benjamin had a nursing admission record completed before surgery (sometimes clients arrive directly to the perioperative unit), the postoperative nurse may need to complete the initial assessment. Of course, vital signs, including pain assessment, must be recorded on the vital signs flow sheet, and medications must be recorded on the medication administration record. If he is

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receiving intravenous fluids or medications, there will be an IV record. ­Postoperative clients may have intake and output measured and recorded to ensure they are taking adequate fluids (once permitted to do so following anesthesia) and their urine output is sufficient (through voiding or a catheter). He may also have special sheets for wound and skin assessment. The nurse’s notes page is where you would record assessments, care, and client responses that cannot be written in the other documents described. A method such as SOAP or SOAPIER is used to help ensure that the nurse has included all relevant information. In all cases, the nurse uses only proper terminology and accepted/ approved abbreviations.

Unit 4 Suggested Answers:

1. Appropriate outcomes for Manuela might focus on maintaining her current level of mobility so she is able to use her computer, go out to desired events, and socialize. In addition, although some of her functional limitations cannot be reversed, it would be appropriate to create expected outcomes that prevent or delay additional complications such as skin breakdown or infection. 2. The nurse creates expected outcomes and goals based on knowledge of both the physiological and psychological condition of the client. It would be inappropriate to set outcomes without knowing how Manuela sees her level of wellness and ability to influence her health status. 3. Manuela is at risk for further joint and pulmonary complications. Her physical environment needs to be examined and modified if necessary so it is protective and does not increase risk. She needs to be able to reach emergency help should she need it. Her family and friends should be incorporated into the plan. We need to know if she is currently living alone so that teaching includes not only Manuela, but also any roommates. 4. Other than physicians and nurses, Manuela’s health care team should include social services personnel to assist her with disability and financial issues. If she wishes, a clergy of her faith or spiritual counselor should be considered. She may also benefit from physical and occupational therapy. If her condition worsens, home health assistance and hospice personnel should be involved. 5. Since Manuela’s condition is chronic and progressive, her treatment is symptom focused. At the minimum, the nurse should consider evidence supporting the use of nonpharmacologic pain methodologies and stress-reduction techniques.

Unit 5 Suggested Answers:

1. The 19-year-old is a young adult and sleeping on the couch may impact his quality of sleep, interfering with the task of committing to work and relationships. The 15-year-old is an adolescent who is likely to have a strong need to fit in with others in his age range. Therefore, he may be embarrassed to bring friends to his home or be seen with his grandmother. The 10-year-old school-age child is seeking to develop senses of competence and perseverance, which could be encouraged if the child finds satisfaction in helping the grandmother meet daily needs. The 5-year-old is in the phase of initiative versus guilt, and must be carefully assessed to determine if the child is potentially feeling it is his or her fault that grandmother is sick. The 2-year-old is seeking to develop autonomy versus shame and doubt, but may develop too much autonomy leading to dangerous situations as a result of the mother being so busy caring for the client. 2. The family is likely to be experiencing high levels of stress, which will increase susceptibility to illness. The high level of stress felt by Mrs. Chavez’ daughter is likely to impact her parenting skills, especially because she is sleep deprived due to staying up all night caring for her mother.

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3. Respite care, the importance of spending quality time together, use of day care facilities, the need for proper sleep and nutrition, and stress management strategies are all important teaching measures that the nurse can provide for this family. 4. Each family member can provide some level of care or distraction that would allow the client’s daughter more time to meet her own needs. The 2-year-old can sing to her grandmother, which is often very calming and pleasant for older adults diagnosed with Alzheimer’s disease. It will also allow the child to express herself and develop self-esteem. The 5-year-old can be reassured that the grandmother’s illness is not the result of magical thinking. The school-age child can read to the grandmother, which will improve the child’s senses of competence and perseverance and also help the child develop language skills. The adolescent can be helped to understand that illness is not shameful and can use the experience to actualize the child’s own abilities and clarify strengths. The young adult can be encouraged to commit to a helping relationship, which will help to avoid the risk of isolation. 5. Alzheimer’s disease will cause regression of behavior to that of a much younger person, making achievement of the normal tasks of maturity impossible for Mrs. Chavez.

Unit 6 Suggested Answers:

1. The nurse shows compassion by recognizing the impact of Michael’s illness on Michael, his wife, and others who love him. The nurse shows competence by providing the best care to maintain Michael’s comfort while promoting communication between Michael and his wife. The nurse shows confidence by openly communicating with the couple in order to foster a trusting relationship, answering questions honestly while promoting hope. The nurse demonstrates conscience by following the nursing code of ethics in the delivery of client care and taking care of herself or himself in order to maintain good physical health. The nurse shows commitment by recognizing obligations to the client and his wife and acting in accordance. The nurse shows comportment by maintaining the client as the center for all nursing actions, behaving professionally in all interactions with Michael and his wife. 2. Sitting with Michael and/or his wife, listening attentively to them, gentle and caring touch, maintaining a facial expression that demonstrates interest and concern, gestures such as nodding in agreement, and being physically present are all means the nurse can use to demonstrate caring. 3. Readiness to learn is the demonstration of behaviors or cues that reflect the learner’s motivation and ability to learn at a specific time. Statements by Michael’s wife such as “He is so weak. It can’t be much longer now” or “I’m worried about what his final minutes will be like” or other statements regarding Michael’s imminent death indicate she is ready to hear more about what the final moments and his death will be like. Once readiness to learn is assessed, the nurse can begin to teach her what to expect. 4. The nurse can delegate tasks such as performance of activities of daily living including measuring vital signs, bathing, toileting, meeting hygiene needs, and comfort measures. Tasks requiring advanced knowledge and skills such as medication administration, assessment, sterile procedures, and complex tasks cannot be delegated to the UAP. 5. The UAP should be instructed to notify the nurse if the client is in pain, if anything unexpected occurs, or if the UAP notices anything abnormal. In this situation, the UAP should be instructed to notify the nurse if the client dies or is in any distress such as shortness of breath, bleeding, or change in level of consciousness. 6. The nurse should instruct the UAP on the importance of turning and repositioning, the discomfort the client will experience if a pressure ulcer develops, demonstrate positions to maintain client comfort, and answer any questions the UAP may have related to the procedure. The

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nurse should assess the UAP’s ability to perform this task and be sure to speak with the UAP privately to avoid embarrassment.

Unit 7 Suggested Answers:

1. One of the very first things you need to consider is how the reported temperature fits with the other vital signs and with the client’s previously reported temperature. How does the client feel and are there other signs of fever such as diaphoresis, chills, and skin color changes? If the other assessments do not seem to fit someone with a high fever, recheck the temperature yourself or have the assistant take it with another thermometer. If the temperature is accurate, what does it mean? Is the temperature higher or lower than it has been previously? What, if any, treatments for fever has the client received or have ordered? Some chemotherapy agents are known to cause a high fever. If this is the case, the primary care provider might not need to be notified since there would already be a care plan and orders to respond to this anticipated effect. 2. There is no indication that the assistant should not have been expected to be able to measure vital signs on this client accurately. However, once you determine the answers to the questions in item 1, you should discuss the situation with the assistant and see if there are any “lessons learned” that should be shared. For example, would you expect that the assistant would already have double-checked the high temperature a few minutes later or with another thermometer or should she just have reported it to you immediately? If there are any indications that the assistant did not perform the assessment correctly, you would want to follow up, determine the reasons, and develop a plan to correct the deficiency. 3. In this situation, one previous nurse reported findings inconsistent with your current assessment. It is unusual for a hospitalized client with COPD to have normal breath sounds throughout the lung fields. Thus, you might wish to have another nurse auscultate the client’s lungs to validate your findings. And, it certainly is expected that each nurse caring for the client will assess and record findings related to lung sounds. It would be important to communicate both previous shift nurses’ actions to the nurse in charge with the intent of improving practice. Possibly the one nurse could benefit from a review of lung sounds and assessment techniques, and the night shift nurse must be reminded to record assessments. Beyond this situation, what systems are in place to support nurses’ ongoing competencies in assessment and safeguards to ensure that needed assessments are recorded in the chart? This example is an opportunity for quality improvement. 4. Each nurse must perform self-assessment on a regular basis and participate in performance appraisal according to the employer’s standards. As in item 3, you may ask another nurse to check the client’s pedal pulses. This is important primarily for the client and secondarily for your skill assessment. If you have previously had difficulty palpating pedal pulses, you would want to work with a colleague to enhance your skill. Do you have difficulty in all situations or possibly only when there is edema, or when the pulses are faint?   Sometimes it is embarrassing to admit that you are unable to complete an expected nursing responsibility, whether it is feeling a pulse, performing venipuncture, or inserting a catheter. It can be even more difficult if you must report that you have made an error. However, selfevaluation and peer evaluation of practice are essential components of a career focused on personal growth, client safety, and quality care.

Unit 8 Suggested Answers

1. Important data to obtain includes the types of products she normally uses, cultural beliefs related to the need for same sex caregivers, normal bathing frequency, ability to function using her nondominant left hand

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Answers to determine the amount of assistance required, desire to have friends bring her own products for use in the hospital, and understanding of normal hospital routine related to hygiene (i.e., am care, pm care) and any preferences she may have. 2. Vital signs will serve as baseline data, appearance of the pin insertion site in her fractured leg, appearance and size of laceration on her fractured arm, color and temperature of fingers on casted hand and left foot, appearance and presence of any alterations in skin integrity, and amount of weight applied to traction. All of this information will serve as a baseline for comparison as the nurse assesses wound healing and recovery from injuries. 3. Priority assessments include vital signs to ensure that respirations are adequate to meet oxygen needs, airway is clear, and circulation is adequate to perfuse the tissues. Assessment of perfusion in the casted arm and fractured leg is also a priority assessment. Other important assessment data includes pain level, level of consciousness, and data related to safety such as proper body alignment, side rails up, bed in the low position, weights hanging freely off the floor, and elevation of casted arm to reduce risk of edema. 4. Likely nursing diagnoses for Fairuz include Acute Pain, Risk of Infection related to immobility secondary to traction, Impaired Comfort, Risk for Constipation, Risk for Disuse Syndrome, Impaired Mobility secondary to required bedrest, Ineffective Role Performance secondary to prolonged hospitalization and recovery period, BathingSelf-Care Deficit, Toileting Self-Care Deficit, Impaired Skin Integrity, and Social Isolation.   The client with a fracture will be likely to receive narcotic analgesics to manage pain. These medications can impair breathing pattern, cause sedation resulting in reduced mobility and deep breathing, and must be assessed to determine their effectiveness in controlling pain. Traction limits the client’s ability to move because the left leg is immobilized. The client must make a conscious effort to reposition frequently, employ deep breathing and coughing exercises, and exercise other muscles such as arms and the right leg to avoid muscle atrophy.

Unit 9 Suggested Answers:

1. Christina’s statements are the type common to individuals who are anxious and under stress. She has a somewhat fatalistic perspective and is seeking a cause for her cancer, which will most likely never be found. In this unit, you have learned strategies for helping her explore her concerns and putting them into perspective with her belief systems. Even if you believe that none of the three causes she mentions is a realistic one, you must respond in a respectful manner and not belittle her. You have an opportunity to assist her in identifying her strengths and resources, plus exploring a variety of coping strategies. 2. Many individuals wonder if external exposure to things like chemicals in personal care products or environmental conditions such as highvoltage wires can cause cancer. Considering the competencies for this standard, you would want to explore sources of evidence-based information to help answer the reality of such health risks. Beyond the evidence, there are her personal values and nurses know that values have a strong influence on health and health behaviors. Might Christina and her husband seriously consider moving their home away from the wires? If so, how might this worsen or alleviate her stress and feelings of loss? What other things might she do to make her feel safe and in control around her home?

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3. Although you may have personal views of attractiveness, body image, and marital relationships at her age, first you must respond to Christina in a way that acknowledges the validity of her feelings and your openness to hearing her. These responses honor her with respect and dignity. When a client expresses concerns and the nurse cannot fully implement and evaluate the care plan, it is essential that the nurse initiate a plan that can be shared with other health care team members. In this case, you should document Christina’s concern and ensure that this documentation is received by the primary care provider, social worker, clergy, and any other appropriate members of the team. 4. The nurse is never the sole member of the health care team. Depending on the structure of your work setting, there may be other nurses who specialize in cancer care such as clinical specialists and nurse practitioners. These nurses would be extremely knowledgeable about the physical effects of cancer and its treatment. Other colleagues with specialized knowledge include the medical oncologist, surgical oncologist, radiation therapist, sex therapist, social services personnel, psychologist, and clergy. You may also investigate local chapters of professional organizations with a cancer focus such as the American Cancer Society, Komen Foundation, or Oncology Nurses Society.

Unit 10 Suggested Answers:

1. Expected outcomes may include: • Activity and exercise: Agnes will regain the ability to ambulate independently within 2 months. • Pain management: Agnes will report pain or discomfort to the nurse when her pain tolerance is exceeded and she will maintain comfort and report a pain level less than 3 within 24 hours postoperatively. • Fecal elimination: Agnes will maintain normal fecal elimination based on her prior bowel elimination habits. • Circulation: Agnes will avoid development of a thrombus until returning to normal activity patterns. 2. Risks faced by Agnes include those related to immobility such as pneumonia, thrombophlebitis, muscle atrophy, and muscle weakness. Her sleep may be disturbed by hospital routine and pain. Nutrition must be monitored to assure she has adequate intake of nutrients to promote healing while reducing calorie intake secondary to immobility. Airway clearance must be carefully monitored in the immediate postoperative period and then coughing and deep breathing encouraged to reduce the risk of pneumonia. 3. Priorities of care will follow the ABC’s including airway, breathing, and circulation followed by pain management, and monitoring of fluid, electrolyte and acid-base balance. Of importance, but lower in priority, are elimination, nutrition, sleep, and activity. 4. Based on Agnes’s current condition, the greatest risk to her independence is related to activity and exercise, because if she is unable to regain mobility it will impact both her independence and her quality of life. Certainly, if a threat arises to airway, breathing, and circulation, these would be of highest priority, but in her current health status these considerations do not present a problem. 5. The nurse can promote independence by encouraging Agnes to do as much for herself as possible, and motivate her to attend physical therapy and follow the exercise regimen developed by the health care team caring for her.

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Glossary 24-hour food recall  client recall of all the food and beverages consumed during a typical 24-hour period Abdominal paracentesis  a procedure to obtain a specimen of ascetic fluid for laboratory study and to relieve pressure on the abdominal organs due to the presence of excess fluid Absorption  the process by which a drug passes into the bloodstream Accommodation  a process of change whereby cognitive processes mature sufficiently to allow a person to solve problems that were previously unsolvable Accountability  the ability and willingness to assume responsibility for one’s actions and to accept the consequences of one’s behavior Acculturation  the involuntary process that occurs when people adapt to or borrow traits from another culture Acid  a substance that releases hydrogen ions (H+) in solution Acidosis  a condition that occurs with increases in blood carbonic acid or with decreases in blood bicarbonate; blood pH below 7.35 Acquired immunity  see Passive immunity Action stage  occurs when a person actively implements behavioral and cognitive strategies to interrupt previous behavior patterns and adopt new ones; this stage requires a great commitment of time and energy Active euthanasia  actions that directly bring about the client’s death with or without consent Active immunity  a resistance of the body to infection in which the host produces its own antibodies in response to natural or artificial antigens Active range-of-motion exercises  Isotonic exercises in which the client independently moves each joint in the body through its complete range of movement, maximally stretching all muscle groups within each plane, over the joint Active transport  movement of substances across cell membranes against the concentration gradient Activity theory  the best way to age is to stay active physically and mentally Activity tolerance  the type and amount of exercise or daily activities an individual is able to perform Activity-exercise pattern  refers to a person’s pattern of exercise, activity, leisure, and recreation Actual loss  can be identified by others and can arise either in response to or in anticipation of a situation Acupressure  a technique that uses the fingers to apply pressure to specific points along meridians throughout the body Acupuncture  a form of healing in which the therapist applies needles to stimulate specific sites of the body Acute confusion  abrupt onset of confusion that has a reversible cause; also called delirium Acute illness  typically characterized by severe symptoms of relatively short duration Acute infection  those that generally appear suddenly or last a short time Acute pain  pain that lasts only through the expected recovery period (as opposed to chronic) Adaptation  the process of modifying to meet new, changing, or different conditions Adaptive mechanism  learned behaviors that assist an individual to adjust to the environment Adherence  the extent to which an individual’s behavior (for example, taking medications, following diets, or making lifestyle changes) coincides with medical or health advice; commitment or attachment to a regimen

Adolescence  the period during which a person becomes physically and psychologically mature and acquires a personal identity Adolescent growth spurt  the period during puberty when sudden and dramatic physical changes occur Adult day care  a day care center that provides health and social services to older adults Advance health care directive  a variety of legal and lay documents that allow individuals to specify aspects of care they wish to receive should they become unable to make or communicate their preferences Adventitious breath sounds  abnormal breath sounds that occur when air passes through narrowed airways or airways filled with fluid or mucus, or when pleural linings are inflamed Adverse effects  severe side effects that may justify the discontinuation of a drug Advocate  individual who pleads the cause of another or argues or pleads for a cause or proposal Aerobic  growing only in the presence of oxygen Aerobic exercise  any activity during which the body takes in more or an equal amount of oxygen than it expends Aesthetic knowing  providing care and meeting the needs of clients through creativity and style Afebrile  absence of a fever Affective domain  known as the “feeling” domain and is divided into categories that specify the degree of a person’s depth of emotional response to tasks; includes feelings, emotions, interests, attitudes, and appreciations Afterload  the resistance against which the heart must pump to eject blood into the circulation Ageism  deep and profound prejudice in American society against older adults Agglutinins  specific antibodies formed in the blood Agglutinogens  a substance that acts as an antigen and stimulates the production of agglutinins Agnostic  a person who doubts the existence of God or a supreme being or believes the existence of God has not been proved Agonist  a drug that interacts with a receptor to produce a response Agonist analgesic  pure opioid drugs that bind slightly to mu receptor sites, producing maximum pain inhibition (morphine, oxycodone, hydromorphone) Agonist–antagonist analgesic  a drug that can act like opioids and relieve pain (agonist effect) when given to a client who has not taken any pure opioids Airborne precautions  used for clients known to have or suspected of having serious illnesses transmitted by airborne droplet nuclei smaller than 5 microns Alarm reaction  the initial reaction of the body to stress, which alerts the body’s defenses Algor mortis  the gradual decrease of the body’s temperature after death Alkalosis  a condition that occurs with increases in blood bicarbonate or decreases in blood carbonic acid; blood pH above 7.45 Allodynia  when nonpainful stimuli (e.g., contact with linen, water, or wind) produce pain Allopathic medicine  term used to describe Western medical practice Alopecia  the loss of scalp hair (baldness) or body hair

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Alternative medicine  an unrelated group of nonorthodox practices, often with explanatory systems that do not follow conventional biomedical explanations Alzheimer’s disease  disease that involves progressive dementia, memory loss, and inability to care for self Amblyopia  reduced visual acuity in one eye Ambulation  the act of walking Ampule  a glass container usually designed to hold a single dose of a drug Anabolism  a process in which simple substances are converted by the body’s cells into more complex substances (e.g., building tissue, positive nitrogen balance) Anaerobic  growing only in the absence of oxygen Anaerobic exercise  involves activity in which the muscles cannot draw out enough oxygen from the bloodstream; used in endurance training Anal stimulation  stimulation applied to anus for sexual pleasure Anaphylactic reaction  a severe allergic reaction that usually occurs immediately after the administration of a drug Andragogy  the art and science of helping adults learn Androgyny  belief that most characteristics and behaviors are human qualities and not limited to a gender Anemia  a condition in which the blood is deficient in red blood cells or hemoglobin Anger  an emotional state consisting of a subjective feeling of animosity or strong displeasure Angiography  a diagnostic procedure enabling x-ray visual examination of the vascular system after injection of a radiopaque dye Angle of Louis  the junction between the body of the sternum and the manubrium; the starting point for locating the ribs anteriorly Animal-assisted therapy  the use of specifically selected animals as a treatment modality in health and human service settings Anions  ions that carry a negative charge; includes chlorine (Cl–), bicarbonate (HCO3–), phosphate (HPO42–), and sulfate (SO4–) Ankylosed  permanently immobile joints Anorexia  loss of appetite Anorexia nervosa  a disease characterized by a prolonged inability or refusal to eat, rapid weight loss, and emaciation in individuals who continue to believe they are fat Anoscopy  visual examination of the anal canal using an anoscope (a lighted instrument) Answer  (legal) a written response made by a defendant Antagonist  drug that inhibits cell function by occupying the drug’s receptor sites Antibodies  part of the body’s plasma proteins, that defend primarily against the extracellular phases of bacterial and viral infections; also called immunoglobulins Anticipatory grief  grief experienced in advance of an event Anticipatory loss  the experience of loss before the loss actually occurs Antigen  a substance capable of inducing the formation of antibodies Antihelix  the anterior curve of the auricle’s upper aspect Antiseptic  an agent that inhibits the growth of some microorganisms Anuria  the failure of the kidneys to produce urine, resulting in a total lack of urination or output of less than 100 mL/day in an adult Anxiety  a state of mental uneasiness, apprehension, or dread producing an increased level of arousal caused by an impending or anticipated threat to self or significant relationships Apgar scoring system  a scoring system to assess newborn babies Aphasia  any defects in or loss of the power to express oneself by speech, writing, or signs, or to comprehend spoken or written language due to disease or injury of the cerebral cortex Apical pulse  a central pulse located at the apex of the heart

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Apical–radial pulse  measurement of the apical and radial pulse simultaneously Apnea  a complete absence of respirations Apocrine glands  sweat glands located largely in the axillae and anogenital areas; they begin to function at puberty under the influence of androgens Approximated  closed tissue surfaces Aromatherapy  therapeutic use of essential oils of plants in which odor or fragrance plays an important part Arrhythmia  an irregular heart rhythm Arterial blood gases  specimen of arterial blood that assesses oxygenation, ventilation, and acid–base status Arterial blood pressure  the measure of the pressure exerted by the blood as it pulsates through the arteries Arteriosclerosis  a condition in which the elastic and muscular tissues of the arteries are replaced with fibrous tissue Ascites  a large amount of fluid accumulation in the abdominal cavity Asepsis  freedom from infection or infectious material Asphyxiation  lack of oxygen due to interrupted breathing Aspiration  withdrawal of fluid that has abnormally collected (e.g., pleural cavity, abdominal cavity) or to obtain a specimen (e.g., cerebrospinal fluid) Assault  an attempt or threat to touch another person unjustifiably Assessing  the process of collecting, organizing, validating, and recording data (information) about a client’s health status Assimilation  the process by which an individual develops a new cultural identity and becomes like the members of the dominant culture Assisted living  facility with various degrees of personal care assistance designed to meet the needs of an older person Assisted suicide  a form of active euthanasia in which clients are given the means to kill themselves Astigmatism  an uneven curvature of the cornea that prevents horizontal and vertical light rays from focusing on the retina Atelectasis  collapse of the air sacs Atheist  one who denies the existence of God Atherosclerosis  buildup of fatty plaque within the arteries Atria  two upper hollow chambers of the heart Atrioventricular (AV) node  conduction pathways that slightly delay transmission of the impulse from the atria to the ventricles of the heart Atrioventricular (AV) valves  between the atria and ventricles of the heart, the tricuspid valve on the right and the bicuspid or mitral valve on the left Atrophy  wasting away; decrease in size of organ or tissue (e.g., muscle) Attentive listening  listening actively, using all senses, as opposed to listening passively with just the ear Attitudes  mental stance that is composed of many different beliefs; usually involving a positive or negative judgment toward a person, object, or idea Audit  examination or review of records Auditory  related to or experienced through hearing Auricle  flap of the ear; also called pinna Auscultation  the process of listening to sounds produced within the body, such as with the use of a stethoscope that amplifies sounds and conveys them to the nurse’s ears Auscultatory gap  the temporary disappearance of sounds normally heard over the brachial artery when the sphygmomanometer cuff pressure is high, followed by the reappearance of sounds at a lower level Authoritarian leader  the individual who makes decisions for the group Authority  the power given by an organization to direct the work of others; the right to act Autoantigen  an antigen that originates in a person’s own body

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Glossary Autocratic leader  see Authoritarian leader Automaticity  an electrical impulse and contraction independent of the nervous system and generated by the cardiac muscle Autonomy  the state of being independent and self-directed, without outside control, to make one’s own decisions Autopsy  an examination of the body after death to determine the cause of death and to learn more about a disease process; also called postmortem examination Awareness  the ability to perceive environmental stimuli and body reactions and to respond appropriately through thought and action Ayurveda  Indian system of medicine where illness is viewed as a state of imbalance among the body’s systems Baby boomers  generation that includes those born in years 1945–1964 Bacteremia  bacteria in the blood Bacteria  the most common infection-causing microorganisms Bactericidal  bacteria-killing action Balance  a state of equilibrium in which opposing forces counteract each other Bandage  a strip of cloth used to wrap some part of the body Basal metabolic rate (BMR)  the rate of energy utilization in the body required to maintain essential activities such as breathing Base of support  the foundation on which an object rests Bases  (alkalis) have low hydrogen ion concentration and can accept hydrogen ions in solution Battery  (legal) the willful or negligent touching of a person (or the person’s clothes or even something the person is carrying), which may or may not cause harm Bed rest  strict confinement to bed (complete bed rest), or the client may be allowed to use a bedside commode or have bathroom privileges Bedpan  a receptacle for urine and feces Behaviorist theory  includes the careful identification of what is to be taught and the immediate identification of and reward for correct responses Beliefs  interpretations or conclusions that one accepts as true Beneficence  the moral obligation to do good or to implement actions that benefit clients and their support people Bereavement  a subjective response of a person who has experienced the loss of a significant other through death Bevel  the slanted part at the tip of a needle Bicultural  used to describe a person who crosses two cultures, lifestyles, and sets of values Bier block  see Intravenous block Binder  a type of bandage applied to large body areas (abdomen or chest) that are designed for a specific body part (e.g., arm sling); used to provide support Bioelectromagnetics  science that studies how living organisms interact with electromagnetic fields Bioethics  ethical rules or principles that govern right conduct concerning life Biofeedback  a stress management technique that brings under conscious control bodily processes normally thought to be beyond voluntary command Biomedical health belief  see Scientific health belief Biomedicine  term used to describe Western medical practice Biopsy  removal and examination of tissue Biorhythms  inner rhythms that appear to control a variety of biologic processes Bioterrorism  intentional attack using biologic weapons such as viruses, bacteria, or other germs Biotransformation  process by which a drug is converted to a less active form; also called detoxification Biot’s respirations  shallow breaths interrupted by apnea

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Bladder training  client postpones voiding, resists or inhibits the sensation of urgency, and voids according to a timetable rather than according to the urge to void Blanch test  a test during which the client’s fingertip is temporarily pinched to assess capillary refill and peripheral circulation Blood chemistry  a number of tests performed on blood serum (the liquid portion of the blood) Blood pressure (BP)  the force exerted on arterial walls by blood flowing within the vessel Blood urea nitrogen (BUN)  a measure of blood level of urea, the end product of protein metabolism Bloodborne pathogens  potentially infectious organisms that are carried in and transmitted through blood or materials containing blood Body image  how a person perceives the size, appearance, and functioning of his or her body and its parts Body mass index (BMI)  indicates whether weight is appropriate for height Body temperature  the balance between the heat produced by the body and the heat lost from the body Bodymind  a state of integration that includes body, mind, and spirit Boomerang kids  slang term used for young adults who move back into their parents’ homes after an initial period of independent living Bottle mouth syndrome  describes the decay of an infant’s teeth caused by constant contact with sweet liquid from a bottle Boundary  the real or imaginary lines that differentiate one system from another system or a system from its environment Bowel (fecal) incontinence  loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter Bradycardia  abnormally slow pulse rate, less than 60 beats per minute Bradypnea  abnormally slow respiratory rate, usually less than 10 respirations per minute Brand name  name of the drug given by the drug manufacturer; also called the trade name Breach of duty  a standard of care that is expected in the specific situation but that the nurse did not observe; this is the failure to act as a reasonable, prudent nurse under the circumstances Bronchoscopy  visual examination of the bronchi using a bronchoscope Bruit  a blowing or swishing sound created by turbulence of blood flow Buccal  a medication (e.g., a tablet) that is held in the mouth against the mucous membranes of the cheek until the drug dissolves Buffers  prevent excessive changes in pH by removing or releasing hydrogen ions Bulimia  an uncontrollable compulsion to eat large amounts of food and then expel it by self-induced vomiting or by taking laxatives Bundle of His  the right and left bundle branches of the ventricular conduction pathways Burden of proof  the duty of proving an assertion Bureaucratic leader  does not trust self or others to make decisions and instead relies on the organization’s rules, policies, and procedures to direct the group’s work efforts Burn  results from excessive exposure to thermal, chemical, electric, or radioactive agents Burnout  a complex syndrome of behaviors that can be likened to the exhaustion stage of the general adaptation syndrome; an overwhelming feeling that can lead to physical and emotional depletion, a negative attitude and self-concept, and feelings of helplessness and hopelessness Calculi  renal stones Callus  a thickened portion of the skin Caloric value  the amount of energy that nutrients or foods supply to the body Calorie (c, cal, kcal)  a unit of heat energy equivalent to the amount of heat required to raise the temperature of 1 kg of water 1°C

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Cancer pain  pain associated with cancers; can be related or unrelated to the disease or its treatment Cannula  a tube with a lumen (channel) that is inserted into a cavity or duct and is often fitted with a trocar during insertion for abdominal paracentesis; the part of the needle that is attached to the hub; also called a shaft Carbon monoxide  an odorless, colorless, tasteless gas that is very toxic Cardiac arrest  the cessation of heart function Cardiac output (CO)  the amount of blood ejected by the heart with each ventricular contraction Cardinal signs  see Vital signs Caregiver  a role that has traditionally included those activities that assist the client physically and psychologically Caregiver burden  responses to long-term stress, such as chronic fatigue, sleeping difficulties, and high blood pressure, in family members who undertake the care of a person in the home for a long period Caregiver role strain  physical, emotional, social, and financial burdens that can seriously jeopardize the caregiver’s own health and well-being Caries  tooth cavities Caring  intentional action that conveys physical and emotional security and genuine connectedness with another person or group of people Caring practice  nursing care that includes connection, mutual recognition, and involvement Carminative  an agent that promotes the passage of flatus from the colon Carrier  a person or animal that harbors a specific infectious agent and serves as a potential source of infection, yet does not manifest any clinical signs of disease Case management  a method for delivering nursing care in which the nurse is responsible for a caseload of clients across the health care continuum Case manager  a nurse who works with the multidisciplinary health care team to measure the effectiveness of the case management plan and monitor outcomes Catabolism  a process in which complex substances are broken down into simpler substances (e.g., breakdown of tissue) Cataract  an opacity of the eye lens or its capsule that blocks light rays Cathartics  drugs that induce defecation Cations  ions that carry a positive charge; includes sodium (Na+), potassium (K+), calcium (Ca2+), and magnesium (Mg2+) Causation  a fact that must be proven that the harm occurred as a direct result of the nurse’s failure to follow the standard of care and the nurse could have (or should have) known that failure to follow the standard of care could result in such harm Cell-mediated defenses  see Cellular immunity Cellular immunity  occurs through the T-cell system; also known as cell-mediated defenses Center of gravity  the point at which all of the mass (weight) of an object is centered Central neuropathic pain  pain that results from malfunctioning nerves in the central nervous system (e.g., spinal cord injury pain, poststroke pain, or multiple sclerosis) Central venous access device  defined by the location of the catheter tip in a central vein, in the lower one third of the superios vena cava, above the right atrium Central venous catheter  catheter that is usually inserted into the subclavian or jugular vein, with the distal tip of the catheter resting in the superior vena cava just above the right atrium Cephalocaudal  proceeding in the direction from head to toe Cerebral death  occurs when the cerebral cortex is irreversibly destroyed; also called higher brain death Cerumen earwax Change  process of making something different from what it was

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Change agents  individuals (or groups) who initiate change or who assist others in making modifications in themselves or in the system Change-of-shift report  a report given to nurses on the next shift Charismatic leader  characterized by an emotional relationship between the leader and the group members; personality of the leader evokes strong feelings of commitment to both the leader and the leader’s cause and beliefs Chart  a formal, legal document that provides evidence of a client’s care Charting  the process of making an entry on a client record Charting by exception (CBE)  a documentation system in which only significant findings or exceptions to norms are recorded Chemical name  the name by which a chemist knows a drug; describes the constituents of the drug precisely Chemical restraints  medications used to control socially disruptive behavior Cheyne-Stokes respirations  rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure, increased intracranial pressure, or brain damage Chiropractic  from the Greek meaning “done by hand”; involves adjustments of the spine and joints and is grounded in the assumption that maintaining the alignment of the spine and joints facilitates the flow of energy throughout the body, including the nervous, circulatory, respiratory, gastrointestinal, and limbic systems Cholesterol  a lipid that does not contain fatty acid but possesses many of the chemical and physical properties of other lipids Chronic illness  illness that lasts for an extended period of time, usually longer than 6 months Chronic infection  infection that occurs slowly, over a very long period, and may last months or years Chronic pain  prolonged pain, usually recurring or persisting over 6 months or longer, that interferes with functioning Chyme  contents of the colon Circulating immunity  see Humoral immunity Circulating nurse  coordinates activities and manages client care by continually assessing client safety, aseptic practice, and the environment (e.g., temperature, humidity, and lighting); with the scrub nurse, is responsible for accounting for all sponges, needles, and instruments at the close of surgery Civil action  deals with the relationship between individuals in society Civil law  the body of law that deals with relationships among private individuals; also known as private law Clara Barton  a schoolteacher who volunteered as a nurse during the Civil War. Most notably, she organized the American Red Cross, which linked with the International Red Cross when the U.S. Congress ratified the Geneva Convention in 1882 Clean  free of potentially infectious agents Clean voided specimen  urine specimens for routine urinalysis Clean-catch specimen  urine specimens for urine culture; also called midstream urine specimen Cleansing bath  a bath given for hygienic purposes Client  a person who engages the advice or services of another person who is qualified to provide this service Client record  see Chart Climacteric  the point in development when reproduction capacity in the female terminates (menopause) and the sexual activity of the male decreases (andropause) Clinical aromatherapy  the controlled use of essential oils for specific measurable outcomes Clinical judgment  decision-making process to ascertain the right nursing action to be implemented at the appropriate time in the client’s care

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Glossary Clinical reasoning  cognitive process that uses thinking strategies to gather, analyze, and evaluate the relevance of client information, and decide on possible nursing actions to improve the client’s physiological and psychosocial outcomes Closed awareness  a type of awareness in which the client is unaware of impending death Closed questions  restrictive question requiring only a short answer Closed suction system  a method for suctioning an endotracheal tube or tracheostomy in which the suction catheter, enclosed in a plastic sheath, attaches to the ventilator tubing, and the client does not need to be disconnected from the ventilator Closed wound drainage system  consists of a drain connected to either electric suction or a portable drainage suction Clubbing  elevation of the proximal aspect of the nail and softening of the nail bed Coanalgesic  a medication that is not classified as a pain medication but has properties that may reduce pain alone or in combination with other analgesics, relieve other discomforts, potentiate the effect of pain medication, or reduce the pain medication’s side effects Cochlea  a seashell-shaped structure found in the inner ear; essential for sound transmission and hearing Code blue  term used by an agency such as a hospital to indicate a medical emergency such as a cardiac or respiratory arrest Code of ethics  a formal statement of a group’s ideals and values; a set of ethical principles shared by members of a group, reflecting their moral judgments and serving as a standard for professional actions Cognitive development  refers to the manner in which people learn to think, reason, and use language Cognitive domain  the “thinking” domain, includes six intellectual abilities and thinking processes beginning with knowing, comprehending, and applying to analysis, synthesis, and evaluation Cognitive skills  intellectual skills that include problem solving, decision making, critical thinking, and creativity Cognitive theory  recognition of developmental levels of learners, and acknowledgments of the learner’s motivation and environment Coinsurance  an insurance plan in which the client pays a percentage of the payment and some other group (e.g., employer, government) pays the remaining percentage Collaboration  a collegial working relationship with another health care provider in the provision of client care Collaborative care plans  see Critical pathways Collaborative interventions  actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and physicians Collagen  a protein found in connective tissue; a whitish protein substance that adds tensile strength to a wound Colloid osmotic pressure  a pulling force exerted by colloids that help maintain the water content of blood; also called oncotic pressure Colloids  substances such as large protein molecules that do not readily dissolve into true solutions Colonization  the presence of organisms in body secretions or excretions in which strains of bacteria become resident flora but do not cause illness Colonoscopy  visual examination of the interior of the colon with a colonoscope Colostomy  a temporary or permanent opening into the colon (large bowel) to divert and drain fecal material Commode  a portable chair with a toilet seat and a receptacle underneath that can be emptied; often used for the adult client who is able to get out of bed but is unable to walk to the bathroom Common law  the body of principles that evolves from court decisions Communicable disease  a disease that can spread from one person to another

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Communication  a two-way process involving the sending and receiving of messages Communicator  a nurse identifies client problems and then communicates them verbally or in writing to other members of the health team Community  a collection of people who share some attribute of their lives Community health nursing  the synthesis of nursing and public health practice as applied to promoting and preserving the health of populations Community nursing centers (CNCs)  provide primary care to specific populations and are staffed by nurse practitioners and community health nurses Community-based health care (CBHC)  a system that provides health-related services within the context of people’s daily lives; that is, in places where people spend their time in the community Community-based nursing (CBN)  nursing care directed toward a specific population or group within the community; primary, secondary, or tertiary care may be provided to individuals or groups Compensation  defense mechanism in which a person substitutes an activity for one that he or she would prefer doing or cannot do Compensatory counterbalancing Complaint  (legal) a document filed by a plaintiff Complementary and alternative medicine (CAM)  those practices that do not form part of the dominant system for managing health and disease Complementary medicine  see Alternative medicine Complementary therapies  therapeutic practices that are not currently considered an integral part of conventional allopathic medical practice Complete blood count (CBC)  specimens of venous blood; includes hemoglobin and hematocrit measurements, erythrocyte (RBC) count, leukocyte (WBC) count, red blood cell indices, and a differential white cell count Complete proteins  a protein that contains all of the essential amino acids as well as many nonessential ones Compliance  the extent to which an individual’s behavior coincides with medical or health advice Complicated grief  pathologic grief; exists when coping strategies are maladaptive Compress  a moist gauze dressing applied frequently to an open wound, sometimes medicated Compromised host  any person at increased risk for an infection Computed tomography (CT)  a painless, noninvasive x-ray procedure that has the unique capability of distinguishing minor differences in the density of tissues Computer-based patient records (CPRs)  electronic client data retrievable by caregivers, administrators, accreditors, and other individuals who require the data Concept map  a visual tool in which ideas or data are enclosed in circles or boxes of some shape and relationships between these are indicated by connecting lines or arrows Concepts  abstract ideas or mental images of phenomena or reality Conceptual framework  a group of related concepts Conceptual model  a graphic illustration of the relationships among concepts Concurrent audit  evaluation of a client’s health care while the client is still receiving care from the agency Conduction  the transfer of heat from one molecule to another in direct contact Conductive hearing loss  the result of interrupted transmission of sound waves through the outer and middle ear structures Confidentiality  any information a subject relates will not be made public or available to others without the subject’s consent Congruent communication  occurs when the verbal and nonverbal aspects of the message match

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Conjunctivitis  inflammation of the bulbar and palpebral conjunctiva Conscious sedation  a minimal depression of level of consciousness during which the client retains the ability to consciously maintain a patent airway and respond appropriately to verbal and physical stimuli Consequence-based (teleological) theories  the ethics of judging whether an action is moral Constant fever  a state in which the body temperature fluctuates minimally but always remains above normal Constipation  passage of small, dry, hard stool or passage of no stool for a period of time Consultative leader  see Democratic leader Consumer  an individual, a group of people, or a community that uses a service or commodity Contact precautions  used for clients known or suspected to have serious illnesses easily transmitted by direct client contact or by contact with items in the client’s environment (GI, respiratory, skin or wound infections, etc.) Contemplation stage  stage in which a person acknowledges having a problem, seriously considers changing a specific behavior, actively gathers information, and verbalizes plans to change the behavior in the near future Continuing education (CE)  formalized experiences designed to enlarge the knowledge or skills of practitioners Continuity of care  the coordination of health care services by health care providers for clients moving from one health care setting to another and between and among health care professionals Continuity theory  people maintain their values, habits, and behavior in old age Contract  a written or verbal agreement between two or more people to do or not do some lawful act Contract law  the enforcement of agreements among private individuals or the payment of compensation for failure to fulfill the agreement Contractility  the inherent ability of cardiac muscle fibers to shorten or contract Contractual obligations  duty of care established by the presence of an expressed or implied contract Contractual relationships  vary among practice settings; may be as an independent or employer–employee relationship Contracture  permanent shortening of a muscle Convection  the dispersion of heat by air currents Conventional medicine  term used to describe Western medical practice Coordinating  the process of ensuring that plans are carried out and evaluating outcomes Coping  dealing with change Coping mechanism  an innate or acquired way of responding to a changing environment or specific problem or situation Coping strategy  see Coping mechanism Core self-concept  the beliefs and images that are most vital to an individual’s identity Core temperature  the temperature of the deep tissues of the body (e.g., abdominal cavity, pelvic cavity). When measured orally, the average body temperature of an adult is between 36.7°C and 37°C (98°F and 98.6°F) Corn  a conical, circular, painful, raised area on the toe or foot Coronary arteries  a network of vessels known as the coronary circulation Coroner  a physician who is authorized by the county or other government agency to determine causes of deaths under unusual circumstances Costal (thoracic) breathing  movement of the chest upward and outward Counseling  the process of helping a client to recognize and cope with stressful psychological or social problems, to develop improved interpersonal relationships, and to promote personal growth

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Countershock phase  second part of the alarm reaction in which the changes the body experienced during the shock phase are reversed Covert data (systems, subjective data)  information (data) apparent only to the person affected that can be described or verified only by that person Creatine kinase (CK)  enzyme that is released into the blood during a myocardial infarction Creatinine  a nitrogenous waste that is excreted in the urine Creativity  thinking that results in the development of new ideas and products Credentialing  the process of determining and maintaining competence in practice; includes licensure, registration, certification, and accreditation Credé’s maneuver  manual exertion of pressure on the bladder to force urine out Crepitation  (1) a dry, crackling sound like that of crumpled cellophane, produced by air in the subcutaneous tissue or by air moving through fluid in the alveoli of the lungs; (2) a crackling, grating sound produced by bone rubbing against bone Crime  an act committed in violation of public (criminal) law and punishable by a fine and/or imprisonment Criminal actions  deal with disputes between an individual and the society as a whole Criminal law  deals with actions against the safety and welfare of the public Crisis counseling  therapy focused on solving immediate problems involving individuals, groups, or families in crisis Crisis intervention  a short-term helping process of assisting clients to work through a crisis to its resolution and restore their precrisis level of functioning Critical analysis  a set of questions one can apply to a particular situation or idea to determine essential information and ideas and discard superfluous information and ideas Critical pathways  multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes Critical theory  describes theories that help elucidate how social structures affect a wide variety of human experiences from art to social practices Critical thinking  a cognitive process that includes creativity, problem solving, and decision making Cross-dresser  individual of one gender (typically male) who dresses in clothing specific to the opposite gender Crystalloids  salts that dissolve readily into true solutions Cues  any piece of information or data that influences decisions Cultural care deprivation  lack of culturally assistive, supportive, or facilitative acts Cultural deprivation  see Cultural care deprivation Culturally appropriate  application of underlying background knowledge that must be possessed to provide a given client with the best possible health care Culturally competent  within the delivered care the nurse understands and attends to the total context of the client’s situation and uses a complex combination of knowledge, attitudes, and skills Culturally sensitive  care that demonstrates basic knowledge of and constructive attitudes toward the health traditions observed among the diverse cultural groups found in the setting Culture  a worldview and set of traditions used and transmitted from generation to generation by a particular group; includes related attitudes and institutions Culture shock  a disorder that occurs in response to transition from one cultural setting to another Cultures  laboratory cultivations of microorganisms in a special growth medium

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Glossary Cumulative effect  the increasing response to repeated doses of a drug that occurs when the rate of administration exceeds the rate of metabolism or excretion Curanderismo  cultural healing tradition found in Latin America that uses Western medicine beliefs, treatments, and practices at three levels of care: material level, spiritual level, and mental level Cyanosis  a bluish tinge of skin color Cystoscope  a lighted instrument used to visualize the interior of the urinary bladder Cystoscopy  visual examination of the urinary bladder with a cystoscope Dacryocystitis  inflammation of the lacrimal sac Damages  if professional negligence caused an injury, the nurse is held liable for compensation in the form of damages Dandruff  a diffuse scaling of the scalp, often accompanied by itching Data information Data warehousing  the accumulation of large amounts of data that are stored over time Database  all information about a client, includes nursing health history and physical assessment, physician’s history, physical examination, and laboratory and diagnostic test results Debridement  removal of infected and necrotic material Decision  (legal) outcome made by a judge Decision making  the process of establishing criteria by which alternative courses of action are developed and selected Decode  to relate the message perceived to the receiver’s storehouse of knowledge and experience and to sort out the meaning of the message Decubitus ulcers  see Pressure ulcers Deductive reasoning  making specific observations from a generalization Defamation  (legal) a communication that is false, or made with careless disregard for the truth, and results in injury to the reputation of another Defecation  expulsion of feces from the anus and rectum Defendant  (legal) person against whom a plaintiff files a complaint Defense mechanism  method the ego uses to fulfill the needs of the id in a socially acceptable manner; also called adaptive mechanism Defining characteristics  client signs and symptoms that must be present to validate a nursing diagnosis Dehiscence  the partial or total rupturing of a sutured wound; usually involves an abdominal wound in which the layers below the skin also separate Dehydration  insufficient fluid in the body Delegation  transference of responsibility and authority for an activity to a competent individual Delirium  abrupt onset of confusion that has a reversible cause; also called acute confusion Demand feeding  the feeding of a child when the child is hungry Dementia  a global impairment of cognitive function that usually is progressive and may be permanent; interferes with normal social and occupational activities Democratic leader  encourages group discussion and decision making Demography  the study of population, including statistics about distribution by age and place of residence, mortality, and morbidity Dental caries  tooth decay Denver Developmental Screening Test (DDST-II)  a screening test used to assess children from birth to 6 years of age Dependent functions  with regard to medical diagnoses, physician-prescribed therapies and treatments nurses are obligated to carry out Dependent interventions  activities carried out on the orders or supervision of a licensed physician or other health care provider authorized to write orders for nurses

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Dependent variable  the behavior, characteristic, or outcome that the researcher wishes to explain or predict Depression  feelings of sadness and dejection, often accompanied by physiological change such as decreased functional activity Descriptive statistics  procedures that summarize large volumes of data; used to describe and synthesize data, showing patterns and trends Desire phase  part of the response cycle, which starts in the brain, with conscious sexual desires Desired effect  see Therapeutic effect Detoxification  see Biotransformation Detrusor muscle  the smooth muscle layers of the bladder Development  an individual’s increasing capacity and skill in functioning, related to growth Developmental stage  level of achievement for a particular segment of a person’s life Developmental task  skill or behavior pattern learned during stages of development Diagnosis  a statement or conclusion concerning the nature of some phenomenon Diagnosis-related groups (DRGs)  a Medicare payment system to hospitals and physicians that establishes fees according to diagnosis Diagnostic labels  title used in writing a nursing diagnosis; taken from the NANDA International standardized taxonomy of terms Dialysis  the technique by which blood is filtered for the removal of body wastes and excess fluid Diaphragmatic (abdominal) breathing  breathing that involves the contraction and relaxation of the diaphragm, as observed by the movement of the abdomen Diarrhea  defecation of liquid feces and increased frequency of defecation Diastolic pressure  the pressure of the blood against the arterial walls when the ventricles of the heart are at rest Diastole  in measuring blood pressure, the period during which the ventricles relax Diet history  a comprehensive assessment of a client’s food intake that involves an extensive interview by a nutritionist or dietitian Differentiated practice  a system in which the best possible use of nursing personnel is based on their educational preparation and resultant skill sets Diffusion  the mixing of molecules or ions of two or more substances as a result of random motion Directing  a management function that involves communicating the task to be completed and providing guidance and supervision Directive interview  a highly structured interview that uses closed questions to elicit specific information Dirty  denotes the likely presence of microorganisms, some of which may be capable of causing infection Disaccharides  sugars that are composed of double molecules Discharge planning  the process of anticipating and planning for client needs after discharge Discovery  (legal) pretrial activities to gain all of the facts of a situation Discrimination  the differential treatment of individuals or groups Discussion  an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem Disease  an alteration in body function resulting in a reduction of capacities or shortening of the normal life span Disease prevention  behavior motivated by a desire to actively avoid illness, detect it early, or maintain functioning within the constraints of illness (also called health protection) Disengagement theory  aging involves mutual withdrawal (disengagement) between an older individual and others in that individual’s environment

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Disinfectant  agent that destroys microorganisms other than spores Dissatisfaction problems  dissatisfaction with sexual encounters despite desire, arousal, and orgasm Distance learning  learning in which people communicate effectively across long distances Distribution  the transportation of a drug from its site of absorption to its site of action Diuresis  the production of large amounts of urine by the kidneys without an increased fluid intake; also known as polyuria Diuretics  agents that increase urine secretion Diversity  the fact or state of being different Documenting  the process of making an entry on a client record; charting, recording Dorothea Dix  woman leader who provided nursing care during the Civil War Dorsal position  a back-lying position without a pillow; also called the supine position Dorsal recumbent (back-lying) position  a supine position with the head and shoulders slightly elevated Drop factor  the number of drops that equal 1 mL as specified on the package of IV tubing Droplet nuclei  residue of evaporated droplets emitted by an infected host, such as someone with tuberculosis, that can remain in the air for long periods of time Droplet precautions  used for clients known or suspected to have serious illnesses transmitted by particle droplets larger than 5 microns (diphtheria, mycoplasma, pneumonia) Drug  a chemical compound taken for disease prevention, diagnosis, cure, or relief or to affect the structure or function of the body Drug abuse  excessive intake of a substance either continually or periodically Drug allergy  an immunologic reaction to a drug Drug dependence  inability to keep the intake of a drug or substance under control Drug habituation  a mild form of psychological dependence on a drug Drug half-life  the time required for the elimination process to reduce the concentration of a drug to one half of what it was at initial administration; also called elimination half-life Drug interaction  the beneficial or harmful interaction of one drug with another drug Drug tolerance  a condition in which successive increases in the dosage of a drug are required to maintain a given therapeutic effect Drug toxicity  the quality of a drug that exerts a deleterious effect on an organism or tissue Dullness (of sound)  a thudlike sound produced by dense tissue such as the liver, spleen, or heart Durable medical equipment (DME) companies  companies that provide health care equipment for clients at home Duration (of sound)  Its length (long or short) during auscultation Duty  (legal) the nurse must have (or should have had) a relationship with the client that involves providing care and following an acceptable standard of care Dysesthesia  an unpleasant abnormal sensation that mimics the pathology of central neuropathic pain disorder, such as pain that follows a stroke or spinal cord injury Dysmenorrhea  painful menstruation Dyspareunia  difficult or painful intercourse Dysphagia  difficulty swallowing Dyspnea  difficult or labored breathing Dysrhythmia  a pulse with an irregular rhythm Dysuria  painful or difficult voiding Eccrine glands  glands that produce sweat; found over most of the body

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Echocardiogram  a noninvasive test that uses ultrasound to visualize structures of the heart and evaluate left ventricular function Ectoderm  the outer layer of tissue formed in the second week of life Edema  the presence of excess interstitial fluid in the body that makes skin appear swollen, shiny, and taut, and tends to blanch color Effectiveness  a measure of the quality or quantity of services provided Efficiency  a measure of the resources used in the provision of nursing services Effleurage  a stroking massage technique Ego  the realistic part of the person that balances the gratification demands of the id with the limitations of social and physical circumstances Ejaculation  expulsion of seminal fluid and sperm Elasticity of the arterial wall  expansibility or stretching of the vessels Elderspeak  speech style similar to babytalk; gives the message of dependence and incompetence to older adults Elective surgery  performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening or to improve the client’s life Electric shock  occurs when a current travels through the body to the ground rather than through electric wiring, or from static electricity that builds up on the body Electrocardiogram (ECG, EKG )  a graph of the electric activity of the heart Electrocardiography  provides a graphic recording of the heart’s electrical activity Electroencephalogram (EEG)  a graph of the electrical activity of the brain Electrolytes  chemical substances that develop an electric charge and are able to conduct an electric current when placed in water; ions Electromyogram (EMG)  a graph of the electrical activity of muscles Electronic communication  communication involving computers and technology (i.e., e-mail) Electronic health records (EHRs)  see Computer-based patient records (CPRs) Electro-oculogram (EOG)  a graph of the electrical activity of eye to eye movement Elimination half-life  see Drug half-life Embolus  a blood clot (or a substance such as air) that has moved from its place of origin and is causing obstruction to circulation elsewhere (plural: emboli) Embryonic phase  the phase during which the fertilized ovum develops into an organism with most of the features of a human Emergency surgery  surgery that is performed immediately to preserve function or the life of the client Emmetropic  normal refraction so that the eyes focus images on the retina Empathy  the ability to discriminate what the other person’s world is like and to communicate to the other this understanding in a way that shows that the helper understands the client’s feelings and the behavior and experience underlying these feelings Emphysema  a chronic pulmonary condition in which the alveoli are dilated and distended Empirical data  information collected from the observable world Empirical knowing  knowledge that comes from science; ranges from factual, observable phenomena to theoretical analysis Encoding  involves the selection of specific signs or symbols (codes) to transmit the message, such as which language and words to use, how to arrange the words, and what tone of voice and gestures to use Endocardium  a layer of the heart wall lining the inside of the heart’s chambers and great vessels Endoderm  the inner layer of tissue formed in the second week of life

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End-of-life care  the care provided in the final weeks before death Endogenous  developing from within

Excretion  elimination of a waste product produced by the body cells from the body

Enema  used most often as a treatment for constipation, it distends the intestine and sometimes irritates the intestinal mucosa, thereby increasing peristalsis and the excretion of feces and flatus Energy  the force that integrates the body, mind, and spirit Enteral  through the gastrointestinal system Entoderm  see Endoderm Enuresis  bed-wetting; involuntary passing of urine in children after bladder control is achieved Environment  all of the conditions, circumstances, and influences surrounding and affecting the development of an organism or person Enzymes  biologic catalysts that speed up chemical reactions

Exercise  a type of physical activity; a planned, structured, and repetitive bodily movement done to improve or maintain one or more components of physical fitness

Epicardium  the visceral pericardium adhering to the surface of the heart, forming the heart’s outermost layer Epidural  the injection of an anesthetic agent into the epidural or intrathecal (subarachnoid) space Epidural anesthesia  the injection of an anesthetic agent into the epidural space; also known as peridural anesthesia Equianalgesia  refers to the relative potency of various opioid analgesics compared to a standard dose of parenteral morphine Equilibrium  a state of balance Erectile dysfunction  the inability to achieve or maintain an erection sufficient for sexual satisfaction for oneself or one’s partner Erythema  a redness tinge of skin color associated with a variety of skin rashes Erythrocytes  red blood cells (RBCs) Eschar  necrotic tissue Essential amino acids  amino acids that cannot be manufactured in the body and must be supplied as part of the protein ingested in the diet Ethical knowing  knowledge that focuses on matters of obligation or what ought to be done Ethics  the rules or principles that govern right conduct Ethnic  belonging to a specific group of individuals who share a common social and cultural heritage Ethnocentrism  the belief that one’s own culture or way of life is better than that of others Ethnography  research that provides a framework to focus on the culture of a group of people Ethnopharmacology  study of the effect of ethnicity on responses to prescribed medicines Etiology  the causal relationship between a problem and its related or risk factors Eupnea  normal, quiet breathing Eustachian tube  the part of the middle ear that connects the middle ear to the nasopharynx; stabilizes air pressure between the external atmosphere and the middle ear Euthanasia  the act of painlessly putting to death individuals suffering from incurable or distressing disease Evaluating  a planned ongoing, purposeful activity in which clients and health care professionals compare expected outcomes to actual outcomes Evaluation statement  a statement that consists of two parts: a conclusion and supporting data Evidence-based practice (EBP)  the use of some form of substantiation in making clinical decisions Evisceration  extrusion of the internal organs Exacerbation  the period during a chronic illness when symptoms reappear after remission Excitement/plateau phase  part of the response cycle, involves vasocongestion and myotonia Excoriation  loss of the superficial layers of the skin

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Exhalation (expiration)  breathing out, or the movement of gases from the lungs to the atmosphere Exogenous  developing from outside sources Exophthalmos  a protrusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or staring expression Expectorate  spit out Expert witness  one who has special training, experience, or skill in a relevant area and is allowed by the court to offer an opinion on some issue within that area of expertise Expiration (exhalation)  the outflow of air from the lungs to the atmosphere Express consent  an oral or written agreement Extended family  family that includes the relatives of the nuclear family (e.g., grandparents, aunts, uncles) External auditory meatus  the entrance to the ear canal Extinction  the failure to perceive touch on one side of the body when two symmetric areas of the body are touched simultaneously Extracellular fluid (ECF)  fluid found outside the body cells Exudate  purulent drainage Fabiola  a wealthy Roman matron; viewed by some as the patron saint of early nursing who used her position and wealth to establish hospitals for the sick Fad  a widespread but short-lived interest, or a practice followed with considerable zeal Failure to thrive (FTT)  a unique syndrome in which an infant falls below the fifth percentile for weight and height on a standard growth chart or is falling in percentiles on a growth chart Faith  an active “mode of being-in-relation” to another or others in which we invest commitment, belief, love, and hope False imprisonment  the unlawful restraint or detention of another person against his or her wishes Family  the basic unit of society that consists of those individuals, male or female, youth or adult, legally or not legally related, genetically or not genetically related, who are considered by others to represent their significant individuals Family-centered nursing  nursing that considers the health of the family as a unit in addition to the health of individual family members Fats  lipids that are solid at room temperature Fat-soluble vitamins  A, D, E, and K vitamins that the body can store Fatty acids  the basic structural units of most lipids made up of carbon chains and hydrogen Fear  an emotional response to an actual, present danger Feasibility  the availability of time as well as the material and human resources needed to investigate a research problem or question Febrile  pertaining to a fever; feverish Fecal impaction  a mass or collection of hardened, putty-like feces in the folds of the rectum Fecal incontinence  see Bowel incontinence Feces  excreted waste products; also called stool Feedback  the response or message that the receiver returns to the sender during communication Felony  a crime of a serious nature, such as murder, punishable by a term in prison Female orgasmic disorder  when the female sexual response stops before orgasm occurs Female sexual arousal disorder  when lack of vaginal lubrication causes discomfort or pain during intercourse

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Glossary

Fetal phase  characterized by a period of rapid growth in the size of the fetus; both genetic and environmental factors affect its growth Fever  elevated body temperature Fever spike  a temperature that rises to fever level rapidly following a normal temperature and then returns to normal within a few hours Fibrin  an insoluble protein formed from fibrinogen during the clotting of blood Fidelity  a moral principle that obligates the individual to be faithful to agreements and responsibilities one has undertaken Fifth vital sign  pain, as viewed by many health facilities Filtration  process whereby fluid and solutes move together across a membrane from one compartment to another Filtration force  see Hydrostatic pressure Filtration pressure  the pressure in a compartment that results in the movement of fluid and substances dissolved in fluid out of the compartment First-level manager  a manager responsible for managing the work of nonmanagerial personnel and the day-to-day activities of a specific work group or groups Fissures  deep grooves that occur as a result of dryness and cracking of the skin Fixation  immobilization or the inability of the personality to proceed to the next developmental stage because of anxiety Flaccid  weak or lax Flatness (of sound)  an extremely dull sound produced, during percussion, by very dense tissue, such as muscle or bone Flatulence  the presence of excessive amounts of gas in the stomach or intestines Flatus  gas or air normally present in the stomach or intestines Florence Nightingale  considered the founder of modern nursing, she was influential in developing nursing education, practice, and administration Flow sheet  a record of the progress of specific or specialized data such as vital signs, fluid balance, or routine medications; often charted in graph form Fluid volume deficit (FVD)  (hypovolemia) loss of both water and electrolytes in similar proportions from the extracellular fluid Fluid volume excess (FVE)  (hypervolemia) retention of both water and sodium in similar proportions to normal extracellular fluid (ECF) Focus charting  a method of charting that uses key words or foci to describe what is happening to the client Folk medicine  beliefs and practices relating to illness prevention and healing that derive from cultural traditions rather than from modern medicine’s scientific base Fontanels  unossified membranous gaps in the bone structure of the skull of a newborn that make molding of the head possible Food diary  a detailed record of measured amounts (portion sizes) of all food and fluids a client consumes during a specified period, usually 3 to 7 days Food frequency record  a checklist that indicates how often general food groups or specific foods are eaten Foot drop  plantar flexion contracture Foreseeability  a link that must exist between the nurse’s act and the injury suffered Formal leader  an appointed leader selected by an organization and given official authority to make decisions and act Formal nursing care plan  a written or computerized guide that organizes information about the client’s care Fowler’s position  a semisitting position in which the head of the bed is raised to an angle between 45° and 60°, typically at 45° Friction  rubbing; the force that opposes motion Full disclosure  a basic right, which means that deception, either by withholding information about a client’s participation in a study or by

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giving the client false or misleading information about what participating in the study will involve, must not occur Functional strength  ability of the body to perform work Fungi  infection-causing microorganisms that include yeasts and molds Gait  the way a person walks Gastrocolic reflex  increased peristalsis of the colon after food has entered the stomach Gastrostomy  an opening through the abdominal wall into the stomach Gastrostomy tube  a tube that is surgically placed directly into the client’s stomach and provides another route for administering nutrition and medications Gauge  the diameter of the shaft of a needle; the larger the gauge number, the smaller the diameter of the shaft Gender  indicates biologic male or female status Gender identity  a person’s sense of being masculine or feminine, as distinct from being male or female Gender-role behavior  outward expression of a person’s sense of maleness or femaleness General adaptation syndrome (GAS)  (Selye) a general arousal response of the body to a stressor characterized by certain physiological events and dominated by the sympathetic nervous system General anesthesia  the induced loss of all sensation and consciousness Generation X  generation that includes those born in years 1965–1978 Generation Y  generation that includes those born in years 1979–2000 Generativity  concern for establishing and guiding the next generation Generic name (of drug)  given before a drug officially becomes an approved medication; generally used throughout the drug’s lifetime Genital intercourse  penile/vaginal intercourse (coitus) Geragogy  the term used to describe the process involved in stimulating and helping older adults to learn Geriatrics  medical care of older adults Gerontology  the study of aging and older adults Gingival  of or relating to the gums Gingivitis  red, swollen gingivae (gums) Glaucoma  a disturbance in the circulation of aqueous fluid that causes an increase in intraocular pressure Global self  refers to the collective beliefs and images one holds about oneself; the most complete description that individuals can give of themselves at any one time Global self-esteem  how much one likes one’s perceived self as a whole Glomerulus  a tuft of capillaries in the kidney surrounded by Bowman’s capsule Glossitis  inflammation of the tongue Glycerides  the most common form of lipids consisting of a glycerol molecule with up to three fatty acids Glycogen  the chief carbohydrate stored in the body, particularly in the liver and muscles Glycogenesis  the process of glycogen formation Goals/desired outcomes  a part of a care plan that describes, in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions Goniometer  a handheld device used to measure the angle of a joint in degrees Governance  the establishment and maintenance of social, political, and economic arrangements by which practitioners control their practice, self-discipline, working conditions, and professional affairs Grand theories  articulate a broad range of the significant relationships among the concepts of a discipline Granulation tissue  young connective tissue with new capillaries formed in the wound healing process

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Glossary Grief  emotional suffering often caused by bereavement Gross negligence  involves extreme lack of knowledge, skill, or decision making that the person clearly should have known would put others at risk for harm Grounded theory  research to understand social structures and social processes; this method focuses on the generation of categories or hypotheses that explain patterns of behavior of people in the study Group  two or more people with shared purposes and goals Group dynamics  forces that determine the behavior of the group and the relationships among the group members Growth  physical change and increase in size Guaiac  a test performed for occult (hidden) blood in the stool to detect gastrointestinal bleeding not visible to the eye Guided imagery  state of focused attention that encourages changes in attitudes, behavior, and physiological reactions Gustatory  referring to the sense of taste Habit training  attempts to keep clients dry by having them void at regular intervals; also referred to as timed voiding or scheduled toileting Hardware  the physical parts of a computer Harm  (injury) the client or plaintiff must demonstrate some type of harm or injury (physical, financial, or emotional) as a result of the breach of duty owed the client; the plaintiff will be asked to document physical injury, medical costs, loss of wages, “pain and suffering,” and any other damages Harriet Tubman  African American woman known as “the Moses of Her People” for her work with the Underground Railroad; during the Civil War she nursed the sick and suffering of her own race Haustra  pouches that form in the large intestine when the longitudinal muscles are shorter than the colon Haustral churning  (shuffling) movement of the chyme back and forth within the haustra in the large intestine Health behaviors  the actions a person takes to understand his or her health state, maintain an optimal state of health, prevent illness and injury, and reach his or her maximum physical and mental potential Health beliefs  concepts about health that an individual believes are true Health care proxy  a legal statement that appoints a proxy to make medical decisions for the client in the event the client is unable to do so Health care system  the totality of services offered by all health disciplines Health literacy  ability to read, understand, and act on provided health information Health maintenance organization (HMO)  a group health care agency that provides basic and supplemental health maintenance and treatment services to voluntary enrollees Health promotion  any activity undertaken for the purpose of achieving a higher level of health and well-being Health protection  behavior motivated by a desire to actively avoid illness, detect it early, or maintain functioning within the constraints of illness Health risk assessment (HRA)  an assessment and educational tool that indicates a client’s risk for disease or injury during the next 10 years by comparing the client’s risk with the mortality risk of the corresponding age, sex, and racial group Health status  the health of a person at a given time Heart failure  a condition that develops if the heart cannot keep up with the body’s need for oxygen and nutrients to the tissues; usually occurs because of myocardial infarction, but it may also result from chronic overwork of the heart Heart-lung death  the traditional clinical signs of death: cessation of the apical pulse, respirations, and blood pressure Heat balance  the state a person is in when the amount of heat produced by the body exactly equals the amount of heat lost Heat exhaustion  condition that is the result of excessive heat and dehydration

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Heat stroke  life-threatening condition with body temperature greater than 41°C (106°F) Heimlich maneuver  abdominal thrusts used to clear an obstructed airway Helix  the posterior curve of the auricle’s upper aspect Helping relationships  the nurse–client relationship Hematocrit  the proportion of red blood cells (erythrocytes) to the total blood volume Hematoma  a contusion or “black eye” resulting from injury Hemoglobin (Hg)  the red pigment in red blood cells that carries oxygen Hemoglobin A1C  measurement of blood glucose that is bound to hemoglobin Hemolytic transfusion reaction  destruction of red blood cells as a result of transfusion of incompatible blood Hemoptysis  the presence of blood in the sputum Hemorrhage  excessive loss of blood from the vascular system Hemorrhagic exudate  see Sanguineous exudate Hemorrhoids  distended veins in the rectum Hemostasis  cessation of bleeding Hemothorax  the accumulation of blood in the pleural cavity Herbal medicine  treating illness with herbs Heritage consistency  the degree to which one’s lifestyle reflects his or her respective tribal culture Heritage inconsistency  the observance of the beliefs and practices of one’s acculturated belief system Hernia  a protrusion of an organ or tissue through an opening such as the abdominal or inguinal muscles Higher brain death  see Cerebral death High-Fowler’s position  a bed-sitting position in which the head of the bed is elevated 60° to 90° Hirsutism  the growth of excessive body hair Holism  all living organisms are seen as interacting, unified wholes that are more than the sums of their parts Holistic health  a model of health based on the belief that the whole is more than the sum of its parts Holistic health belief  holds that the forces of nature must be maintained in balance or harmony Holistic health care  a system that considers all components of health: health promotion, health maintenance, health education and illness prevention, and restorative–rehabilitative care Holistic nursing  nursing practice that has as its goal the healing of the whole person Holy day  a day set aside for special religious observance Homans’ sign  pain in calf with passive dorsiflexion of the foot Home care  providing care in the client’s home Home health care nursing  services and products provided to clients in their homes that are needed to maintain, restore, or promote their physical, psychological, and social well-being Homeopathy  an alternative therapy based on the theory that the cure for the disease lies in the disease itself; thus, treatment is with highly diluted amounts of substances that at a higher concentration would produce the same symptoms as the disease Homeostasis  the tendency of the body to maintain a state of balance or equilibrium while continually changing; a mechanism in which deviations from normal are sensed and counteracted Hope  a multidimensional concept that includes perceiving realistic expectations and goals, having motivation to achieve goals, anticipating outcomes, establishing trust and interpersonal relationships, relying on internal and external resources, having determination to endure, and being oriented to the future Hordeolum  redness, swelling, and tenderness of the hair follicle and glands that empty at the edge of the eyelids; also called a sty

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Glossary

Horticultural therapy  adjunct therapy to occupational and physical therapy that may involve viewing nature, visiting a healing garden or wander garden, or actively gardening; also called gardening or healing garden Hospice  care that focuses on support and care for the dying person and family, with the goal of facilitating a peaceful and dignified death Hospice nursing  care frequently given to terminally ill clients in their home; often considered a subspecialty of public health nursing Hospital information system (HIS)  computer software program suite used to manage client, financial, and administrative data Hub  the part of the needle that fits onto the syringe Humanism  learning that focuses on the feelings and attitudes of learners, the importance of the individual in identifying learning needs and taking responsibility for them, and the self-motivation of the learners to work toward self-reliance and independence Humanist  a perspective that includes propositions such as the mind and body are indivisible, people have the power to solve their own problems, and people are responsible for their lives and well-being Humidifier  a device that adds water vapor to inspired air Humoral immunity  antibody-mediated defense; resides ultimately in the B lymphocytes and is mediated by the antibodies produced by B cells Hydrostatic pressure  the pressure a liquid exerts on the sides of the container that holds it; also called filtration force Hygiene  the science of health and its maintenance Hyperalgesia  a heightened response to painful stimuli Hypercalcemia  an excess of calcium in the blood plasma Hypercapnia  a condition in which carbon dioxide accumulates in the blood Hypercarbia (hypercapnia)  accumulation of carbon dioxide in the blood Hyperchloremia  an excess of chloride in the blood plasma Hyperemia  increased blood flow to an area Hyperinflation  giving the client breaths that are greater than the client’s normal tidal volume set on the ventilator through the ventilator circuit or via a manual resuscitation bag Hyperkalemia  an excess of potassium in the blood plasma Hypermagnesemia  an excess of magnesium in the blood plasma Hypernatremia  an excess of sodium in the blood plasma Hyperopia farsightedness Hyperoxygenation  increasing the oxygen flow before suctioning and between suction attempts to avoid suction-related hypoxemia Hyperpathia  heightened response to a painful stimulus; hyperalgesia Hyperphosphatemia  an excess of phosphate in the blood plasma Hyperpyrexia  an extremely high body temperature (e.g., 41°C [105.8°F]) Hyperresonance  an abnormal booming sound produced during percussion of the lungs Hypersomnia  excessive sleep Hypertension  an abnormally high blood pressure; over 140 mmHg systolic and/or 90 mmHg diastolic Hyperthermia  a body temperature above the usual range Hypertonic  solutions that have a higher osmolality than body fluids Hypertrophy  enlargement of a muscle or organ Hyperventilation  very deep, rapid respirations Hypervolemia  increased blood volume Hypnotherapy  application of hypnosis (trance state or altered state of consciousness) to a medical or psychological disorder Hypoactive sexual desire disorder  involves a persistent or recurring absence of sexual thoughts or disinterest in sexual activity Hypocalcemia  deficiency of calcium in the blood plasma Hypochloremia  deficiency of chloride in the blood plasma

# 153613   Cust: Pearson   Au: Berman  Pg. No. 1440 & Erb’s Fundamentals of Nursing   10e

Z05_BERM4362_10_GE_GLOS.indd 1440 Title: Kozier

Hypodermic  under the skin Hypodermic syringe  a type of syringe that comes in 2-, 2.5-, and 3-mL sizes; the syringe usually has two scales marked on it: the minim and the milliliter Hypokalemia  deficiency of potassium in the blood plasma Hypomagnesemia  deficiency of magnesium in the blood plasma Hyponatremia  deficiency of sodium in the blood plasma Hypophosphatemia  deficiency of phosphate in the blood plasma Hypotension  an abnormally low blood pressure; less than 100 mmHg systolic in an adult Hypothalamic integrator  the center in the brain that controls the core temperature; located in the preoptic area of the hypothalamus Hypothermia  a core body temperature below the lower limit of normal Hypothesis  a prediction of the relationships among two or more variables Hypotonic  solutions that have a lower osmolality than body fluids Hypoventilation  very shallow respirations Hypovolemia  an abnormal reduction in blood volume Hypoxemia  low partial pressure of oxygen or low saturation of oxyhemoglobin in the arterial blood Hypoxia  insufficient oxygen anywhere in the body Iatrogenic disease  disease caused unintentionally by medical therapy Iatrogenic infections  infections that are the direct result of diagnostic or therapeutic procedures Id  the source of instinctive and unconscious psychological urges Ideal body weight (IBW)  the optimal weight recommended for optimal health Ideal self  how we would prefer to be; the individual’s perception of how one should behave based on certain personal standards, aspirations, goals, or values Identification  perceiving one’s self as similar to and behaving like another person Idiosyncratic effect  a different, unexpected, or individual effect from the normal one usually expected from a medication; the occurrence of unpredictable and unexplainable symptoms Ileal conduit (ileal loop)  urinary diversion in which the client must wear an external pouch over the stoma to collect the continuous flow of urine Ileostomy  a colostomy that generally empties from the distal end of the small intestine Illicit drugs  drugs that are sold illegally; street drugs Illness  a highly personal state in which a person feels unhealthy or ill; may or may not be related to disease Illness behavior  the course of action a person takes to define the state of his or her health and pursue a remedy Imagery  the internal experience of memories, dreams, fantasies, and visions that serve as a bridge connecting body, mind, and spirit Imagination  an important part of preschoolers’ life (the preschooler has an active imagination and fantasizes in play) Imitation  copying the behaviors and attitudes of another person Immobility  prescribed or unavoidable restriction of movement in any area of a person’s life Immune defenses  see Specific defenses Immunity  a specific resistance of the body to infection; it may be natural, or resistance may develop after exposure to a disease agent Immunoglobulins  see Antibodies Impaired nurse  a nurse whose practice has deteriorated because of chemical abuse Implementing  the phase of the nursing process in which the nursing care plan is put into action Implied consent  consent that is assumed in an emergency when consent cannot be obtained from the client or a relative

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Glossary Implied contract  a contract that has not been explicitly agreed to by the parties but that the law nevertheless considers to exist Incentive spirometer  a device that measures the flow of air inhaled through a mouthpiece; also called a sustained maximal inspiration device (SMI) Incomplete proteins  protein that lacks one or more essential amino acids; usually derived from vegetables Incus  the anvil bone of the middle ear Independent functions  areas of health care unique to nursing, separate and distinct from medical management Independent interventions  activities that the nurse is licensed to initiate as a result of the nurse’s own knowledge and skills Independent practice associations (IPAs)  provide care in offices; clients pay a fixed prospective payment and IPA pays the provider; earnings or losses are assumed by the IPA Independent variable  the presumed cause or influence on a dependent variable Indicator  an observable client state, behavior, or self-reported perception or evaluation; similar to desired outcomes in traditional language Individualized care plan  a plan tailored to meet the unique needs of a specific client—needs that are not addressed by the standardized plan Individualized exercise prescription  exercise mode and dose tailored to a specific individual to ensure greater adherence to an exercise program Inductive reasoning  making generalizations from specific data Infection  the disease process produced by microorganisms Inferences  interpretations or conclusions made based on cues or observed data Infiltration  occurs when the tip of an IV is outside the vein and the fluid is entering the tissues instead; manifested by local swelling, coolness, pallor, and discomfort at the IV site Inflammation  local and nonspecific defensive tissue response to injury or destruction of cells Influence  an informal strategy used to gain the cooperation of others without exercising formal authority Informal leader  an individual selected by a group as its leader because of seniority, age, special abilities, or charisma Informal nursing care plan  a strategy for action that exists in the nurse’s mind Informed consent  a client’s agreement to accept a course of treatment or a procedure after receiving complete information, including the risks of treatment and facts relating to it, from the health care provider Infrared photoenergy therapy  treatment to improve sensory impairment associated with peripheral neuropathy Ingestion  the act of taking in food or medication Ingrown toenail  the growing inward of a nail into the soft tissues around it; most often results from improper nail trimming Inhalation  the intake of air into the lungs; also called inspiration Inhibiting effect  the decreased effect of one or both drugs Injury  see Harm Input  consists of information, material, or energy that enters a system Inquest  a legal inquiry into the cause or manner of a death Insensible fluid loss  fluid loss that is not perceptible to an individual Insensible heat loss  heat loss that occurs from evaporation (vaporization) of moisture from the respiratory tract, mucosa of the mouth, and the skin Insensible water loss  continuous and unnoticed water loss In-service education  education that is designed to upgrade the knowledge or skills of employees Insomnia  inability to obtain a sufficient quality or quantity of sleep Inspection  visual examination, which is assessing by using the sense of sight

# 153613   Cust: Pearson   Au: Berman  Pg. No. 1441 & Erb’s Fundamentals of Nursing   10e

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Inspiration  see Inhalation Insulin syringe  syringe that has a scale specially designed for insulin and is the only type of syringe that should be used to administer insulin Integrated delivery system (IDS)  a system that incorporates acute care services, home health care, extended and skilled care facilities, and outpatient services Integrated health care system  one that makes all levels of care available in an integrated form—primary care, secondary care, and tertiary care Intensity (amplitude)  the loudness or softness of auscultated sound Intention tremor  involuntary trembling when an individual attempts a voluntary movement Intermittent fever  a body temperature that alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures Internet  a worldwide computer network Interpersonal skills  all verbal and nonverbal activities people use when communicating directly with one another Interpreter  an individual who mediates spoken communication between people speaking different languages without adding, omitting, or distorting meaning or editorializing Intersex  ambiguous gender Interstate compact  an agreement between two or more states Interstitial fluid  fluid that surrounds the cells, includes lymph Interview  a planned communication; a conversation with a purpose Intimacy  a close friendship Intracellular fluid (ICF)  fluid found within the body cells; also called cellular fluid Intractable pain  pain that is resistant to cure or relief Intradermal  under the epidermis (into the dermis) Intradermal (ID) injection  the administration of a drug into the dermal layer of the skin just beneath the epidermis Intramuscular  into the muscle Intramuscular (IM) injection  the administration of a drug into the muscle tissue Intraoperative phase  the phase of surgery that begins when the client is transferred to the operating room and ends when the client is admitted to the postanesthesia care unit Intrapleural pressure  pressure in the pleural cavity surrounding the lungs Intrapulmonary pressure  pressure within the lungs Intraspinal (intrathecal)  into the spinal canal Intrathecal  see Intraspinal Intravascular fluid plasma Intravenous  within a vein Intravenous block  anesthesia used most often for procedures involving the arm, wrist, and hand Intravenous pyelography (IVP)  x-ray filming of the kidney and ureters after injection of a radiopaque material into the vein Introjection  the assimilation of the attributes of others Intuition  the understanding or learning of things without the conscious use of reasoning Invasion of privacy  a direct wrong of a personal nature, it injures the feelings of the person and does not take into account the effect of revealed information on the standing of the person in the community Ions  atoms or group of atoms that carry a positive or negative electric charge; electrolytes Iron deficiency anemia  a form of anemia caused by inadequate supply of iron for synthesis of hemoglobin Irrigation  a flushing or washing out with a specified solution; administration of a solution to wash out the conjunctival sac to remove secretions or foreign bodies or to remove chemicals that may injure the eye

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Glossary

Ischemia  deficiency of blood supply caused by obstruction of circulation to the body part

Learning  a change in human disposition or capability that persists over a period of time and cannot be solely accounted for by growth

Isokinetic (resistive) exercises  muscle contraction or tension against resistance

Learning need  a desire or a requirement to know something that is currently unknown to the learner

Isolation  practices that prevent the spread of infection and communicable diseases

Leukocytes  white blood cells

Isometric (static or setting) exercise  muscle contraction without moving the joint (muscle length does not change), which involves exerting pressure against a solid object.

Liability  the quality or state of being legally responsible for one’s obligations and action and to make financial restitution for wrongful acts

Isotonic  solutions that have the same osmolality as body fluids Isotonic (dynamic) exercise  exercise in which muscle tension is constant and the muscle shortens to produce muscle contraction and active movement Jaundice  a yellowish tinge to skin color Jejunostomy  a tube that is placed surgically or by laparoscopy through the abdominal wall into the jejunum for long-term nutritional support Justice fairness Kardex  the trade name for a method that makes use of a series of cards to concisely organize and record client data and instructions for daily nursing care—especially care that changes frequently and must be kept up to date Keloid  a hypertrophic scar containing an abnormal amount of collagen Kidneys/ureters/bladder (KUB)  x-ray of the kidneys, ureters, and bladder

Leukocytosis  an increase in the number of white blood cells

Libel  defamation by means of print, writing, or pictures Libido  urge or desire for sexual activity License  a legal permit granted to individuals to engage in the practice of a profession and to use a particular title Licensed vocational (practical) nurse (LVN/LPN)  a nurse who practices under the supervision of a registered nurse, providing basic direct technical care to clients Lifestyle  the values and behaviors adopted by a person in daily life Lift  an abnormal anterior movement of the chest related to enlargement of the right ventricle Lillian Wald  founder of the Henry Street Settlement and Visiting Nurse Service, which provided nursing and social services and organized educational and cultural activities; considered the founder of public health nursing Linda Richards  America’s first formally trained nurse

Kilocalorie (kcal)  see Calorie

Line of gravity  an imaginary vertical line drawn through an object’s center of gravity

Kilojoule (kJ)  a metric measurement referring to the amount of energy required when a force of 1 newton (N) moves 1 kg of weight 1 m of distance

Lipids  organic substances that are greasy and insoluble in water but soluble in alcohol or ether

Kinesthetic  refers to awareness of the position and movement of body parts

Litigation  the action of a lawsuit

Knights of Saint Lazarus  an order of knights that dedicated themselves to the care of people with leprosy, syphilis, and chronic skin conditions Korotkoff’s sounds  the five phases of blood pressure sounds Kosher  acceptable or prepared according to Jewish law Kussmaul’s breathing  hyperventilation that accompanies metabolic acidosis in which the body attempts to compensate (give off excess body acids) by blowing off carbon dioxide through deep and rapid breathing Kyphosis  excessive convex curvature of the thoracic spine Laissez-faire leader  recognizes a group’s need for autonomy and self-regulation; also called nondirective leader or permissive leader Lanugo  the fine, woolly hair or down on the shoulders, back, sacrum, and earlobes of the unborn child that may remain for a few weeks after birth Large calorie (Calorie, kilocalorie [kcal])  see Calorie Laryngoscopy  visual examination of the larynx with a laryngoscope Lateral (side-lying) position  position in which a person lies on one side of the body Lavage  an irrigation or washing of a body organ, such as the stomach Lavinia L. Dock  a nursing leader and suffragist who was active in the protest movement for women’s rights that resulted in the U.S. Constitution amendment allowing women to vote in 1920

Lipoproteins  soluble compounds made up of various lipids Living will  a document that states medical treatments(s) the client chooses to omit or refuse in the event that the client is unable to make these decisions Livor mortis  discoloration of the skin caused by breakdown of the red blood cells; occurs after blood circulation has ceased; appears in the dependent areas of the body Lobule earlobe Local adaptation syndrome (LAS)  the reaction of one organ or body part to stress Local anesthesia  an anesthetic agent used for minor surgical procedures that is injected into a specific area Local area network (LAN)  personal computers (PCs) linked directly to nearby PCs and servers by wires or wireless communication devices Local infection  an infection that is limited to the specific part of the body where the microorganisms remain Locus of control (LOC)  a concept about whether clients believe their health status is under their own or others’ control Logrolling  a technique used to turn a client whose body must at all times be kept in straight alignment Long-term memory  the repository for information stored for periods longer than 72 hours and usually weeks and years Lordosis  an exaggerated concavity in the lumbar region of the vertebral column

Law  a rule made by humans that regulates social conduct in a formally prescribed and binding manner

Loss  an actual or potential situation in which a valued ability, object, or person is inaccessible or changed so that it is perceived as no longer valuable

Laxatives  medications that stimulate bowel activity and assist fecal elimination

Low Fowler’s position  a bed-sitting position in which the head of the bed is elevated between 15° and 45°, with or without knee flexion

Leader  a person who influences others to work together to accomplish a specific goal

Lumbar puncture (LP)  procedure in which cerebrospinal fluid is withdrawn through a needle inserted into the subarachnoid space of the spinal canal between the third and fourth lumbar vertebrae, or between the fourth and fifth lumbar vertebrae; also called a spinal tap Lung compliance  expansibility of the lung Lung recoil  the tendency of lungs to collapse away from the chest wall

Leadership style  describes traits, behaviors, motivations, and choices used by individuals to effectively influence others Leading question  a question that influences the client to give a particular answer

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Glossary Lung scan  records the emissions from radioisotopes that indicate how well gas and blood are traveling through the lungs; also known as a V/Q (ventilation/perfusion) scan Maceration  the wasting away or softening of a solid as if by the action of soaking; often used to describe degenerative changes and eventual disintegration Macrominerals  any of the minerals that people require daily in amounts over 100 mg Macronutrients  carbohydrates, fats, and protein that are needed in large amounts to provide energy Magico-religious health belief  a belief system in which people attribute the fate of the world and those in it to the actions of God, the gods, or other supernatural forces for good or evil Magnetic resonance imaging (MRI)  a noninvasive diagnostic scanning technique in which the client is placed in a magnetic field Maintenance stage  stage at which a person integrates newly adopted behavior patterns into his or her lifestyle Major surgery  surgery that involves a high degree of risk for a variety of reasons; it may be complicated or prolonged; large losses of blood may occur; vital organs may be involved; postoperative complications may occur Male erectile disorder  when a man has erection problems during 25% or more of his sexual interactions Male orgasmic disorder  disorder where a man can maintain an erection but has difficulty ejaculating Malleus  hammer bone of the middle ear Malnutrition  the lack of necessary or appropriate food substances that includes both undernutrition and overnutrition Malpractice  the negligent acts of individuals engaged in professions or occupations in which highly technical or professional skills are employed Managed care  a method of organizing care delivery that emphasizes communication and coordination of care among all health care team members Management information system (MIS)  software designed to facilitate the organization and application of data used to manage an organization or department Manager  one who is appointed to a position in an organization that gives the power to guide and direct the work of others Mandated reporters  a role of the nurse in which he or she identifies and assesses cases of violence against others, and in every case the situation must be reported to the proper authorities Manometer  a glass or plastic tube calibrated in millimeters that is used to take cerebrospinal pressure readings Manslaughter  second-degree murder Manubrium  the handle-like superior part of the sternum that joins with the clavicles Margaret Higgins Sanger  considered the founder of Planned Parenthood, was imprisoned for opening the first birth control information clinic in Baltimore in 1916 Mary Breckinridge  a nurse who practiced midwivery in England, Australia, and New Zealand; founded the Frontier Nursing Service in Kentucky in 1925 to provide family-centered primary health care to rural populations Mary Mahoney  first African American professional nurse Mass peristalsis  involves a wave of powerful muscular contraction that moves over large areas of the colon; usually occurs after eating Mastoid  a bony prominence behind the ear Masturbation  sexual self-stimulation Maturity  the state of maximal function and integration; the state of being fully developed Mean  a measure of central tendency, computed by summing all scores and dividing by the number of subjects; commonly symbolized as X or M Measures of central tendency  measures that describe the center of a distribution of data, denoting where most of the subjects lie; include the mean, median, and mode

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Measures of variability  measures that indicate the degree of dispersion or spread of the data; include range, variance, and standard deviation Meatus  referring to the urinary meatus, which is the external opening from the urethra to the surface of the body Meconium  the first fecal material passed by a newborn, normally up to 24 hours after birth Median  a measure of central tendency, representing the exact middle score or value in a distribution of scores; the median is the value above and below which 50% of the scores lie Medicaid  a U.S. federal public assistance program paid out of general taxes and administered through the individual states to provide health care for those who require financial assistance Medical asepsis  all practices intended to confine a specific microorganism to a specific area, limiting the number, growth, and spread of microorganisms Medical examiner  a physician who usually has advanced education in pathology or forensic medicine who determines causes of death Medicare  a national and state health insurance program for U.S. residents older than 65 years of age Medication  a substance administered for the diagnosis, cure, treatment, or relief of a symptom or for prevention of disease Medication reconciliation  process of creating the most accurate list possible of all medications a client is taking—including drug name, dosage, frequency, and route—and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the client at all transition points within the hospital Meditation  mental exercise that directs the mind to think inwardly by closing the sense organs to external stimulation Menarche  onset of menstruation Meniscus  the crescent-shaped upper surface of a column of liquid Menopause  cessation of menstruation Menstruation  the monthly discharge of blood through the vagina occurring in nonpregnant women from puberty to menopause Mentor  a person who serves as an experienced guide, adviser, or advocate and assumes responsibility for promoting the growth and professional advancement of a less experienced individual Mesoderm  middle layer of the embryonic tissue that forms during the first 3 weeks of life Metabolic acidosis  a condition characterized by a deficiency of bicarbonate ions in the body in relation to the amount of carbonic acid in the body; the pH falls to less than 7.35 Metabolic alkalosis  a condition characterized by an excess of bicarbonate ions in the body in relation to the amount of carbonic acid in the body; the pH rises to greater than 7.45 Metabolism  the sum of all physical and chemical processes by which a living substance is formed and maintained and by which energy is made available for use by the organism Metabolites  end products or enzymes Metaparadigm  originates from the Greek meta, meaning “with,” and paradigm, meaning “pattern”; based on four theoretical concepts of nursing: person, environment, health, and nursing Metered-dose inhaler (MDI)  a handheld nebulizer that is a pressurized container of medication that can be used by the client to release the medication through a mouthpiece Microminerals  a vitamin or mineral Micronutrients  those vitamins and minerals required in small amounts to metabolize the energy-providing nutrients Micturition  see Urination Mid-arm circumference (MAC)  a measure of fat, muscle, and skeleton Mid-arm muscle circumference (MAMC)  calculated by using reference tables or by using a formula that incorporates the triceps skinfold and the MAC

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Glossary

Middle-level manager  a manager who supervises a number of firstlevel managers and is responsible for the activities in the departments supervised Midlevel theories  focus on exploration of concepts such as pain, self-esteem, learning, and hardiness Midstream urine specimen  see Clean-catch urine specimen Milliequivalent  one thousandth of an equivalent, which is the chemical combining power of a substance Minerals  a substance found in organic compounds, as inorganic compounds and as free ions Minor surgery  surgery that involves little risk, produces few complications, and is often performed in a “day surgery” facility Miosis  constricted pupils Misdemeanor  a legal offense usually punishable by a fine or a short-term jail sentence, or both Mixed hearing loss  a combination of conduction and sensorineural loss Mobility  ability to move about freely, easily, and purposefully in the environment Mode  the score or value that occurs most frequently in a distribution of scores Modeling  observing the behavior of people who have successfully achieved a goal that one has set for oneself and, through observing, acquiring ideas for behavior and coping strategies Monosaccharides  sugars that are composed of single molecules Monotheism  belief in the existence of one God Monounsaturated fatty acids  a fatty acid with one double bond Moral  relating to right and wrong Moral behavior  the way a person perceives the requirements necessary for people to live together and how he or she responds to them Moral development  process of learning to tell the difference between right and wrong and of learning what ought and ought not to be done Moral rules  specific prescriptions for actions Morality  a doctrine or system denoting what is right and wrong in conduct, character, or attitude Mortician  a person trained in the care of the dead; also called an undertaker Motivation  the desire to learn Mourning  the process through which grief is eventually resolved or altered Multidisciplinary care plan  a standardized plan that outlines the care required for clients with common, predictable—usually medical—conditions Music therapy  the behavioral science concerned with the systematic application of music to produce relaxation and desired changes in emotions, behavior, and physiology Mutual pretense  a type of awareness in which the client, family, and health personnel know that the prognosis is terminal but do not talk about it and make an effort not to raise the subject Mutual recognition model  a regulatory model developed by the National Council of State Boards of Nursing, which allows for multistate licensure Mydriasis  enlarged pupils Myocardial infarction (MI)  heart attack; cardiac tissue necrosis owing to obstruction of blood flow to the heart Myocardium  a layer of the heart wall; cardiac muscle cells that form the bulk of the heart and contract with each beat Myopia nearsightedness Narcolepsy  an uncontrollable desire for sleep or attacks of sleep during the day Narrative charting  a descriptive record of client data and nursing interventions, written in sentences and paragraphs

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Nasoenteric tube  a tube inserted through one of the nostrils, down the nasopharynx, and into the alimentary tract Nasogastric (NG) tube  a tube inserted by way of the nasopharynx or the oropharynx; it is placed into the stomach for the temporary purpose of feeding the client or to remove gastric secretions Naturopathic medicine  practice that focuses on nutrition, herbs, homeopathy, acupuncture, hydrotherapy, physical medicine, counseling, and minor surgical interventions Negative feedback  feedback that inhibits change Negligence  failure to behave in a reasonable and prudent manner; an unintentional tort Nephrostomy  diversion of urine from a kidney to a stoma Nerve block  chemical interruption of a nerve pathway effected by injecting a local anesthetic Network linkages Networking  a process by which people develop linkages throughout a profession to communicate, share ideas and information, and offer support and direction to each other Neurectomy  surgery in which peripheral or cranial nerves are interrupted to alleviate localized pain Neurogenic bladder  interference with the normal mechanisms of urine elimination in which the client does not perceive bladder fullness and is unable to control the urinary sphincters; the result of impaired neurologic function Neuropathic pain  experienced by people who have damaged or malfunctioning nerves as a result of illness, injury, or undetermined reasons Neutral question  a question that does not direct or pressure a client to answer in a certain way Nitrogen balance  a measure of the degree of protein anabolism and catabolism; net result of intake and loss of nitrogen Nociception  the physiological processes related to pain perception Nociceptor  a pain receptor Nocturia  voiding two or more times at night Nocturnal emissions  orgasm and emission of semen during sleep Nocturnal enuresis  involuntary urination at night Nocturnal frequency  the need for older adults to arise during the night to urinate Nondirective interview  an interview using open-ended questions and empathetic responses to build rapport and learn client concerns Nondirective leader  see Laissez-faire leader Nonessential amino acids  an amino acid that the body can manufacture Nonmaleficence  the duty to do no harm Nonspecific defenses  bodily defenses that protect a person against all microorganisms, regardless of prior exposure Nonsteroidal anti-inflammatory drugs (NSAIDs)  drugs such as aspirin and ibuprofen that have anti-inflammatory, analgesic, and antipyretic effects Nonverbal communication  communication other than words, including gestures, posture, and facial expressions Norm  an ideal or fixed standard; an expected standard of behavior of group members Normocephalic  normal head size Normocephaly  normal head circumference at birth; usually 35 cm (14 in.) Nosocomial infections  infections that originate in a hospital NPO  Nothing by mouth; literally, “nil per os” NREM (non-REM) sleep  a deep restful sleep rate; also called slow wave sleep Nuclear family  a family of parents and their offspring Nurse informaticist  an expert who combines computer, information, and nursing science to develop policies and procedures that promote

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Glossary effective use of computerized records by nurses and other health care professionals Nursing  the attributes, characteristics, and actions of a nurse providing care on behalf of, or in conjunction with, a client Nursing diagnosis  the nurse’s clinical judgment about individual, family, or community responses to actual and potential health problems/ life processes to provide the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable Nursing ethics  ethical issues that occur in nursing practice Nursing informatics  the science of using computer information systems in the practice of nursing Nursing intervention  any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes Nursing Interventions Classification (NIC)  a taxonomy of nursing actions each of which includes a label, a definition, and a list of activities Nursing Outcomes Classification (NOC)  a taxonomy for describing client outcomes that respond to nursing interventions Nursing process  a systematic rational method of planning and providing nursing care Nutrients  organic, inorganic, energy-producing substances found in foods and required for body functioning Nutrition  the sum of all interactions between an organism and the food it consumes Nutritive value  the nutrient content of a specified amount of food Nystagmus  rapid involuntary rhythmic eye movement Obese (obesity)  when body mass index (BMI) is greater than 30 kg/m2 Objective data  information (data) that is detectable by an observer or can be tested against an accepted standard; can be seen, heard, felt, or smelled; also called signs Obligatory losses  essential fluid losses required to maintain body functioning Occult blood  hidden blood Occupational exposure  skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties Official name (of drug)  the name under which a drug is listed in one of the official publications (e.g., the United States Pharmacopeia) Oils  lipids that are liquid at room temperature Olfactory  related to smell Oliguria  production of abnormally small amounts of urine by the kidney Oncotic pressure  see Colloid osmotic pressure One-point discrimination  the ability to sense whether one or two areas of the skin are being stimulated by pressure Online  connected to a computer network Onset of action  the time after drug administration when the body initially responds to the drug Open awareness  a type of awareness in which a client and people around know about an impending death Open-ended questions  questions that specify only a broad topic to be discussed and invite clients to discover and explore their thoughts and feelings about the topic Operational definitions  definitions that specify the instruments or procedures by which concepts will be measured Ophthalmic  pertaining to medications for the eye Opportunistic pathogen  a microorganism causing disease only in a susceptible individual Oral  a method of administration in which the drug is swallowed Oral–genital sex  oral stimulation of either female or male genitals Organizing  determining responsibilities, communicating expectations, and establishing the chain of command for authority and communication Orgasmic phase  part of the response cycle, the involuntary climax of sexual tension, accompanied by physiological and psychological release

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Orthopnea  ability to breathe only when in an upright position (sitting or standing) Orthopneic position  a sitting position to relieve respiratory difficulty in which the client sits either in bed or on the side of the bed, leaning over an overbed table across the lap; an adaptation of the high-Fowler’s position Orthostatic hypotension  decrease in blood pressure related to positional or postural changes from lying to sitting or standing positions Osmolality  the concentration of solutes in body fluids Osmosis  passage of a solvent through a semipermeable membrane from an area of lesser solute concentration to one of greater solute concentration Osmotic pressure  pressure exerted by the number of nondiffusible particles in a solution; the amount of pressure needed to stop the flow of water across a membrane Ossicles  the three middle ear bones of sound transmission Osteoporosis  demineralization of the bone Ostomy  an opening on the abdominal wall for the elimination of feces or urine Otic  refers to instillations or irrigations of the external auditory canal Otoscope  an instrument used to view the ear Outcome evaluation  focuses on demonstrable changes in a client’s health status as a result of nursing care Output  energy, matter, or information from a system given out by the system as a result of its processes Overhydration  occurs when water is gained in excess of electrolytes, resulting in low serum osmolality and low serum sodium levels, also known as hypo-osmolar imbalance or water intoxication Overnutrition  refers to a caloric intake in excess of daily energy requirements, resulting in storage of energy in the form of increased adipose tissue Overweight  a BMI of 25 to 29.9 kg/m2 Oxyhemoglobin  the compound of oxygen and hemoglobin Pace  number of steps taken per minute or the distance taken in one step when walking Packing  filling an open wound or cavity with a material such as gauze Pain  whatever the experiencing person says it is, existing whenever he or she says it does Pain threshold  the least amount of stimuli that is needed for a person to label a sensation as pain Pain tolerance  the maximum amount of painful stimuli that a person is willing to withstand without seeking avoidance of the pain or relief Palliative care  the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual Pallor paleness Palpation  the examination of the body using the sense of touch Papanicolaou (Pap) test  a method of taking a sample of cervical cells for microscopic examination to detect malignancy Paradigm  a pattern of shared understandings and assumptions about reality and the world Parasites  microorganisms that live in or on another from which it obtains nourishment Parasomnia  a cluster or pattern of waking behavior that appears during sleep, such as somnambulism (sleepwalking), sleeptalking, and enuresis (bed-wetting) Parenteral  drug administration using a medication route other than the alimentary or digestive tract; injected into the body intradermally, subcutaneously, intramuscularly, or intravenously Paresis  slight or incomplete paralysis Parotitis  inflammation of the parotid salivary gland Partial pressure  the pressure exerted by each individual gas in a mixture according to its percentage concentration in the mixture

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Partially complete proteins  proteins that contain less than the required amount of one or more essential amino acids; cannot alone support continued growth Participative leader  see Democratic leader Passive (acquired) immunity  a resistance of the body to infection in which the host receives natural or artificial antibodies produced by another source Passive euthanasia  allowing a person to die by withholding or withdrawing measures to maintain life Passive range-of-motion (ROM) exercise  exercise in which another person moves each of the client’s joints through their complete range of movement, maximally stretching all muscle groups within each plane over each joint Pathogenicity  the ability to produce disease; a pathogen is a microorganism that causes disease Pathologic fractures  spontaneous fractures to which older adults are prone Patient  a person who is waiting for or undergoing medical treatment and care Patient-controlled analgesia (PCA)  an interactive method of pain management that permits clients to treat their pain by self-administering doses of analgesics Patient-focused care  delivery model that brings all services and care providers to the client Patient Self-Determination Act (PSDA)  legislation requiring that every competent adult be informed in writing on admission to a health care institution about his or her rights to accept or refuse medical care and to use advance directives Peak level  indicates the highest concentration of the drug in the blood serum Peak plasma level  the concentration of a drug in the blood plasma that occurs when the elimination rate equals the rate of absorption Pedagogy  the discipline concerned with helping children learn Pediculosis (lice)  infestation with head lice, Pediculus capitis; body lice, Pediculus corporis; or crab lice, Pediculus pubis Peer groups  assume great importance and have a number of functions: provide a sense of belonging, pride, social learning, and sexual roles; most peer groups have well-defined, gender-specific modes of acceptable behavior and in adolescence, the peer groups change with age Penrose drain  a flat, thin, rubber tube inserted into a wound to allow for fluid to flow from the wound; it has an open end that drains onto a dressing Perceived loss  the loss experienced by a person that cannot be verified by others Perception  the ability to interpret the environment through the senses Percussion (in assessment)  a method in which the body surface is struck to elicit sounds that can be heard or vibrations that can be felt Percutaneous  route of absorption of a topical medication through the skin Percutaneous endoscopic gastrostomy (PEG)  a procedure in which a PEG catheter is inserted into the stomach through the skin and subcutaneous tissues of the abdomen; used as a feeding tube Percutaneous endoscopic jejunostomy (PEJ)  a procedure in which a PEJ catheter is inserted into the jejunum through the skin and subcutaneous tissues of the abdomen; used as a feeding tube Perfusion  passage of blood constituents through the vessels of the circulatory system Pericardium  double layer of fibroserous membrane of the heart; the parietal, or outermost, pericardium serves to protect the heart and anchor it to surrounding structures Peridural anesthesia  see Epidural anesthesia Perineal (peri-) care  cleansing of the perineum (genitalia) Periodontal disease  disorder of the supporting structures of the teeth

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Perioperative period  refers to the three phases of surgery: preoperative, intraoperative, and postoperative Peripheral neuropathic pain  phantom pain, post-herpetic neuralgia, or carpal tunnel syndrome that follows damage and/or sensitization of peripheral nerves Peripheral pulse  a pulse located in the periphery of the body (e.g., foot, hand, or neck) Peripheral vascular resistance (PVR)  impedance or opposition to blood flow to the tissues; determined by viscosity, or thickness, of the blood; blood vessel length; blood vessel diameter Peripherally inserted central catheter (PICC)  a long venous catheter inserted in an arm vein and extending into the distal third of the superior vena cava Peripherals  at the edge or outward boundary Peristalsis  wavelike movements produced by circular and longitudinal muscle fibers of the intestinal walls; the movement propels the intestinal contents onward Permissive leader  see Laissez-faire leader Personal computer (PC)  an individual microcomputer system referred to as a desktop, portable, laptop, notebook, or handheld computer Personal knowing  promotes wholeness and integrity in the personal encounter to achieve engagement Personal protective equipment (PPE)  barriers such as gloves, mask, and gown used to protect individuals from contact with potentially infective materials Personal space  the distance people prefer in interactions with others Personal values  values internalized from the society or culture in which one lives Personality  the outward expression of the inner self PES format  the three essential components of nursing diagnostic statements including the terms describing the problem, the etiology of the problem, and the defining characteristics or cluster of signs and symptoms pH  a measure of the relative alkalinity or acidity of a solution; a measure of the concentration of hydrogen ions Phagocytes  cells that ingest microorganisms, other cells, and foreign particles Pharmacist  a person licensed to prepare and dispense drugs and prescriptions Pharmacodynamics  the process by which a drug alters cell physiology Pharmacogenetics  process by which the effect of a drug is influenced by genetic variations such as gender, size, and body composition Pharmacokinetics  the study of the absorption, distribution, biotransformation, and excretion of drugs Pharmacology  the scientific study of the actions of drugs on living animals and humans Pharmacopoeia  a book containing a list of drug products used in medicine, including their descriptions and formulas Pharmacy  the art of preparing, compounding, and dispensing drugs; also refers to the place where drugs are prepared and dispensed Phenomenology  research that investigates people’s life experiences and how they interpret those experiences Philosophy  an early effort to define phenomena that serves as the basis for later theoretical formulations Phlebotomist  a person from a laboratory who performs venipuncture, collecting the blood specimen for the tests ordered by the primary care provider Physical activity  bodily movement produced by skeletal muscles that requires energy expenditure and produces progressive health benefits Physical restraints  any manual method or physical or mechanical device, material, or equipment attached to a client’s body that cannot be removed easily and that restricts the client’s movement Physiological dependence  biochemical changes occurring in the body as a result of excessive use of a drug

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Glossary Physiological pain  experienced when an intact, properly functioning nervous system sends signals that tissues are damaged, requiring attention and repair PIE  an acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions Piggyback  a secondary IV setup that connects a second container to the tubing of a primary container at the upper port; used solely for intermittent drug administration Pilates  method of physical movement and exercise designed to stretch, strengthen, and balance the body, in particular the core of the body Pinna  see Auricle Pitch  the frequency (number of the vibrations per second) heard during auscultation Pitting edema  edema in which firm finger pressure on the skin produces an indentation (pit) that remains for several seconds Placebo  any medication or procedure that produces an effect in a client because of its implicit or explicit intent, and not because of its specific physical or chemical properties Placenta  a flat, disc-shaped organ that is highly vascular and normally forms in the upper segment of the endometrium of the uterus; exchanges nutrients and gases between the fetus and the mother Plaintiff  a person claiming infringement of legal rights by one or more individuals Planned change  an intended, purposive attempt by an individual, group, organization, or larger social system to influence its own status quo or that of another organism or situation Planning  an ongoing process that involves (a) assessing a situation, (b) establishing goals and objectives based on assessment of a situation or future trends, and (c) developing a plan of action that identifies priorities, delineates who is responsible, determines deadlines, and describes how the intended outcome is to be achieved and evaluated Plantar wart  a wart on the sole of the foot Plaque  an invisible soft film consisting of bacteria, molecules of saliva, and remnants of epithelial cells and leukocytes that adheres to the enamel surface of teeth Plasma  the fluid portion of the blood in which the blood cells are suspended Plateau  a maintained concentration of a drug in the plasma during a series of scheduled doses Pleximeter  in percussion, the middle finger of the dominant hand that is placed firmly on the client’s skin Plexor  in percussion, the middle finger of the nondominant hand or a percussion hammer used to strike the pleximeter Pneumothorax  accumulation of air in the pleural space Point of maximal impulse (PMI)  the point where the apex of the heart touches the anterior chest wall and heart movements are most easily observed and palpated Policies  rules developed to govern the handling of frequently occurring situations Polycythemia  a condition in which clients with chronic hypoxia may develop higher than normal counts of red blood cells Polydipsia  excessive thirst Polypnea  abnormally fast respirations Polysaccharides  a branched chain of dozens, sometimes hundreds, of glucose molecules; starches Polysomnography  a cluster or pattern of waking behavior that appears during sleep, such as somnambulism (sleepwalking), sleeptalking, and enuresis (bed-wetting) Polytheism  the belief in more than one God Polyunsaturated fatty acids  fatty acid with more than one double bond (or many carbons not bonded to a hydrogen atom) Polyuria  see Diuresis Population  includes all possible members of a group who meet the criteria for a study

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Positive feedback  feedback that stimulates change Positive reinforcement  giving rewards such as praise for a learner’s achievements Positron emission tomography (PET)  a noninvasive radiologic study that involves the injection or inhalation of a radioisotope Possible nursing diagnosis  one in which evidence about a health problem is incomplete or unclear Postanesthesia care unit (PACU)  unit the client is transferred to after surgery Postanesthesia room (PAR)  see Postanesthesia care unit (PACU) Postmortem care  care of the body after death Postmortem examination  see Autopsy Postoperative phase  the period of surgery that begins with the admission of a client to the postanesthesia area and ends when healing is complete Postural drainage  positioning of a client to allow the drainage, by gravity, of secretions from the lungs Potentiating effect  the increased effect of one or both drugs Practice discipline  field of study in which the central focus is performance of a professional role (nursing, teaching, management, making music) Prayer  human communication with divine and spiritual entities Preceptor  an experienced nurse who assists the novice nurse in improving nursing skill and judgment Precontemplation stage  a person typically denies having a problem and instead views others as having a problem and therefore wants to change the other person’s behavior Precordium  an area of the chest overlying the heart Preemptive analgesia  the administration of analgesics prior to an invasive or operative procedure in order to treat pain before it occurs Preferred provider arrangements (PPAs)  similar to preferred provider organizations, but PPAs can contract with individual health care providers; the plan can be limited or unlimited Preferred provider organization (PPO)  a group of physicians or a hospital that provides companies with health services at a discounted rate Prefilled unit-dose system  disposable units that provide injectable medications that are available as prefilled syringes ready for use, or as prefilled sterile cartridges and needles that require the attachment of a reusable holder before use Prejudice  a negative belief or preference that is generalized about a group and that leads to “prejudgment” Preload  the degree to which muscle fibers in the ventricle are stretched at the end of diastole Preoperative phase  the period of surgery that begins when the decision for surgery has been made and ends when the client is transferred to the operating room bed Preparation stage  occurs when the person undertakes cognitive and behavioral activities that prepare the person for change Presbycusis  generalized loss of hearing related to aging Presbyopia  loss of elasticity of the lens and thus loss of ability to see close objects as a result of the aging process Prescription  the written direction for the preparation and administration of a drug Presencing  being present, being there, or just being with a client Pressure  a compressing downward force on a body area Pressure ulcers  reddened areas, sores, or ulcers of the skin occurring over bony prominences Primary care (PC)  the point of entry into the health care system at which initial health care is given Primary health care (PHC)  essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community

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through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination Primary intention healing  tissue surfaces are approximated (closed) and there is minimal or no tissue loss, formation of minimal granulation tissue and scarring Primary prevention  activities directed toward the protection from or avoidance of potential health risks Primary sexual characteristics  relate to the organs necessary for reproduction, such as the testes, penis, vagina, and uterus Principles-based (deontological) theories  emphasize individual rights, duties, and obligations Priority setting  the process of establishing a preferential order for nursing strategies Private (civil) law  the body of law that deals with relationships between private individuals Prn order  “as needed order”; permits the nurse to give a medication when, in the nurse’s judgment, the client requires it Problem solving  obtaining information that clarifies the nature of the problem and suggests possible solutions Problem-oriented medical record (POMR)  data about the client are recorded and arranged according to the client’s problems, rather than according to the source of the information Problem-oriented record (POR)  see Problem-oriented medical record (POMR) Procedures  steps used in carrying out policies or activities Process evaluation  a component of quality assurance that focuses on how care was given Process recording  the verbatim (word-for-word) account of a conversation Proctoscopy  the viewing of the rectum Proctosigmoidoscopy  the viewing of the rectum and sigmoid colon Productivity  in health care, frequently measured by the amount of nursing resources used per client or in terms of required versus actual hours of care provided Profession  an occupation that requires extensive education or a calling that requires special knowledge, skill, and preparation Professional values  values acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers Professionalism  a set of attributes, a way of life that implies responsibility and commitment Professionalization  the process of becoming professional; acquiring characteristics considered to be professional Progress notes  chart entries made by a variety of methods and by all health professionals involved in a client’s care for the purpose of describing a client’s problems, treatments, and progress toward desired outcomes Prompted voiding  supplements habit training by encouraging the client to try to use the toilet (prompting) and reminding the client when to void Prone position  position in which a client lies on his or her abdomen with the head turned to one side Proprioception  awareness of posture, movement, and changes in equilibrium; knowledge of position, weight, and resistance of objects in relation to body Proprioceptors  sensory receptors that are sensitive to movement and the position of the body Protein-calorie malnutrition (PCM)  an imbalance between nutritional intake and the body’s protein requirements Protocols  a predetermined and preprinted plan specifying the procedure to be followed in a particular situation Proxemics  the study of distance between people in their interactions Psychological dependence  a state of emotional reliance on a drug to maintain one’s well-being; a feeling of need or craving for a drug

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Psychological homeostasis  emotional or psychological balance or state of mental well-being Psychomotor domain  the “skill” domain; includes motor skills such as giving an injection Puberty  the first stage of adolescence in which sexual organs begin to grow and mature Public law  refers to the body of law that deals with relationships between individuals and the government and governmental agencies Pulse  the wave of blood within an artery that is created by contraction of the left ventricle of the heart Pulse deficit  the difference between the apical pulse and the radial pulse Pulse oximeter  a noninvasive device that measures the arterial blood oxygen saturation by means of a sensor attached to the finger or other location Pulse pressure  the difference between the systolic and the diastolic blood pressure Pulse rhythm  the pattern of the beats and intervals between the beats Pulse volume  the strength or amplitude of the pulse, the force of blood exerted with each heartbeat Pureed diet  a modification of the soft diet wherein liquid may be added to the food, which is then blended to a semisolid consistency Purkinje fibers  fibers of the ventricular conduction pathways that terminate in ventricular muscle, stimulating contraction Purulent exudates  an exudate consisting of leukocytes, liquefied dead tissue debris, and dead and living bacteria Pus  pooled exudates Pyogenic bacteria  bacteria that produce pus Pyorrhea  advanced periodontal disease in which teeth are loose and pus is evident when the gums are pressed Pyrexia  a body temperature above the normal range; fever Qi  body’s vital energy Qigong  breathing and mental exercises combined with body movements Qualifiers  words that have been added to some NANDA labels to give additional meaning to the diagnostic statement Quality  a subjective description of an auscultated sound (e.g., whistling, gurgling, or snapping) Quality assurance (QA) program  an ongoing systematic process designed to evaluate and promote excellence in the health care provided to clients Quality improvement  an organizational commitment and approach used to continuously improve all processes in the organization with the goal of meeting and exceeding customer expectations and outcomes; also known as total quality management (TQM) and continuous quality improvement (CQI) Race  classification of people according to shared biologic characteristics and physical features Radiating pain  pain perceived at the source and in surrounding or nearby tissues Radiation  the transfer of heat from the surface of one object to the surface of another without contact between the two objects Radiopharmaceutical  a pharmaceutical (targeted to a specific organ) labeled with a radioisotope, administered through various routes, to determine hyperfunction or hypofunction of the organ Random access memory (RAM)  data and instructions stored on chips; RAM storage is temporary and cleared when the computer is turned off Range  a measure of variability, consisting of the difference between the highest and lowest values in a distribution of scores Range of motion (ROM)  the maximum degree of movement possible for each joint Rapport  a relationship between two or more people of mutual trust and understanding

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Glossary Rationale  the scientific reason for selecting a specific action RBC indices  may be performed as part of the CBC to evaluate the size, weight, and hemoglobin concentration of red blood cells Reactive hyperemia  a bright red flush on the skin occurring after pressure is relieved Readiness  behaviors or cues that reflect a learner’s motivation to learn at a specific time Reagent  a substance used to produce a chemical reaction to detect or measure other substances Recent memory  deals with activities of the recent past of minutes to a few hours Receptor  a location on the surface of a cell membrane or within a cell (usually a protein) to which a drug chemically binds Reconstitution  the technique of adding a diluent to a powdered drug to prepare it for administration Record  a written communication providing formal, legal documentation of a client’s progress Recording  the process of making written entries about a client on the medical record Red blood cell (RBC) count  number of red blood cells per cubic millimeter of whole blood Red blood cell (RBC) indices  evaluate size, weight, and hemoglobin concentrations of RBCs Referred pain  pain perceived to be in one area but whose source is another area Reflection  thinking from a critical point of view, analyzing why one acted in a certain way, and assessing the results of one’s actions Reflex  an automatic response of the body to a stimulus Reflexology  a treatment based on massage of the feet to relieve symptoms in other parts of the body Reflux  backward flow Regeneration  renewal, regrowth, the replacement of destroyed tissue cells by cells that are identical or similar in structure and function Regional anesthesia  the temporary interruption of the transmission of nerve impulses to and from a specific area or region of the body; the client loses sensation in an area of the body but remains conscious Registry  private duty agency that contracts with individual practitioners Regression  a defense mechanism in which one adapts behavior that was comforting earlier in life to overcome the discomfort and insecurity of the present situation Regurgitation  the spitting up or backward flow of undigested food Relapsing fever  the occurrence of short febrile periods of a few days interspersed with periods of 1 or 2 days of normal temperature Relationship-based (caring) theories  stress courage, generosity, commitment, and the need to nurture and maintain relationships Relaxation response  physiological state achieved through deep relaxation breathing Reliability  the degree to which an instrument produces consistent results on repeated use Religion  an organized system of worship REM sleep  sleep during which the person experiences rapid eye movements Remission  a period during a chronic illness when there is a lessening of severity or cessation of symptoms Remittent fever  the occurrence of a wide range of temperature fluctuations, more than 2°C (3.6°F) over a 24-hour period, all of which are above normal Renin-angiotensin-aldosterone system  system initiated by specialized receptors in the juxtaglomerular cells of the kidney nephrons that respond to changes in renal perfusion Report  oral, written, or computer-based communication intended to convey information to others Repression  a defense mechanism in which painful thoughts, experiences, and impulses are removed from awareness

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Res ipsa loquitur  “the thing that speaks for itself”; a legal doctrine that relates to negligence in which the harm cannot be traced to a specific health care provider or standard but does not normally occur unless there has been a negligent act Researchability  the problem can be subjected to scientific investigation Reservoir  a source of microorganisms Resident flora  microorganisms that normally reside on the skin and mucous membranes, and inside the respiratory and gastrointestinal tracts Residual urine  the amount of urine remaining in the bladder after a person voids Resolution phase  the part of the response cycle period of return to the unaroused state, which may last 10 to 15 minutes after orgasm, or longer if there is no orgasm Resonance  a hollow sound as produced by lungs filled with air during percussion Respiration  the act of breathing; includes the intake of oxygen and the output of carbon dioxide from the cells to the atmosphere Respiratory acidosis  (hypercapnia) a state of excess carbon dioxide in the body Respiratory alkalosis  a state of excessive loss of carbon dioxide from the body Respiratory character  see Respiratory quality Respiratory membrane  where gas exchange occurs between the air on the alveolar side and the blood on the capillary side; the alveolar and capillary walls form the respiratory membrane Respiratory quality  refers to those aspects of breathing that are different from normal, effortless breathing, includes the amount of effort exerted to breathe and the sounds produced by breathing Respiratory rhythm  refers to the regularity of expirations and inspirations Respondeat superior  a legal term meaning “let the master answer”; an employer assumes responsibility for the conduct of its employees and can also be held responsible for malpractice by employees Responsibility  the specific accountability or liability associated with the performance of duties of a particular role Resting energy expenditure (REE)  the amount of energy required to maintain basic body functions Resting tremor  a tremor that is apparent when the client is at rest and diminishes with activity Restraints  protective devices used to limit physical activity of the client or a part of the body Retrograde pyelography  a radiographic study used to evaluate the urinary tract Retrospective audit  evaluation of a client’s record after discharge from an agency Review of systems  see Screening examination Rhizotomy  interruption of the anterior or posterior nerve root between the ganglion and the cord; generally performed on cervical nerve roots to alleviate pain of the head and neck Right  (legal) a privilege or fundamental power to which an individual is entitled unless it is revoked by law or given up voluntarily Right of self-determination  subjects feel free from constraints, coercion, or any undue influence to participate in a study Rigor mortis  stiffening of the body that occurs 2 to 4 hours after death Risk factors  factors that cause a client to be vulnerable to developing a health problem Risk management  having in place a system to reduce danger to clients and staff Risk nursing diagnosis  clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene Risk of harm  exposure to the possibility of injury going beyond everyday situations

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Role  the set of expectations about how a person occupying a specific position behaves Role ambiguity  unclear role expectations; people do not know what to do or how to do it and are unable to predict the reactions of others to their behavior Role conflict  a clash between the beliefs or behaviors imposed by two or more roles fulfilled by one person Role development  involves socialization into a particular role Role mastery  performance of role behaviors that meet social expectations Role model  providing an example of acceptable behavior(s) through demonstration Role performance  what a person does in a particular role in relation to the behaviors expected of that role Role strain  a generalized state of frustration or anxiety experienced with the stress of role conflict and ambiguity Root cause analysis  process for identifying factors that bring about deviations in practices that lead to an event S1  the first heart sound; occurs when the atrioventricular valves (mitral and tricuspid) close S2  the second heart sound; occurs when the semilunar valves (aortic and pulmonic) close Safety monitoring device  an electronic sensor or monitor that detects when clients are attempting to get out of a bed or chair and triggers an alarm Sairy Gamp  a character in the Charles Dickens book Martin Chizzlewit who represented the negative image of nurses in the early 1800s Saliva  the clear liquid secreted by the salivary glands in the mouth Sample  (statistics) segment of the population from whom data will be collected Sanguineous exudate  an exudate containing large amounts of red blood cells; also called hemorrhagic exudate Sarcopenia  steady decrease in muscle fibers Saturated fatty acids  those in which all carbon atoms are filled to capacity (i.e., saturated) with hydrogen Scabies  a contagious skin infestation by the itch mite that produces intense itching, especially at night Scald  a burn from a hot liquid or vapor, such as steam Scientific health belief  based on the belief that life and life processes are controlled by physical and biochemical processes that can be manipulated by humans Screening examination  a brief review of essential functioning of various body parts or systems; also called review of systems Scrub person  usually UAP but can be a registered nurse (RN) or LPN; assists the surgeons by draping the client with sterile drapes and handling sterile instruments and supplies; with the circulating nurse, is responsible for accounting for all sponges, needles, and instruments at the close of surgery Sebaceous glands  active under the influence of androgens in both males and females, which secrete sebum and become most active on the face, neck, shoulder, upper back, and chest; are often the cause of an increased incidence of acne Sebum  the oily, lubricating secretion of sebaceous glands in the skin Secondary intention healing  wound in which the tissue surfaces are not approximated and there is extensive tissue loss; formation of excessive granulation tissue and scarring Secondary prevention  activities designed for early diagnosis and treatment of disease or illness Secondary sexual characteristics  physical characteristics that differentiate the male from the female but do not relate directly to reproduction Seizure  a sudden onset of excessive electrical discharges in one or more areas of the brain

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Seizure precautions  safety measures taken to protect clients from injury should they have a seizure Selectively permeable  cell membranes that allow substances to move across them with varying degrees of ease Self-awareness  the relationship between one’s perception of oneself and others’ perceptions of oneself Self-concept  the collection of ideas, feelings, and beliefs one has about oneself Self-esteem  the value one has for oneself; self-confidence Self-regulation  homeostatic mechanisms that come into play automatically in the healthy person Semicircular canals  in the inner ear; contain the organs of equilibrium Semi-Fowler’s (low-Fowler’s) position  a bed-sitting position in which the head of the bed is raised 15° to 45°, typically at a 30° angle Semilunar valves  crescent moon-shaped valves between the cardiac ventricles and the pulmonary artery (pulmonic valve) and the aorta (aortic valve) Sensorineural hearing loss  the result of damage to the inner ear, the auditory nerve, or the hearing center in the brain Sensoristasis  the need for sensory stimulation Sensory deficit  partial or complete impairment of any sensory organ Sensory deprivation  insufficient sensory stimulation for a person to function Sensory memory  momentary perception of stimuli by the senses Sensory overload  an overabundance of sensory stimulation Sensory perception  the organization and translation of stimuli into meaningful information Sensory reception  process of receiving environmental stimuli Sentinel event  an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof Separation anxiety  the fear and frustration experienced by young children that comes with parental absences Sepsis  the presence of pathogenic organisms or their toxins in the blood or body tissues Septicemia  occurs when bacteremia results in systemic infection Septum  a dividing structure such as that between the cardiac chambers or between the two sides of the nose Serosanguineous exudate  inflammatory material consisting of a combination of clear and blood-tinged drainage Serous exudates  inflammatory material composed of serum (clear portion of blood) derived from the blood and serous membranes of the body such as the peritoneum, pleura, pericardium, and meninges; watery in appearance and has few cells Serum osmolality  a measure of the solute concentration of the blood Sexual aversion disorder  severe distaste for sexual activity or thought of sexual activity Sexual health  the integration of the somatic, emotional, intellectual, and social aspects of sexuality, in ways that are positively enriching and that enhance personality, communication, and love Sexual orientation  the preference of a person for one gender or the other Sexual pain disorders  include dyspareunia, vaginismus, and genital pain Sexual self-concept  how one values oneself as a sexual being Shaft  the part of the needle that is attached to the hub; also called the cannula Shaken baby syndrome (SBS)  violent shaking of an infant by the arms or shoulders causing a whiplash, which can lead to severe injury Shared governance  a method that aims to distribute decision making among a group of people Shared leadership  a contemporary theory of leadership that recognizes the leadership capabilities of each member in a professional group

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Glossary and assumes that appropriate leadership will emerge in relation to the challenges that confront the group Shearing force  a combination of friction and pressure that, when applied to the skin, results in damage to the blood vessels and tissues Shock phase  first part of the alarm reaction in which the stressor may be perceived consciously or unconsciously by the person Short-term memory  information held in the brain for immediate use or what one has in mind at a given moment Shroud  a large piece of plastic or cotton material used to enclose a body after death Side effect  the secondary effect of a drug that is unintended; usually predictable and may be either harmless or potentially harmful Significance  the potential to contribute to nursing science by enhancing client care, testing or generating a theory, or resolving a dayto-day clinical problem Signs  detectable by an observer or can be measured or tested against an accepted standard; can be seen, heard, felt, or smelled; also called objective data Sims’ (semiprone) position  side-lying position with lowermost arm behind the body and the upper arm at the shoulder and the elbow, with the client’s legs flexed in front Single order  an order that is to be carried out one time only at a specified time Sinoatrial (SA or sinus) node  the primary pacemaker of the heart located where the superior vena cava enters the right atrium Situation, background, assessment, and recommendation (SBAR) process  a structured approach to documentation used when nurses communicate with primary care providers and other nurses about client status Situational leader  adapts style according to consideration of the staff members’ abilities, knowledge of the nature of the task to be done, and sensitivity to the context or environment in which the task takes place Sitz bath  a bath in which the client sits in warm water to help soothe and heal the perineum Skinfold measurement  an indicator of the amount of body fat, the main form of stored energy Slander  defamation by the spoken word, stating unprivileged (not legally protected) or false words by which a reputation is damaged Sleep  an altered state of consciousness in which the individual’s perception of and reaction to the environment are decreased Sleep apnea  periodic cessation of breathing during sleep Sleep architecture  basic organization of normal sleep Sleep hygiene  refers to interventions used to promote sleep Small calorie (c, cal)  the amount of heat required to raise the temperature of 1 g of water 1°C SOAP  an acronym for a charting method that follows a recording sequence of subjective data, objective data, assessment, and planning Socialization  a process by which a person learns the ways of a group or society in order to become a functioning participant Socratic questioning  a technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate what one knows from what one merely believes Sojourner Truth  an abolitionist, Underground Railroad agent, preacher, and women’s rights advocate, she was a nurse for more than 4 years during the Civil War and worked as a nurse and counselor for the Freedman’s Relief Association after the war Solutes  substances dissolved in a liquid Solvent  the liquid in which a solute is dissolved Somatic pain  originates in the skin, muscles, bone, or connective tissue Somnology  the study of sleep Sordes  accumulation of foul matter (food, microorganisms, and epithelial elements) on the teeth and gums

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Source-oriented clinical record  a record in which each person or department makes notations in a separate section or sections of the client’s chart Spastic  describing the sudden, prolonged involuntary muscle contractions of clients with damage to the central nervous system Specific defenses  immune functions directed against identifiable bacteria, viruses, fungi, or other infectious agents; also called immune defenses Specific gravity  the weight or degree of concentration of a substance compared with that of an equal volume of another, such as distilled water, taken as a standard Specific self-esteem  how much one approves of a certain part of oneself Spinal anesthesia  anesthesia produced by injecting an anesthetic agent into the subarachnoid space surrounding the spinal cord; also referred to as a subarachnoid block (SAB) Spinal cord stimulation (SCS)  involves the insertion of a cable that allows the placement of an electrode directly on the spinal cord and is used with nonmalignant pain that has not been controlled with less invasive therapies Spinal tap  see Lumbar puncture (LP) Spiritual distress  a disturbance in or a challenge to a person’s belief or value system that provides strength, hope, and meaning to life Spiritual health  see Spiritual well-being Spiritual well-being  a feeling of inner peace and of being generally alive, purposeful, and fulfilled; the feeling is rooted in spiritual values and/ or specific religious beliefs Spirituality  belief in or relationship with some higher power, creative force, driving being, or infinite source of energy Spreadsheet  programs that manipulate primarily numbers Sputum  the mucous secretion from the lungs, bronchi, and trachea Stage of exhaustion  the third stage in the adaptation syndromes that occurs when the adaptation that the body made during the second stage cannot be maintained Stage of resistance  the second stage in the adaptation syndromes when the body’s adaptation takes place Standard  a generally accepted rule, model, pattern, or measure Standard deviation  the most frequently used measure of variability, indicating the average to which scores deviate from the mean; commonly symbolized as SD or S Standard precautions (SP)  the risk of caregiver exposure to client body tissues and fluids rather than the suspected presence or absence of infectious organisms determines the use of clean gloves, gowns, masks, and eye protection Standardized care plan  formal plan that specifies the nursing care for groups of clients with common needs (e.g., all clients with myocardial infarction) Standards of care  the skills and learning commonly possessed by members of a profession Standards of practice  descriptions of the responsibilities for which nurses are accountable Standards of professional performance  as set by the American Nurses Association (ANA), describe behaviors expected in the professional nursing role Standing order  an order that may be carried out indefinitely until another order is written to cancel it, or that may be carried out for a specified number of days Stapes  stirrups bone of the middle ear Stat order  indicates an order that is to be carried out immediately and only once Statistically significant  term applied after data have been analyzed to determine whether the results had a probability less than 0.05, which is considered the acceptable level of significance

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Glossary

Statutory law  a law enacted by any legislative body Steatorrhea  excessive amount of fat in the stool due to a malabsorption syndrome or pancreatic enzyme deficiency Stereognosis  the ability to recognize objects by touching and manipulating them Stereotyping  assuming that all members of a culture or ethnic group are alike Sterile field  a microorganism-free area Sterile technique  practices that keep an area or object free of all microorganisms; also called surgical asepsis Sterilization  a process that destroys all microorganisms, including spores and viruses

Surface temperature  the temperature of tissue, the subcutaneous tissue, and fat Surfactant  a surface-active agent (e.g., soap or a synthetic detergent); in pulmonary physiology, a mixture of phospholipids secreted by alveolar cells into the alveoli and respiratory air passages that reduces the surface tension of pulmonary fluids and thus contributes to the elastic properties of pulmonary tissue Surgical asepsis  practices that keep an area or object free of all microorganisms; also called sterile technique Sustained maximal inspiration device (SMI)  see Incentive spirometer Suture  a thread used to sew body tissues together Sutures  junction lines of the skull bones

Sternum  the breastbone

Sweat glands  see Sudoriferous glands

Stimulus-based stress model  stress is defined as a stimulus, life event, or set of circumstances that arouses physiological and/or psychological reactions that may increase the individual’s vulnerability to illness Stoma  an opening created in the abdominal wall by an ostomy

Sympathectomy  severance of the pathways of the sympathetic division of the autonomic nervous system; eliminates vasospasm, improves peripheral blood supply, and is effective in treating painful vascular disorders

Stool  see Feces Strabismus cross-eye Stress  an event or set of circumstances causing a disrupted response; disruption caused by a noxious stimulus or stressor Stress electrocardiography  uses ECGs to assess a client’s response to an increased cardiac workload during exercise Stressor  any factor that produces stress or alters the body’s equilibrium Stridor  a harsh, crowing sound made on inhalation caused by constriction of the upper airway Strike  an organized work stoppage by a group of employees to express a grievance, enforce a demand for changes in condition of employment, or solve a dispute with management Stroke volume (SV)  the amount of blood ejected with each cardiac contraction Structure evaluation  focuses on the setting in which care is given Subarachnoid block (SAB)  see Spinal anesthesia Subculture  usually composed of people who have a distinct identity and yet are related to a larger cultural group Subcutaneous  beneath the layers of the skin; hypodermic Subjective data  data that are apparent only to the person affected; can be described or verified only by that person Sublingual  a method of drug administration in which the drug is placed under the tongue Subsystems  system components Suctioning  the aspiration of secretions through a catheter connected to a suction machine or wall suction outlet Sudden infant death syndrome (SIDS)  the sudden and unexpected death of an infant Sudoriferous glands  glands of the dermis that secrete sweat; also known as sweat glands Superego  the conscience of personality; the source of feelings of guilt, shame, and inhibition Supine position  see Dorsal position Supplemental Security Income (SSI)  special payments for people with disabilities, those who are blind, and people who are not eligible for Social Security; these payments are not restricted to health care costs Suppositories  solid, cone-shaped, medicated substances inserted into the rectum, vagina, or urethra Suppuration  the formation of pus Suprapubic catheter  an indwelling catheter that has been surgically placed in the bladder through the abdominal wall, either with or without a urethrally placed catheter Suprasystem  the system above another system Surface anesthesia  see Topical anesthesia

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Sympathetically maintained pain  occurs occasionally when abnormal connections between pain fibers and the sympathetic nervous system perpetuate problems with both the pain and sympathetically controlled functions (e.g., edema, temperature, and blood flow regulation) Symptoms  see Covert data Syndrome diagnosis  a diagnosis that is associated with a cluster of other diagnoses Synergistic  when two different drugs increase the action of one or another drug System  a set of interacting identifiable parts or components Systemic infection  occurs when pathogens spread and damage different parts of the body Systole  the period during which the ventricles contract Systolic pressure  the pressure of the blood against the arterial walls when the ventricles of the heart contract Tachycardia  an abnormally rapid pulse rate; greater than 100 beats per minute Tachypnea  abnormally fast respirations; usually more than 24 respirations per minute Tactile  related to touch T’ai chi  discipline that combines physical fitness, meditation, and self-defense Tandem  a secondary IV setup in which a second IV container is attached to the line of the first container at the lower, secondary port to permit medications to be administered intermittently or simultaneously with the primary solution Tartar  a visible, hard deposit of plaque and dead bacteria that forms at the gum lines Taxonomy  a classification system or set of categories, such as nursing diagnoses, arranged on the basis of a single principle or consistent set of principles Teacher  a nurse who helps clients learn about their health and the health care procedures they need to perform to restore or maintain their health Teaching  system of activities intended to produce learning Team nursing  the delivery of individualized nursing care to clients by a team led by a professional nurse Technical skills  “hands-on” skills such as those required to manipulate equipment, administer injections, and move or reposition clients Telecommunications  the transmission of information from one site to another, using equipment to transmit information in the forms of signs, signals, words, or pictures by cable, radio, or other systems Telemedicine  technology used to transmit electronic medical data about clients to individuals at distant locations Temperament  the way individuals respond to their external and internal environment

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Glossary Teratogen  anything that adversely affects normal cellular development in the embryo or fetus Termination stage  the ultimate goal where the individual has complete confidence that the problem is no longer a temptation or threat Territoriality  a concept of the space and things that individuals consider their own Tertiary intention  healing that occurs in wounds left open for 3 to 5 days and then closed with sutures, staples, or adhesive skin closures Tertiary prevention  activities designed to restore individuals with disabilities to their optimal level of functioning Theory  a system of ideas that is proposed to explain a given phenomenon (e.g., theory of gravity) Therapeutic bath  a bath given for physical effects, such as to soothe irritated skin or to promote healing of an area (e.g., the perineum); two common types are the sitz bath and the medicated bath Therapeutic communication  an interactive process between nurse and client that helps the client overcome temporary stress, to get along with other people, to adjust to the unalterable, and to overcome psychological blocks that stand in the way of self-realization Therapeutic effect  the primary effect intended of a drug; reason the drug is prescribed Third space syndrome  fluid shifts from the vascular space into an area where it is not readily accessible as extracellular fluid Thoracentesis  a procedure to remove excess fluid or air from the pleural cavity to ease breathing or to introduce chemotherapeutic drugs intrapleurally Thrill  a vibrating sensation over a blood vessel that indicates turbulent blood flow Thrombophlebitis  inflammation of a vein followed by formation of a blood clot Thrombus  a solid mass of blood constituents in the circulatory system; a clot (plural: thrombi) Throughput  a transformation that occurs after input is absorbed by the system and is then processed in a way that is useful to the system Ticks  small gray-brown parasites that bite into tissue and suck blood and transmit several diseases to people, in particular Rocky Mountain spotted fever, Lyme disease, and tularemia Tidal volume  the volume of air that is normally inhaled and exhaled Tinea pedis  athlete’s foot (ringworm of the foot), which is caused by a fungus Tissue perfusion  passage of fluid (e.g., blood) through a specific organ or body part Topical  applied externally (e.g., to the skin or mucous membranes) Topical anesthesia  applied directly to the skin and mucous membranes, open skin surfaces, wounds, and burns; also called surface anesthesia Top-level manager  organizational executive primarily responsible for establishing goals and developing strategic plans Torr  millimeters of mercury Tort  a civil wrong committed against a person or a person’s property Tort law  law that defines and enforces duties and rights among private individuals that are not based on contractual agreements Trade name  name of the drug given by the drug manufacturer; also known as a brand name Traditional  observance of the beliefs and practices of one’s heritage or cultural belief system Traditional Chinese medicine (TCM)  based on the premise that the body’s vital energy circulates through pathways or meridians and can be accessed and manipulated through specific anatomic points along the surface of the body Tragus  the cartilaginous protrusion at the entrance to the ear canal Transactional leader  a contemporary theory of leadership in which resources are exchanged as an incentive for loyalty and performance

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Transactional stress theory  a theory that encompasses a set of cognitive, affective, and adaptive (coping) responses that arise out of person–environment transactions; the person and the environment are inseparable and affect each other Transcellular fluid  compartment of extracellular fluids; includes cerebrospinal, pericardial, pancreatic, pleural, intraocular, biliary, peritoneal, and synovial fluids Transcendence  a person’s recognition that there is something other or greater than the self and a seeking and valuing of that greater other, whether it is an ultimate being, force, or value Transcultural nursing  providing care within the differences and similarities of the beliefs, values, and patterns of cultures Transcutaneous electrical nerve stimulation (TENS)  a method of applying low-voltage electrical stimulation directly over pain areas Transdermal patch  a dermatologic medication delivery system that administers sustained-action medications via multilayered films containing the drug and an adhesive layer Transformational leader  leader who fosters creativity, risk taking, commitment, and collaboration by empowering the group to share in the organization’s vision Transgenderism  gradation of human characteristics that run from female to male Translator  a person who converts written material (such as client education pamphlets) from one language into another Tremor  an involuntary trembling of a limb or body part Trial  the period during which all relevant facts are presented to a jury or judge Triangular fossa  a depression of the antihelix Triglycerides  substances that have three fatty acids; they account for more than 90% of the lipids in food and in the body Trigone  a triangular area at the base of the bladder marked by the ureter openings at the posterior corners and the opening of the urethra at the anterior corner Trimesters  the 3-month periods during pregnancy marking certain landmarks for developmental changes in mother and the fetus; three trimesters occur during a pregnancy Tripod (triangle) position  the proper standing position with crutches; crutches are placed about 15 cm (6 in.) in front of the feet and out laterally about 15 cm (6 in.), creating a wide base of support Trocar  a sharp, pointed instrument Troponin  enzyme that is released into the blood during a myocardial infarction Trough level  represents the lowest concentration of a drug in the blood serum Tuberculin syringe  a narrow syringe, calibrated in tenths and hundredths of a milliliter on one scale and in sixteenths of a minim on the other scale that can be useful in administering other drugs, particularly when small or precise measurement is indicated Two-point discrimination  see One-point discrimination Tympanic membrane  the eardrum Tympany  a musical or drumlike sound produced during percussion over an air-filled stomach Ultrasonography  the use of ultrasound to produce an image of an organ or tissue Unconscious mind  the mental life of a person of which the person is unaware Undernutrition  intake of nutrients insufficient to meet daily energy requirements as a result of inadequate food intake or improper digestion and absorption of food Undertaker  see Mortician Universal precautions (UP)  techniques to be used with all clients to decrease the risk of transmitting unidentified pathogens Unplanned change  haphazard change that occurs without control by any person or group

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1454

Glossary

Unprofessional conduct  one of the grounds for action against a nurse’s license; includes incompetence or gross negligence, conviction of practicing without a license, falsification of client records, and illegally obtaining, using, or possessing controlled substances Unsaturated fatty acid  a fatty acid that could accommodate more hydrogen atoms than it currently does Upper-level managers  organizational executives who are primarily responsible for establishing goals and developing strategic plans Urea  a substance found in urine, blood, and lymph; the main nitrogenous substance in blood Ureterostomy  type of urinary diversion that involves surgery of the ureters Urgency  the feeling that one must urinate Urinary frequency  the need to urinate often Urinary hesitancy  a delay and difficulty in initiating voiding; often associated with dysuria Urinary incontinence  a temporary or permanent inability of the external sphincter muscles to control the flow of urine from the bladder Urinary reflux  backward flow of urine Urinary retention  the accumulation of urine in the bladder and inability of the bladder to empty itself Urinary stasis  stagnation of urinary flow Urination  the process of emptying the bladder; also called micturition or voiding Urine osmolality  a measure of the solute concentration of urine, a more exact measurement of urine concentration than specific gravity Utilitarianism  a specific, consequence-based, ethical theory that judges as right the action that does the most good and least amount of harm for the greatest number of individuals; often used in making decisions about the funding and delivery of health care Utility  see Utilitarianism Vaginismus  involuntary spasm of outer one third of vaginal muscles; makes penetration of vagina painful Validation  the determination that the diagnosis accurately reflects the problem of the client, that the methods used for data gathering were appropriate, and that the conclusion or diagnosis is justified by the data Validity  the degree to which an instrument measures what it is intended to measure Valsalva maneuver  forceful exhalation against a closed glottis, which increases intrathoracic pressure and thus interferes with venous blood return to the heart Value set  all of the values (e.g., personal, professional, religious) that a person holds Value system  the organization of a person’s values along a continuum of relative importance Values  something of worth; a belief held dearly by a person Values clarification  a process by which individuals define their own value Vaporization  continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin Variance  a variation or deviation from a critical pathway; goals not met or interventions not performed according to the time frame Vasoconstriction  constricted blood vessels Vasodilation  an increase in the diameter of blood vessels Vector-borne transmission  transport of an infectious agent from an animal or flying or crawling insect that serves as an intermediate means via biting or depositing feces or other materials on the skin Vehicle-borne transmission  transport of an infectious agent into a susceptible host via any intermediate substance (e.g., fomites or food) Venipuncture  puncture of a vein for collection of a blood specimen or for infusion of therapeutic solutions Ventilation  the movement of air in and out of the lungs; the process of inhalation and exhalation Ventricles  two lower chambers of the heart

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Veracity  a moral principle that holds that one should tell the truth and not lie Verbal communication  use of verbal language to send and receive messages Verdict  the outcome made by a jury Vernix caseosa  a protective covering that develops over the unborn fetus’s skin; a white, cheese-like substance that adheres to the skin and can become 1/8-inch thick by birth Vesicostomy  surgical production of an opening into the bladder Vestibule  contains the organs of equilibrium; found in the inner ear Vestibulitis  severe pain on touch or attempted vaginal entry Vial  a small glass medication container with a sealed rubber cap; used for single or multiple doses Vibration  a series of vigorous quiverings produced by hands that are placed flat against the chest wall to loosen thick secretions Virulence  ability to produce disease Viruses  nucleic acid–based infectious agents Visceral  internal organs Visceral pain  pain arising from organs or hollow viscera Viscous  thick, sticky Vision  the mental image of a possible and desirable future state Visiting nursing  delivery of services in the client’s home Visual  related to sight Visual acuity  the degree of detail the eye can discern in an image Visual fields  the area an individual can see when looking straight ahead Vital capacity  the maximum amount of air that can be exhaled after a maximum inhalation Vital signs  body temperature, pulse, respiration, and blood pressure. Many agencies have designated pain as the fifth vial sign Vitamin  an organic compound that cannot be manufactured by the body and is needed in small quantities to catalyze metabolic processes Vitiligo  patches of hypopigmented skin, caused by the destruction of melanocytes in the area Void urinate Volume control infusion set  small fluid containers (100 to 150 mL in size) attached below a primary infusion container so that a medication can be administered through the client’s IV line Volume expanders  used to increase the blood volume following severe loss of blood, or loss of plasma Vulvodynia  constant and unremitting burning of the vulva Water-soluble vitamins  vitamins that the body cannot store, so people must get a daily supply in the diet; include C and B-complex vitamins Well-being  a subjective perception of balance, harmony, and vitality Wellness  a state of well-being; engaging in attitudes and behaviors that enhance quality of life and maximize personal potential Wellness diagnosis  (NANDA) describes human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement White blood cells (WBCs)  body cells that are part of the body’s defense against infection and disease Wide area network (WAN)  computers linked across large distances World Wide Web (WWW)  refers to the complex links among web pages or websites, accessed through “addresses” called universal resource locators (URLs) Xenophobia  the fear or dislike of people different from one’s self Xerostomia  dry mouth as a result of a reduced supply of saliva Yoga  a type of meditation that is a system of exercises for attaining bodily or mental control and well-being Z-track technique  the recommended technique for administering intramuscular injections because it has been found to be less painful than the traditional injection technique and decreases leakage of irritating and discoloring medications into the subcutaneous tissue

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Index Page numbers followed by f indicate figures and those followed by t indicate tables, boxes, or special features. The titles of special features (e.g., Culturally Responsive Care, Lifespan Considerations; Skills) are also capitalized.

A AAP. See American Academy of Pediatrics (AAP) Abbreviated baths, 701 Abbreviations commonly used, 260, 260t “do-not-use” list, 241, 261, 261t medication orders, 786, 786t ABCD (Anthropometric, Biological (laboratory), Clinical (physical examination), Dietary) data for nutritional assessment, 1169, 1169t Abdomen, physical assessment of assessment methods, 598–599 Home Care Considerations, 603t landmarks, 598, 599f Lifespan Considerations, 603t quadrants, regions, and organs, 597–598, 598f, 598t skill for, 599–602t Abdominal binders, 882, 882f Abdominal (diaphragmatic) breathing, 522 Abdominal paracentesis defined, 767 equipment, 767, 767f Lifespan Considerations, 768t procedure, 767–768, 771t site for, 767, 767f Abducens nerve (CN VI), 616t Abduction (movement), 1038t, 1039–1041f, 1039–1041t Abduction pillows, 1061t ABI (ankle brachial index), 1325, 1325t Ablative surgery, 892t Abortion ethical issue, 106 legal aspects, 85 Abrasions, 697t, 855t Absorption of a medication, 781 Abuse child abuse, 83, 363 legal aspects of, 83 sexual abuse and harassment, 83, 84, 975 Abuse Assessment Screen, 382t Abusive head trauma, 360 ACA. See Patient Protection and Affordable Care Act (ACA) Academic Search Premier, 58t Academy of Medical Surgical Nursing, 48 Acceptance communication process, 444 Kübler-Ross’s stage of grieving, 1017t Access to health care services chronic conditions and disabilities, 125t health disparities, 304 Accessory nerve (CN XI), 616t Accommodation, in Piaget’s theory of cognitive development, 345 Accountability management principle, 492 moral principle, 103 Accountable care organizations, 128 Accreditation, 164 Accreditation Commission for Education in Nursing, 35, 47, 77 Acculturation, 305–306 Accuracy in documentation, 261, 261t, 262f

ACE (angiotensin-converting enzyme) inhibitors, 1327 Acetaminophen effectiveness, 1136t inflammatory response, 635t pain management, 1132, 1132t, 1133, 1133t, 1134t, 1135t Acid, defined, 1342 Acid–base balance. See also Fluid, electrolyte, and acid–base balance buffers, 1342, 1342f renal regulation, 1343, 1343t respiratory regulation, 1342–1343, 1343t Acidosis, defined, 1342 Acne described and nursing implications, 697t skin problems and care, 710t Acquired (passive) immunity, 634, 634t Acquired immunodeficiency syndrome (AIDS). See also Human immunodeficiency virus (HIV) clinical manifestations, 963t ethical issues, 106 young adults, 382 Acquired Immunodeficiency Syndrome Information (AIDSInfo), 157t ACS. See American Cancer Society (ACS) Actifed. See Pseudoephedrine Actinomyces species, 629t Action Plan to Reduce Racial and Ethnic Health Disparities, 305 Action stage of health behavior change, 278, 285f Action verbs, for goals/desired outcomes, 224, 224t Actiq lozenges. See Fentanyl Active euthanasia, 108 Active immunity, 634, 634t Active involvement in learning, 468, 468f Active low-air-loss beds, 871t Active ROM exercises, 1076, 1076t, 1077t Active safety syringes, 810, 811f Active transport, defined, 1337–1338, 1338f Active-assistive ROM exercises, 1077t Activities of daily living adolescents, 375t infants, 362t middle-aged adults, 387t older adults, 128t, 407t preschoolers, 368t school-age children, 370t toddlers, 365t young adults, 383t Activity fecal elimination, 1240 level, and temperament theory of Chess and Thomas, 345t oxygen saturation, 533 prenatal development, 355 self-care for nurses, 430, 430f Activity and exercise body alignment and activity, factors affecting external factors, 1043 growth and development, 1038, 1043 nutrition, 1043 personal values and attitudes, 1043 prescribed limitations, 1044 Chapter Highlights, 1089t

exercise benefits of, 1046–1047, 1047f Eastern cultures, 1045f, 1045t types of, 1044, 1044f, 1045t Health People 2020 objectives, 1036–1037 immobility, effects of cardiovascular system, 1048–1049, 1049f, 1049t, 1055t gastrointestinal system, 1051, 1055t integumentary system, 1051, 1055t metabolic system, 1050, 1055t musculoskeletal system, 1048, 1048f, 1055t overview, 1047–1048, 1048t psychoneurologic system, 1051, 1055t respiratory system, 1049–1050, 1049f, 1055t urinary system, 1050–1051, 1050f, 1055t normal movement alignment and posture, 1037, 1037f balance, 1038 coordinated movement, 1038 joint mobility, 1038, 1038t, 1039–1042f, 1039–1042t Nursing Management Anatomy & Physiology Review, 1054f assessing nursing history, 1051, 1052t physical examination, 1051–1055, 1052f, 1054f, 1055t Concept Map, 1088f diagnosing, 1056 evaluating, 1086 implementing ambulating clients (See Ambulation) back injury, preventing, 1060, 1060t body mechanics (See Body mechanics) mechanical aids for walking (See Walking, mechanical aids for) moving and turning clients in bed (See Moving and turning clients in bed) positioning clients (See Positioning clients) ROM exercises, 1076–1077, 1076t, 1077f, 1077t transferring clients (See Transferring clients) Nursing Care Plan, 1087t planning, 1056, 1057t Activity theory of Havighurst, 401 Activity tolerance assessment of, 1053, 1055 defined, 1044 Activity-exercise pattern, 1037 Actual loss, defined, 1015 Acupressure, 327, 1144 Acupuncture, 327, 327f Acute confusion (delirium), 406, 941–943, 942t, 943f, 943t, 1242t. See also Confusion Acute illness, defined, 297 Acute infections, defined, 630 Acute pain Concept Map, 1149f described, 1114, 1114t, 1115t Nursing Care Plan, 1147–1148t AD. See Alzheimer’s disease (AD) ADA. See Americans with Disabilities Act (ADA) Adaptability temperament theory of Chess and Thomas, 345t verbal communication, 439 Adaptation, in Piaget’s theory of cognitive development, 345 Adaptation model. See Roy’s adaptation model Adaptive coping, 1004

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Adaptive mechanisms, 341 Addiction, defined, 1130 Adduction (movement), 1038t, 1039–1041f, 1039–1041t Adequate intake (AI), 1166, 1167t ADH. See Antidiuretic hormone (ADH) Adherence defined, 296, 466 factors influencing, 296t nonadherence risk, 296t, 297t promoting, 296–297 Administrative law, 74, 74f Admission nursing assessment, 256 Adolescence, defined, 370 Adolescent families, 413 Adolescent growth spurt, 371 Adolescents average daily urine output, 1205t bathing, 706t biologic dimension of health, 293 cognitive development, 373 communication with, 443t death, concept of, 1022t defecation, 1238–1239 hair, 724 Havighurst’s age period and developmental tasks, 343t health assessment and promotion, 374, 375t health care decisions, 178t Health Promotion Guidelines, 375t health promotion topics, 276t health risks, 373–374, 373f medication nonadherence, 297t moral development, 373 normal sleep patterns and requirements, 1095–1096, 1096f, 1096t nutrition, 1162 oral health, 717, 717t pain experience, 1120t physical development glandular changes, 371 physical growth, 371, 375t sexual characteristics, 371, 375t psychosocial development, 371–373, 372f, 375t puberty, 370–371 pulse and respiration average and normal range, 513t safety, 673t, 675 safety hazards, 667t self-esteem, enhancing, 956f, 956t sexual development, 960, 961t, 962, 962t, 963t spiritual development, 373 stressors, 999t teaching considerations, 472t Adoption, international, 306t Adult day care, 394, 394f Adulthood, criteria for, 379 Adults average daily urine output, 1205t, 1209t body alignment and activity, 1043 computer use, 165t death, concept of, 1022t massage, uses of, 333t normal sleep patterns and requirements, 1096 oral health, 717, 717t pain experience, 1120t pulse and respiration average and normal range, 513t self-esteem, enhancing, 956–957t sleep disturbances, 1097t urinary elimination, 1204t Advance directives, 108 Advance health care directives described, 85 sample form, 86f Adventitious breath sounds, 524t, 581, 582t, 1273 Adverse effects, defined, 779

Advertising, and nutrition, 1160 Advice, giving, 448t Advil. See Ibuprofen Advocacy caring encounters in nursing, 429 Chapter Highlights, 110t home care, in, 109–110 professional and public advocacy, 110 values basic to client advocacy, 109t Advocate defined, 109 home health care nurse as, 146–147 Aerobic, defined, 866t Aerobic exercise, 1044, 1045t Aerosolization of medications, 846 Aesthetic knowing, 427, 428f Afebrile, defined, 505 Affective domain of learning, 466 Affiliative Faith stage, in Westerhoff ’s theory of spiritual development, 349, 350t Affordable Care Act (ACA). See Patient Protection and Affordable Care Act (ACA) African heritage, people with adolescent families, 413 biocultural considerations in CBCs, 747t blood pressure, 526 cardiovascular disease, 1323t cultural health-related practices, 317t culture that values family inclusion in client teaching, 483t hair care, 726, 726f, 727t hypertension in young adults, 382 nutritional practices, 1158t, 1159 older adults, 391t, 392t pain, responses to, 1119t role strain experienced by African American grandmothers raising grandchildren, 952t social support, cultural aspects of, 281t Afterload cardiac output, 1317, 1317t, 1318f heart failure, 1323t Against medical advice (AMA) form, 90 Age biologic dimension of health, 293 blood pressure, 526 body temperature, 505 cardiovascular risk factor, 1320, 1320t fluid, electrolyte, and acid–base balance, 1343–1344, 1343t infection, susceptibility to, 635 learning, 467, 469t loss and grief responses, 1019, 1019f pressure ulcers, 856 pulse, 513, 513t respiratory function, 1272, 1274t safety, 666, 667t surgical risk, 892 teaching, 470, 472t urination, affecting, 1202–1203, 1204t Ageism, 391, 392t Agency for Healthcare Research and Quality Center for Quality Improvement and Patient Safety (CQuIPS), 240–241 Health Literacy Universal Precautions Toolkit, 474 safety, 667 Agent-host-environment model of health, 290–291, 291f Age-related macular degeneration, 936, 939t Agglutinins, 1384, 1384t Agglutinogens, 1384, 1384t Aggressive nonassertive communication, 460 Aging attitudes toward, 391–392, 392t biological theories of, 395, 395t Agnostic, defined, 981 Agonist, defined, 781

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Agonist analgesic, 1133 Agonist-antagonist analgesic, 1133 AIDS. See Acquired immunodeficiency syndrome (AIDS) AIDSInfo (Acquired Immunodeficiency Syndrome Information), 157t Air transfer system, 1060f, 1060t Airborne precautions, 645, 645t Airborne transmission of microorganisms, 632 Air-fluidized beds, 871f, 871t Airway immediate postanesthetic phase, 907–908, 908t respiratory function alterations, 1273 Airways, artificial endotracheal tubes, 1292, 1292f, 1292t oropharyngeal and nasopharyngeal airways, 1291–1292, 1291f tracheostomy, 1292–1293, 1292f, 1293f, 1293t, 1294f Alanine aminotransferase (ALT) normal levels and clinical implications, 749, 750t preoperative test, 895t Alarm reaction of GAS, 999, 1001f Alarms on equipment, 733 Alaska Natives adolescent families, 413 older adults, 391t Albumin functions of, 748f transfusion of, 1385t Albumin level normal levels and clinical implications, 750t nutrition, 1172–1173 preoperative, 895t Albuterol, 1280t Alcohol use nutrition, 1159–1160 prenatal development, 356, 356t sexual function, 970t sleep, 1098, 1098t Alcohol-based hand rubs, 640, 640t Alcoholism impaired nurses, 84t middle-aged adults, 386 older adults, 406 Alcott, Louisa May, 30 Aldomet. See Methyldopa Aldosterone, 1201 Aldrete Score, 908, 908t Alert! confidential information, faxing, 248t fall potential, assessing clients for, 89t informed consent, obtaining, 82t moral distress, 106t Alexian Brothers, 29 Alginate dressings, 873t Algor mortis, 1029 Alkaline phosphatase, 750t Alkalosis, defined, 1342 Allergic transfusion reaction, 1385t Allergic wheals, 550f Allodynia, 1114–1115, 1115t Allopathic medicine, 321 Allow natural death (AND) orders, 87 Alopecia, 724 Alpha-blockers, 970t Alpha-galactosidase, 1252 ALT. See Alanine aminotransferase (ALT) Alt HealthWatch, 157t Alternating pressure mattresses, 871f, 871t Alternating rhythms, in caring, 424 Alternative (complementary) care providers, 120 Alternative medicine, 321. See also Complementary and alternative healing modalities Altruism, 100, 100t

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Index Alzheimer’s disease (AD) dementia, 406, 406t long-term care facilities, 393 AMA (against medical advice) form, 90 Ambien. See Zolpidem Amblyopia, 364 Ambulation assisting clients to ambulate, 1078, 1078f, 1079–1080t, 1081t defined, 1077 early ambulation, benefits of, 1077, 1078t Home Care Considerations, 1081t Lifespan Considerations, 1081t postoperative care, 914 postural (orthostatic) hypotension, 1079t, 1081 preambulatory exercises, 1078, 1078f Ambulatory care centers, 117 American Academy of Family Physicians, 1170 American Academy of Nursing, 35 American Academy of Pediatrics (AAP) cognitive development, 359 continuity of care, 139 pediculosis, 725 American Anthropological Association, 303 American Assembly for Men in Nursing, 34, 34f American Association of Colleges of Nursing cultural competencies, 306 research-related role expectations for nurses, 53, 54t Tri-Council for Nursing, 31 American Association of Nurse Anesthetists, 48 American Cancer Society (ACS) middle-aged adults, 386 screening guidelines, 541, 541t young adults, 383 American Civil War, 29–30, 29f, 30f, 32 American Diabetes Association diet modifications, 1177 insulin administration, 820 American Dietetic Association, 1170 American Heart Association, 1046 American Hospital Association, 464 The American Nurse, 48 American Nurse Today, 48 American Nurses Association (ANA) BSN as entry into professional nursing practice, 38t Code for Nurses, 104–105 Code of Ethics for Nurses, 105 confidentiality of patient information, 247 disaster planning, 669 Faith Community Nursing: Scope and Standards of Practice, 137 founding, purpose, and publications, 48 health and illness, 288 Health System Reform Agenda, 131 holistic nursing, 322 nursing, definition of, 39 nursing ethics, 101 nursing informatics, 155 nursing process, 181 nursing research, 53 Nursing’s Agenda for Health Care Reform, 131 passive euthanasia and assisted suicide, 108 Patient Protection and Affordable Care Act, 132 professional boundaries, 444 purpose of, 43 safe patient handling and mobility standards, 1058 Scope and Standards of Nursing Practice, 181 Standards of Professional Performance, 41 Tri-Council for Nursing, 31 withdrawing or withholding food and fluids, 109 work-related musculoskeletal disorders, 1058 American Nurses Credentialing Center, 37 American Organization of Nurse Executives (AONE) BSN as entry into professional nursing practice, 38

Transforming Care at the Bedside, 241 Tri-Council for Nursing, 31 American Pain Society, 1128, 1129t American Professional Wound Care Association, 887t American Psychiatric Association, 161 American Red Cross disaster planning, 669 establishment of, 32 American Self-Help Clearinghouse, 119 American Society for Pain Management Nursing, 1128, 1129t, 1130–1131 American Society of Anesthesiologists, 900 American Society of PeriAnesthesia Nurses, 907 American Society of Superintendents of Training Schools for Nurses in the United States, 33 Americans with Disabilities Act (ADA) eligibility for, 83t legal aspects of, 83, 83t Aminoglycosides, 932 Amiodarone, 1160t Amish faith, and health-related information, 990t Amitriptyline nutrition, 1160t pain management, 1132t Ammonia levels, 750t Amphetamines narcolepsy, 1099 sexual function, 970t sleep, 1098t Ampicillin, 783 Ampule, 811, 811f, 812f, 813, 813–814t Amyl nitrate, 970t ANA. See American Nurses Association (ANA) Anabolic steroids, 970t Anabolism defined, 1050 protein metabolism, 1155 Anaerobic, defined, 866t Anaerobic exercise, 1044 Anal canal, 1237, 1238f Anal sphincters artificial, 1257–1258, 1257f fecal elimination, 1237, 1238f Anal stage of psychosexual development, 341, 341t, 344t, 362 Anal stimulation, 966 Analysis of variance, 57t Anaphylactic reaction, 780 Anaprox. See Naproxen Anatomy & Physiology Review client positioning, 907f digestive system, 1155f female and male urinary bladders and urethras, 1203f gas exchange, 1351f glaucoma, 938–939f pharmacokinetics of an oral medication, 782f preload and afterload, 1318f respiratory system, 1270f reticular activating system, 1093f small and large intestines, 1246f upper and lower body integration and the spine’s role in locomotion, 1054f AND (allow natural death) orders, 87 Andragogy, 466 Androgyny, 965 Anemia defined, 1161 signs of, 1324 Aneroid sphygmomanometers, 527, 527t Anesthesia fecal elimination, 1241 local anesthetics, 1132t, 1140, 1145 types of, 904–905, 905t ANF (atrial natriuretic factor), 1339

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Angels of mercy, nurses as, 31 Anger Kübler-Ross’s stage of grieving, 1017t mediating, with stress, 1007, 1007t stress, indication of, 1002–1003 Angiocatheters (over-the-needle IV catheters), 1363–1364, 1365f Angiography, 764 Angiotensin-converting enzyme (ACE) inhibitors, 1327 Angle of Louis, 579–580, 580f Anglicans, and health-related information, 990t Animal-assisted therapy, 332 Anions, in body fluids, 1335, 1336f Anisocoria, 560 Ankle brachial index (ABI), 1325, 1325t Ankles, joint movements, 1042f, 1042t Ankylosed, defined, 1048 Anorexia, 1050 Anorexia nervosa, 1162 Anoscopy, 763 Antacids fecal elimination, 1241 nutrition, 1160t Antagonist, defined, 781 Anthrax, 672t Anthropometric measurements, 1170, 1172, 1172f, 1172t Antibiotics, and fecal elimination, 1241 Antibodies blood transfusions, 1384, 1384t described, 634, 634t Antibody-mediated defenses, 634, 634t Anticholinergic medications preoperative preparation, 901 urinary retention, 1205t Anticipatory grief, 1016 Anticipatory loss, 1015 Anticoagulants fecal occult blood testing, 756 surgical risk, 893 Anticonvulsants pain management, 1222t sexual function, 970t Antidepressants nutrition, 1160t sexual function, 970t sleep, 1098t urinary retention, 1205t Antidiuretic hormone (ADH) fluid and electrolyte balance, 1339, 1340f kidney function, 1201 Antiemboli stockings, 902, 902–904t Antiemetic agents, 901 Antigens blood transfusions, 1384, 1384t defined, 634 Antigravity muscles, 1037 Antihelix, defined, 565 Antihistamines preoperative preparation, 901 sexual function, 970t sleep, 1098t urinary retention, 1205t Antihypertensive medications nutrition, 1160t sexual function, 970t urinary retention, 1205t Anti-inflammatory drugs. See also Nonsteroidal anti-inflammatory drugs (NSAIDs) nutrition, 1160t oxygenation, 1279, 1281t Antineoplastic medications, 1160t Antiparkinsonism medications, 1205t Antipsychotic medications, 970t

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Index

Antiseptics, 643, 644t Anuria, 1206, 1206t Anus anal canal, 1237, 1238f physical assessment Lifespan Considerations, 623t overview of, 622 skill for, 622–623t Anxiety antianxiety agents, 970t minimizing, for stress, 1007, 1007t pain, 1132 stress, indication of, 1001–1002, 1002t AONE. See American Organization of Nurse Executives (AONE) Aortic area on the chest, 587, 587f Apgar scoring system, 360, 360t Aphasia, 606 Apical pulse assessment of, 517–520, 518–520t defined, 513 pulse measurement, 513f, 514, 514f, 514t Apical-radial pulse assessment, skill for, 521t defined, 520 Apnea, 523, 524t, 1273 Apocrine glands adolescents, 371 defined, 696 Apothecaries’ system, 789, 790, 790t App, defined, 156t Appearance, personal middle-aged adults, 384t nonverbal communication, 440–441 Appetite, stimulating, 1178, 1178t Approach, in temperament theory of Chess and Thomas, 345t Approximated, defined, 860 Apresoline. See Hydralazine Aquathermia pads (K-pads), 885, 885f Aqueous solution, 777t Aqueous suspension, 777t Arabic heritage, people with nutritional practices, 1158t pain, responses to, 1119t Aricept. See Donepezil Arlington National Cemetery, 30, 30f Arm slings, 881–882, 882f Aromatherapy, 324f, 325, 326t Arousal mechanism, 930–931, 931t Arrhythmia, 515 Artane. See Trihexyphenidyl Arterial blood gases (ABGs) evaluating, 1358t fluid, electrolyte, and acid–base balance, 1357, 1358t normal values, 1358t oxygenation, 1275 test, described, 748–749 Arterial blood pressure, 525 Arteries arterial circulation, 1317–1318, 1319f compliance, 513 Arteriosclerosis, 526 Artificial saliva, 716 Artificial sphincter, 1257–1258, 1258f Ascending colostomy, 1244, 1244f Ascites, 767 Asepsis. See also Infection Chapter Highlights, 663–664t Critical Thinking Checkpoint, 663t defined, 629 medical asepsis, 629 Skills hand hygiene, performing, 640–642t

personal protective equipment, applying and removing, 647–649t sterile field, establishing and maintaining, 654–657t sterile gloves, applying and removing (open method), 658–659t sterile gown and gloves, applying (closed method), 659–661t surgical asepsis, 629, 652, 653t Asepto syringe, 849, 849f Ashkenazi Jewish faith, and nutritional practices, 1159 Asian heritage, people with adolescent families, 413 blood samples, drawing, 745t cultural health-related practices, 317t culture that values family inclusion in client teaching, 483t nutritional practices, 1159 older adults, 391t pain, responses to, 1119t social support, cultural aspects of, 281t “Ask Me 3” tool, 474 As-needed (prn) care, 696. See also Prn order Aspartate aminotransferase (AST) normal levels and clinical implications, 749, 750t preoperative test, 895t Asphyxiation, 683–684, 684f Aspiration abdominal paracentesis, 767–768, 767f, 768t, 771t defined, 766 lumbar puncture, 766–767, 766f, 767f, 767t, 770t thoracentesis, 768–769, 768f, 769t, 771t Aspirin dysmenorrhea, 962 effectiveness of, 1136t fecal elimination, 1241 fecal occult blood testing, 756 herbal medicine, 324 inflammatory response, 635t nutrition, 1160t older adults, 408t pain management, 1132t, 1133 pain transduction, 1116 sensory function, 932 Assault, 90, 91f Assertive communication, 460 Assessing. See also under Nursing Management activities involved, 185, 187f assessments, types of, 185, 187t Chapter Highlights, 198–199t Critical Thinking Checkpoint, 198t data collection described, 185–186 methods for, 189–193, 190t, 191t, 192t, 193t, 194–195f nursing health history, 186, 188t sources of data, 187–189 types of data, 186–187, 189t data organization, 193, 195–197, 196t data validation, 197, 198t defined, 185 documentation of data, 198 evaluation checklist, 239, 239t nursing process in action, 181, 182–183f characteristics of, 181–182, 185, 185t, 186f phases of, 181, 184t, 185f Assessment Interviews activity and exercise, 1052t body image, 954t circulation, 1325t client at risk for infections, 636t complementary and alternative therapies, 323t eyes, 728t family of the dying client, 1025t fecal elimination, 1247t

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fluid, electrolyte, and acid–base balance, 1353t foot hygiene, 711t hair hygiene, 724t Heritage Assessment Tool, 316t learning needs and characteristics, 471t loss and grieving, 1020t medication nonadherence risk, determining, 296t oral hygiene, 715t oxygenation, 1275t pain history, 1122t personal identity, 953t role performance, 954t sensory perceptual functioning, 933t sexual health history, 972t skin hygiene, 698t sleep disturbances, 1102t spirituality, 986t stress and coping, 1005t urinary elimination, 1208t Assimilation culturally responsive nursing care, 305–306 Piaget’s theory of cognitive development, 345 Assisted living facilities health care agencies, 118 older adults, 393 Assisted suicide, 108 Associate degree programs for registered nurses, 36 Association for the Advancement of Wound Care, 887t AST. See Aspartate aminotransferase (AST) Astigmatism, 559 Asymptomatic infection, 628 Atelectasis defined, 1271 immobility, 1049–1050 postoperative phase, 910t Atheists, 981 Atherosclerosis, 1319 Ativan. See Lorazepam An Atlas of Infant Behavior (Gesell), 340 Atomization/atomizers for medications, 846 Atria, cardiac, 1313 Atrial natriuretic factor (ANF), 1339 Atrioventricular (AV) node, 1316, 1316f Atrioventricular (AV) valves, 1313, 1314f Atrophy muscles, 1048 skin, 551t Atropine herbal medicine, 324 preoperative preparation, 901 urinary retention, 1205t Attachment, in Bowlby’s attachment theory, 345 Attention span, 607, 609t Attitudes communication process, 444 defined, 99 Audit client records, 248 defined, 241 Auditory, defined, 946t Auditory nerve (CN VIII), 616t Auricle (pinna), 565, 565f Auscultation technique, described, 545 Auscultatory gap, 529 Authoritarian (autocratic) leader, 489, 490t Authority, as management principle, 492 Autoantigens, 634 Autocratic (authoritarian) leader, 489, 490t Autologous RBCs, 1385t Autolytic debridement, 872 Automated dispensing cabinets, 797, 797f Automaticity, 1316

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Index Autonomous (postconventional) level of moral development. See Postconventional level of Kohlberg’s theory of moral development Autonomy essential nursing value, 100, 100t moral principle, 102, 103t professional status, aspect of, 43 Autonomy versus shame and doubt Erikson’s theory of developmental stages, 341, 344t self-concept, 949t toddlers, 362 Autopsy, 85 AV (atrioventricular) node, 1316, 1316f AV (atrioventricular) valves, 1313, 1314f Avinza. See Morphine AWA (absence without authority) form, 90 Awareness, states of, 931, 931t Axillae, assessment of Lifespan Considerations, 597t overview, 594, 594f skill for, 594–597t Axillary body temperature measurement advantages and disadvantages, 507t described, 507 infants and children, 512f, 512t thermometer placement, 511t Ayurveda described, 323 detoxification therapy, 332 Azithromycin, 643t

B Babinski (plantar) reflex, 358t, 610t Baby boomers, 379, 390 Baccalaureate programs for registered nurses, 37, 38t, 54t Bacillus anthracis bioterrorism, 672t disinfectants and antiseptics, 643 Back injuries health care workers, 1059t, 1065t preventing, 1060, 1060t “Back to Sleep” guidelines, 360, 360t Bacteremia, 629 Bacteria disinfectants and antiseptics, 644t infection, cause of, 629 Bacterial phlebitis, 1383 Bactericidal bactericidal preparations, 643 defined, 696 Bacteriocins, 628 Bacteriostatic preparations, 643 Bacteroides species, 629t Bacti-Stat. See Triclosan Bag baths, 701 Balance body mechanics, 1057–1058, 1058f defined, 322 described, 1038 healthy lifestyle, 430 Balanced Budget Act (1997), 119 Ball-and-socket joints, 1039f, 1039t, 1041f, 1041t Bandage assessing before applying, 880t circular turns, 879–880, 880f defined, 879 figure-eight turns, 880, 881, 881f Home Care Considerations, 883t Lifespan Considerations, 882t Practice Guidelines, 879t, 880t recurrent turns, 880, 881f

reverse spiral turns, 880, 881f spiral turns, 880, 880f Bandura, Albert, 346, 347t Bandura’s social learning theory, 346, 347t Barbiturates respiratory function, 1273 sexual function, 970t Bar-code technology, 797, 798f Bargaining stage of grieving, 1017t Barium enema, 764, 764f Barrel chest, 580, 581t Barton, Clara, 29, 32, 32f Basal metabolic rate (BMR) body temperature, 504 defined, 1050, 1156–1157 Base of support, 1037, 1037f Bases, defined, 1342 Basic life support (BLS), 1330 Basophils, 747t, 748f Bathing adult clients, skill for, 702–706t categories of, 701, 701f functional levels of self-care, 697t health care–associated infections, 702t Home Care Considerations, 706t Lifespan Considerations, 706t long-term care settings, 707, 707t overview of, 700–701 perineal-genital care, 707–708, 708–709t, 708t Battery, 90, 91t Beano. See Alpha-galactosidase Beards, care of, 728, 728t Beau’s lines, 556, 556f Bed rest body alignment and activity, 1044 effects of, 1048t Bed scales, 548, 548f Bedpans, 1249, 1250–1251t, 1250f Beds, hospital common positions for, 734t described, 733 making beds occupied beds, 739–740, 739–740t overview of, 734, 735t unoccupied beds, 734–738, 735f, 736–738t Bedside change-of-shift reports, 263, 264t Bedside data entry, 159–160, 159f Bedside manner, defined, 437 Bedsores, 855. See also Pressure ulcers Behavior changes, and health promotion, 284–285, 285f pain, response to, 1126 Behavior modification, 482 Behaviorist theory, 466 Behind-the-ear (BTE) open fit hearing aids, 730, 730f Behind-the-ear (BTE) with earmold hearing aids, 730, 730f Beliefs, defined, 99 Beneficence, as moral principle, 102, 103t Benner, Patricia, 38t Benner’s stages of nursing expertise, 43, 44t Benztropine mesylate, 1205t Benzyl alcohol, 725 Bereavement. See also Grief; Loss defined, 1016 Sander’s phases of, 1017, 1018t Beta-adrenergic stimulating agents, 1280 Beta-blockers circulation, 1327 oxygenation, 1280 preoperative preparation, 901 sexual function, 970t sleep, 1098t urinary retention, 1205t

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Bevel of the needle, 809, 809f Beyond Ordinary Nursing, 329 Bible, and management of stressful life events, 991t Bicarbonate functions, 748f regulation of, 1341t, 1342 Bicarbonate and carbonic acid buffer system, 1342, 1342f Bicultural, defined, 303 Bilevel positive airway pressure (BiPAP), 1287–1288 Bilirubin level normal levels and clinical implications, 750t preoperative, 895t Binders arm slings, 881–882, 882f assessing before applying, 880t defined, 881 Home Care Considerations, 883t Lifespan Considerations, 882t straight abdominal binders, 882, 882f Bioelectromagnetics, 332 Bioethics bioethical decision-making model, 107–108t defined, 101 Biofeedback, 330, 330t Biologic dimension of health, 293 Biologic (circadian, or diurnal) rhythms blood pressure, 526 body temperature, 505, 505f learning, barrier to, 469t sleep, 1092–1093 Biological theories of aging, 395, 395t Biomedical health belief, defined, 308 Biomedicine, defined, 321 Biophysical theory of growth and development, 339–340, 347t Biopsy bone marrow biopsy, 769, 769f, 769t, 771–772t defined, 766 liver biopsy, 769–770, 770f, 772t Bioterrorism agents, categories for, 668 nursing management, 669–670, 672t pathogens of highest concern, 672t preparation for, 685 safety, 668 Biotransformation of a medication, 781 Biot’s (cluster) respirations, 1273 BIPAP (bilevel positive airway pressure), 1287–1288 Biracial, defined, 303 Birth, religious beliefs about, 985 Birth control. See Contraception Bisacodyl, 1135t, 1251t Bisexuals, 965 Bismuth subsalicylate diarrhea, 1252t fecal elimination, 1241 flatulence, 1252 Black pepper essential oil for IV catheter insertion, 1364t Black Plague, 29 Bladder anatomy and physiology, 1201–1202, 1201f, 1202f, 1203f bladder retraining, 1214, 1214t normal capacity, 1202 Blanch test, 556 Blended (step) families, 414 Blog/weblog, 156t Blood alterations in, and cardiovascular function, 1324 composition and functions, 748f functions of, 1318–1319 volume and viscosity, and blood pressure, 526 Blood chemistry common tests and clinical implications, 749, 750–751t defined, 749

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Blood glucose meters, 749, 749f Blood pressure (BP) arterial blood pressure, defined, 525 arterial circulation, 1318 assessing assessment sites, 528 common errors, 529, 530t equipment for, 527–528, 527f, 528f methods, 528–529, 529f, 529t Skill for, 530–532t blood pressure cuffs, 527–528, 527f, 528f, 532f, 532t determinants of blood volume and viscosity, 526 heart pumping action, 526 peripheral vascular resistance, 526 equipment for clients in isolation, 652 factors affecting, 526 Home Care Considerations, 533t hypertension, 526–527, 527t hypotension, 527 Lifespan Considerations, 532f, 532t normal values, 527t overview of, 525–526 Blood tests. See also individual tests arterial blood gases, 748–749 blood chemistry, 749, 750–751t capillary blood glucose, 749, 749f, 752, 752–754t complete blood count, 745–747, 746–747t, 748f drug monitoring, 747–748 electrolytes, 747, 748f, 748t metabolic screening, 749 osmolality, 747, 748t Blood transfusions administration of guidelines for, 1386, 1386f, 1386t skill for, 1387–1389t blood and blood products for transfusion, 1384, 1385t blood donors, 1384 blood groups, 1384, 1384t blood typing and crossmatching, 895t, 1384 indications for, 1383 IV push medications, 833t Rhesus (Rh) factor, 1384 transfusion reactions, 1384, 1385t, 1386 two nurses to check information, 1388t Blood typing and crossmatching, 895t, 1384 Blood urea nitrogen (BUN) described, 747, 1210 preoperative, 895t Blood vessels arterial circulation, 1317–1318, 1319f venous return, 1318, 1319f Bloodborne pathogens, 644 BLS (basic life support), 1330 Blue pigtail of the Salem sump tube, 1180 BMI (body mass index), 1157, 1157t BMR. See Basal metabolic rate (BMR) Body alignment assessment of, 1051–1052, 1052f factors affecting, 1038, 1043–1044 posture, 1037, 1037f Body hearing aids, 331 Body image defined, 950–951, 950f self-concept, 953, 954f, 954t sexual health, 964 Body mass index (BMI), 1157, 1157t Body mechanics balance, 1057–1058, 1058f defined, 1057 lifting, 1059, 1059f, 1060f pivoting, 1060 pulling and pushing, 1059, 1060t work-related musculoskeletal disorders, 1058–1059, 1059t

Body of an interview, 192 Body piercing, 901t Body surface area, 793, 794f Body systems model for data organization, 197 Body temperature alterations in hypothermia, 506–507, 506f, 507t nursing interventions, 507, 507t pyrexia, 505–506, 506f, 506t, 507t assessing sites for, 507–508, 507t Skill for, 510–511t temperature scales, 509 thermometers, types of, 508–509, 508f, 508t, 509f blood pressure, 526 defined, 504 factors affecting, 505, 505f heat balance, 504, 504f Home Care Considerations, 512f, 512t Lifespan Considerations, 512f, 512t normal range, 504, 504f, 506f prenatal development, 355 pressure ulcers, 856 regulation of, 505 Body transcendence versus body preoccupation, 342, 344t Body weight. See Weight Boiling water sterilization, 644 Bolus administration, 1139 Bone marrow biopsy Lifespan Considerations, 769t procedure, 769, 771–772t site for, 769, 769f Boomerang kids, 379–380 Borg scale of perceived exertion, 1044 Botanical healing aromatherapy, 324f, 325, 326t herbal medicine, 324–325, 325t homeopathy, 324f, 325–326 naturopathy, 326 types of, 324, 324f Bottle mouth syndrome, 1161 Botulism, 672t Boundaries, in the communication process, 444 Boundary of a system, 271 Bowel incontinence, 1242–1243 Bowel movement. See also Fecal elimination Bowel training programs, 1257 Bowlby, John, 345 Bowlby’s attachment theory, 345 Boykin and Schoenhofer’s theory nursing as caring, 426 BP. See Blood pressure (BP) Brachial artery, 513f, 514, 514t, 516t Bracing of a body part, 1144 Braden Scale for Predicting Pressure Sore Risk, 858, 859f Bradycardia, 515 Bradypnea, 523, 524t, 1273 Brain (B-type) natriuretic peptide, 749, 751t Brand names, 777 Breach of duty, 88, 91f Breast feeding, 54t Breasts breast cancer screening guidelines, 541t young adults, 383 breast self-examination, 973–974, 974t physical assessment Lifespan Considerations, 597t overview, 594, 594f skill for, 594–597t Breath sounds adventitious sounds, 524t, 581, 582t normal sounds, 581, 581t, 1273 Breathing exercises. See Deep breathing and coughing Breathing patterns, 1273

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Breckinridge, Mary, 34, 34f Brevity, in verbal communication, 439 Brewster, Mary, 33 Brief Pain Inventory, 1123 Bronchial (tubular) breath sounds, 581t Bronchodilators oxygenation, 1278–1279, 1280t sleep, 1098t Bronchoscopy, 764, 765f Bronchovesicular breath sounds, 581t Bronfenbrenner, Urie, 346, 347t Bronfenbrenner’s ecologic systems theory, 346, 347t, 348t Brown Report (1948), 36 Bruit, 588 Bruxism, 1101t B-type (brain) natriuretic peptide, 749, 751t Bubbling, defined, 524t Bubonic plague, 672t Buccal route of administration, 784t, 785, 785f Buddhists, and health-related information, 990t Budgets, technology use in, 164 Buffers, defined, 1342, 1342f Bulimia, 1162 Bulk forming laxatives, 1251t Bullae, 550f Bullous pemphigoid, 550f Bullying adolescents, 374 health professionals, among, 458 BUN. See Blood urea nitrogen (BUN) Bundle of His, 1316, 1316f Bupivacaine, 1139 Burden of proof, 75 Bureaucratic leader, 490, 490t Burn, defined, 682 Burnout, 1008 Butorphanol, 1137 Butterfly IV needles, 1364, 1365f

C Cadet Nurse Corps, 30, 31f, 36 Café-au-lait macules, 550f Caffeine narcolepsy, 1100 sleep, 1098, 1098t CAI. See Computer-assisted instruction (CAI) Calcium calcium supplements, 1362 imbalances, 1347, 1349t, 1350, 1350f normal values, 748f, 748t, 1356t regulation of, 1340–1341, 1341t Calcium channel blockers, 1327 Calculi, renal, 1050 Callus, 711 Calor, defined, 633t Caloric value, 1156 Calorie, 1156 CAM. See Complementary and alternative medicine (CAM) Campaign to Prevent Antimicrobial Resistance in Healthcare Settings, 635 Cancer cancer pain, 1114, 1114t, 1115t colorectal, 541t, 757t, 1239, 1240t middle-aged adults, 386 screening, 541, 541t, 757t stress, 1000f young adults, 383 CANCER LITerature (CANCERLIT), 157t Cancer pain, 1114, 1114t, 1115t Candida albicans, 629, 629t Candidiasis, 963t Canes, 1081, 1081f, 1082f, 1082t Cannula (shaft) of the needle, 809, 809f

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Index Cannulas for abdominal paracentesis, 767, 767f Cannulas for oxygen therapy, 1285–1286, 1285f, 1288–1289t Capillary blood glucose equipment for, 749, 749f Home Care Considerations, 754t Lifespan Considerations, 754t sites for, 752 specimen for, obtaining, 752–754t Capillary refill test, 593t Caplets, 777t Capsaicin, 1116 Capsules administering, 802t described, 777t Carative factors, 70 Carbamazepine, 1160t Carbohydrates digestion, 1154 metabolism, 1154 storage and conversion, 1154 types of, 1154 Carbon dioxide acid–base balance, 1342–1343, 1343t diffusion of, 1271, 1272 gas exchange, 1351f transport of, 1271 Carbon monoxide defined, 683 detectors, 683, 683f poisoning, and oxygen saturation, 533 Cardiac cycle, 1314–1315, 1315t Cardiac monitoring, 1325–1326, 1326f, 1326t Cardiac output (CO) calculation of, 1316 defined, 1316 factors affecting, 1317, 1317t kidney function, relation to cardiac output, 758t pulse, 513 Cardiopulmonary resuscitation (CPR), 1330–1331 Cardiotonics, 970t Cardiovascular disorders community health nurses, 139t fecal impaction removal, 1256t middle-aged adults, 386 stress, 1000f surgical risk, 893t Cardiovascular system blood, 1318–1319 blood vessels arterial circulation, 1317–1318, 1319f venous return, 1318, 1319f exercise, benefits of, 1046 fluid, electrolyte, and acid–base imbalance, 1354t heart blood flow through, 1313, 1315f cardiac cycle, 1314–1315, 1315t cardiac output, 1316–1317, 1317t, 1318f chambers and valves, 1313, 1314f conduction system, 1315–1316, 1316f coronary circulation, 1314, 1315f layers of, 1313, 1314f immobility, effects of, 1048–1049, 1049f, 1049t, 1055t middle-aged adults, 384t older adults, 396t, 399–400 pharmacokinetics of an oral medication, 782f physical assessment central vessels, 588, 588f, 588–591t, 591t heart, 586–587, 586t, 587f, 587t, 588–591t visualization procedures, 764, 765f Care plan conferences, 265 Caregiver burden, defined, 1004 Caregiver role strain, defined, 149 Caregivers home health care, 149

home health care nurses, 147, 147f nurses as, 41 Caries, dental, 364, 572, 715 Caring caring encounters compassion, 429 competence, 429–430 empowering the client, 429 knowing the client, 428–429 nursing presence, 429 caring practice, maintaining caring for self, 430–431, 430f, 431t, 432f reflection on practice, 432, 432t, 433t Chapter Highlights, 434t communication process, 444 Critical Thinking Checkpoint, 434t defined, 424 Gilligan’s theory of caring and relationships, 348–349, 350t ingredients of, 424 knowledge for nursing practice, types of, 427–428, 428f nursing theories bureaucratic caring (Ray), 425, 426f caring, the human mode of being (Roach), 425, 425t culture care diversity and universality (Leininger), 425 nursing as caring (Boykin and Schoenhofer), 426 theory of caring (Swanson), 427, 427t theory of human care (Watson), 426–427, 426t professionalization of, 424 six C’s of caring, 425, 425t Caring, the human mode of being (Roach), 425, 425t Caring practice, defined, 424 Caring (relationships-based) theories of morality, 102 Carminative enemas, 1253 Carminatives, 1252 Carotid arteries assessment of, 590t pulse measurement, 513f, 514, 514t, 516t Carpuject system, 809 Carrier, defined, 631 Cascara, 1251t Case management computers in nursing practice, 163–164 defined, 125 documentation, 254–255, 256f, 256t responsibilities of, 125t Case managers health care providers, 120, 120f home health care nurses, 147 nurses, 42 Case method framework for care, 125 Castor oil, 1251t CAT (computerized axial tomography), 764 Catabolism defined, 1050 protein metabolism, 1155 Cataracts, 398, 559, 936 Category-specific isolation precautions, 644 Cathartics, 1249, 1251 Catheter-associated urinary tract infection (CAUTI), 1217, 1217t, 1218t Cations, in body fluids, 1335, 1336f Causation, 88, 91f CAUTI (catheter-associated urinary tract infection), 1217, 1217t, 1218t CBC. See Complete blood count (CBC) CBE (charting by exception), 253, 253f, 254f, 255f CBN. See Community-based nursing (CBN) CDC. See Centers for Disease Control and Prevention (CDC) Cecostomy, 1244, 1244f Ceiling effect, defined, 1133 Ceiling-mounted lifts, 1059f Celebrex. See Celecoxib Celecoxib, 1132t, 1133 Cell-mediated defenses, 634

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Cellular immunity, defined, 634 Cellular response to inflammation, 633 Celsius to Fahrenheit conversion, 509 Center for Quality Improvement and Patient Safety, 240–241 Center of gravity, 1037, 1037f Centers for Disease Control and Prevention (CDC) bioterrorism, 668, 669 Campaign to Prevent Antimicrobial Resistance in Healthcare Settings, 635 Early Hearing Detection and Intervention Tracking and Surveillance System, 935 Guide to Community Preventive Services, 295 hand hygiene, 638, 640 health disparities, 305 infectious diseases, 629 pediculosis, 725 public health agencies, 116 sexual health, 964 Centers for Medicare and Medicaid Services (CMS) CAUTI, hospital reimbursement for, 1217 Electronic Health Record Incentive Program, 160 health care spending in the U.S., 122 home care nursing, resources for, 151 injuries caused by in-hospital falls, 676 safe patient handling and mobility standards, 1058 side rails as restraints, 734 Central blood vessels, assessment of Lifespan Considerations, 591t overview, 588, 588f skill for, 588–591t Central neuropathic pain, 1114 Central venous access devices (CVADs), 834, 1365, 1365f, 1365t, 1367t Cephalocaudal approach to examinations, 193 Cephalocaudal direction of growth and development, 339f, 339t Cerebral death, defined, 1023 Cerebrovascular accident (stroke), 1323t Certification, defined, 77 Cerumen, 565, 730 Cervarix. See Human papillomavirus (HPV) vaccine Cervical cancer screening guidelines, 541t young adults, 383 Chain of infection breaking, 637, 639t etiologic agent, 631, 631f overview, 630–631 portal of entry, 631f, 632 portal of exit, 631f, ‑632, 632t reservoir, 631–632, 631f , 632t susceptible host, 631f, 632–633 transmission method, 631f, 632 Chains of neck lymph nodes, 575–576, 576f, 576t, 577–578t Chair scales, 548, 548f Challenging the client, 448t Chamomile, 326t Change Chapter Highlights, 499t Critical Thinking Checkpoint, 498t defined, 497 nurse’s role in, 497–498, 498t resistance to, dealing with, 498, 498t strategies for, 498 types of, 497, 497t Change agent, nurse as, 41 Change-of-shift report, 263–264, 263t, 264t Changing the subject, as communication barrier, 448t Chapter Highlights activity and exercise, 1089t asepsis, 663–664 assessing, 198–199t caring, 434t circulation, 1331t

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Chapter Highlights—Cont. communication, 460–461t community nursing and care continuity, 142t complementary and alternative healing modalities, 333t critical thinking and clinical reasoning, 179t culturally responsive nursing care, 318t diagnosing, 213t diagnostic testing, 773–774t documenting and reporting, 266t electronic health records and information technology, 166t evidence-based practice and research in nursing, 61t family health, 420t fecal elimination, 1265t fluid, electrolyte, and acid–base balance, 1392t growth and development, 351t health, wellness, and illness, 300t health assessment, 624t health care delivery systems, 129t health promotion, 286t health promotion from conception through adolescence, 376t historical and contemporary nursing practice, 48–49t home care, 153t hygiene, 741t implementing and evaluating, 244t leading, managing, and delegating, 499t legal aspects of nursing, 96–97t loss, grieving, and death, 1031t medications, 850–851t nursing theories and conceptual frameworks, 71t nutrition, 1197t older adults, 408–409t oxygenation, 1310t pain management, 1150t perioperative nursing, 925t planning, 232t safety, 692–693t self-concept, 958t sensory perception, 946t sexuality, 978t skin integrity and wound care, 888–889t sleep, 1109t spirituality, 995t stress and coping, 1013t teaching, 485t urinary elimination, 1233t values, ethics, and advocacy, 110t vital signs, 536t young adults, 388t Characteristics, as personal critical thinking indicators, 171, 172t Charismatic leaders, 490 Chart, defined, 247 Charting, defined, 247 Charting by exception (CBE), 253, 253f, 254f, 255f Cheilosis, 716t Chelation therapy, 332 Chemical debridement, 872 Chemical disposable thermometers, 508, 509f Chemical names, 777 Chemical phlebitis, 1383 Chemical restraints, 685–686 Chemoreceptors, as respiratory regulation, 1272 Chemotherapy mouth dryness, 716 nutrition, 1159 sensory function, 932 Chess, Stella, and temperament theory, 344–345, 345t Chest. See also Thorax and lungs, assessment of chest circumference, 356–357 chest x-ray, 895t Chest tubes and drainage systems described, 1305–1306, 1306f nursing responsibilities, 1306–1307

Cheyne-Stokes respirations, 524t, 1273 Chief complaint, in nursing health history, 188t Child abuse, 83, 360 Child Growth Standards (WHO), 356 Children abdomen, assessment of, 603t antiemboli stockings, 904t anus, assessment of, 623t assessment, 193t assisting a client to ambulate, 1081t average daily urine output, 1205t bandages and binders, applying, 882t bathing, 706t blood pressure, 532f, 532t body alignment and activity, 1038, 1043 body temperature, 512t bone marrow biopsy, 769t breast and axilla assessment, 597t capillary blood glucose, 754t catheterization, 1223t circulation, 1319, 1320t communication with, 443t computer use, 165t death, concept of, 1022t death, responses to, 1029t diagnosing, 211t diagnostic testing, 773t ear and hearing assessment, 569t enema, administering, 1256t eye and vision assessment, 564t factors in potential bowel elimination problems, 1245t female genitalia and inguinal area assessment, 618f, 618t fluid, electrolyte, and acid–base balance, 1343, 1343t hair assessment, 555t hair care, 727t health assessment general survey, 549t health care decisions, 178t health care delivery, 141t health promotion and illness prevention, factors affecting, 282t health promotion topics, 276t heart and central vessels, assessment of, 591t home care, 152t IM injections, 829t infections, 636t international adoption, 306t intradermal injection, administering, 819t learning, 469t loss and grief responses, 1019, 1019f lumbar puncture, 767t male genitalia and inguinal area assessment, 622t massage, uses of, 333t medication administration, 800 medication nonadherence, 297t mouth and oropharynx assessment, 574–575t musculoskeletal system assessment, 606t nail assessment, 557t nasogastric tube, inserting, 1183t neck assessment, 578t neurologic system assessment, 615t nose and sinus assessment, 571t nutrition, 1164t ophthalmic medications, administering, 841t oral hygiene, 723t oral medications, 805t otic medications, administering, 843t oxygen delivery equipment, 1290t pain, 1119, 1120t, 1121t pain management, 1146t PCA pump, 1141t peripheral vascular system assessment, 593t positioning, moving, and turning clients, 1070t postoperative care, 912t preoperative teaching, 899t

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pressure ulcer and wound care, 879t pulse, 520t pulse oximetry, 535t rectal medications, administering, 846t respirations, 525t respiratory development, 1274t restraints, 691t seizure precautions, 681t self-esteem, enhancing, 956f, 956t sensory perception, 939t sequential compression devices, 1330t skin assessment, 554t sleep disturbances, 1097t spiritual development, 983t sputum and throat specimens, 763t stool specimens, 757t stress and coping, 1010t stressors, 999t suctioning, 1297t suctioning a tracheostomy or endotracheal tube, 1301t surgical risk, 892 teaching considerations, 472t teaching tools for children, 481t temperature measurement, 512f, 512t thorax and lungs, assessment of, 586t tracheostomy care, 1305t transferring clients, 1076t urine specimen collection, 760t voiding, factors affecting, 1202–1203, 1204t Children’s Health Insurance Program (CHIP), 127 Children’s Health Insurance Program Reauthorization Act (2009), 127 Chinese heritage, people with cultural views of older adults, 392t nutritional practices, 1158t Chiropractic, described, 326–327 Chi-squared, 57t Chlamydia chlamydial urethritis, 963t young adults, 382 Chloral hydrate, 1105t Chlorhexidine gluconate, 644t, 702t Chloride imbalances, 1350 normal values, 748f, 748t, 1356t regulation of, 1341t, 1342 Chlorine bleach, 644t Chlorpromazine, 716 Cholesterol defined, 1156 normal levels and clinical implications, 751t Choline magnesium trisalicylate, 1132t Christian Scientists blood and blood products, 1384t health-related information, 990t Christman, Luther, 34–35 Chronic grief, 1016–1017 Chronic illness/conditions access to health care services, 125t defined, 297–298 older adults, 405 pressure ulcers, 856 treatment nonadherence, 297t Chronic infections, 630 Chronic obstructive pulmonary disease (COPD), 1280t Chronic pain common syndromes, 1115t described, 1114, 1114t Chronosystem level, in Bronfenbrenner’s ecologic systems theory, 346, 347t Chvostek’s sign, 1347, 1349t, 1350f Chyme, 1236 Cialis. See Tadalafil Cimetidine, 901

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Index CINAHL (Cumulative Index to Nursing and Allied Health Literature), 58t, 157t Circadian (diurnal, or biologic) rhythms blood pressure, 526 body temperature, 505, 505f learning, barrier to, 469t sleep, 1092–1093 Circulating (antibody-mediated) immunity, 634, 634t Circulating nurses, 906 Circulation cardiovascular function, alterations in blood alterations, 1324 decreased cardiac output, 1323–1324, 1323t impaired tissue perfusion, 1324, 1324f overview, 1322–1323 cardiovascular function, factors affecting cigarette smoking, 1320t, 1321 C-reactive protein, 1320t, 1322 diabetes, 1320t, 1321 elevated homocysteine level, 1320t, 1322 elevated serum lipid levels, 1320–1321, 1320t hypertension, 1320t, 1321 metabolic syndrome, 1320t, 1322, 1322t nonmodifiable risk factors, 1320, 1320t obesity, 1320t, 1321 overview, 1319–1320 sedentary lifestyle, 1320t, 1321–1322 cardiovascular system physiology (See Cardiovascular system, physiology) Chapter Highlights, 1331t Critical Thinking Checkpoint, 1331t Lifespan Considerations, 1319, 1320t Nursing Management assessing diagnostic studies, 1325–1326, 1326f, 1326t nursing history, 1324–1325, 1325t physical assessment, 1325, 1325t diagnosing, 1326 evaluating, 1331 implementing cardiopulmonary resuscitation, 1330–1331 circulation, promoting, 1326–1327, 1327t medications, 1327, 1330t venous stasis, preventing, 1327–1330, 1328–1329t, 1328f, 1330t planning, 1326 oxygen saturation, 533, 534t Circulatory overload, 1385t Circumduction (movement), 1038t, 1039f, 1039t, 1041f, 1041t Cisapride, 1160t Citizen, responsibility of nurse as, 79, 79t Citizenship, defined, 303 Citrucel. See Methylcellulose Civil actions, 74–75 Civil judicial process, steps in, 75, 76f Civil law, 74 Civil Rights Act (1964), 304 CK. See Creatine kinase (CK) Clapping (percussion), and oxygenation, 1282, 1282f Clarification, seeking, 447t Clarity, in verbal communication, 439 CLAS Standards (National Standards for Culturally and Linguistically Appropriate Serviced in Health Care), 305 Clean, in medical asepsis, 629 Clean intermittent self-catheterization, 1225, 1225t Clean voided urine specimens, 757–758, 758t Clean wounds, 855 Clean-catch urine specimens, 758–760, 758f, 758–760t Clean-contaminated wounds, 855 Cleansing baths, 701 Cleansing enemas, 1252–1253, 1252t, 1253t Clear absorbent acrylic dressings, 873t Clear liquid diet, 1177, 1177t Client, defined, 39

Client advocate, nurse as, 41 Client and family education. See also Client Teaching communication, 455 health promotion, 284 preoperative teaching, 895–899, 896t, 897–899t skin problems and care, 710, 710t Client communication, 455 Client contracting, 481 Client identification, 797, 797t, 798f, 798t, 799t Client records data sources, 189 defined, 247 Client Teaching. See also Client and family education; Teaching back injuries, preventing, 1060t breast self-examination, 974t canes, using, 1082f, 1082t clean intermittent self-catheterization, 1225t client self-management of pain, 1141t clients with low literacy levels, teaching, 476t collecting stool for occult blood, 756t cough medications, using, 1281t crutches, using, 1084t diagnostic testing, preparing for, 745t dietary fat, reducing, 1165t electrical hazards, reducing, 685t fecal elimination, 1248t fluid and electrolyte balance, promoting, 1360t foot care, 712t forced expiratory technique (huff coughing), 1279t health breathing, promoting, 1278t healthy defecation, 1248t healthy heart, promoting, 1327t healthy nutrition, 1176t home care activity and exercise, 1057t home care and circulation, 1327t home care and fluid, electrolyte, and acid–base balance, 1360t home care oxygenation, 1277t incentive spirometer, using, 1282t infection prevention, 638t learning, attributes of, 466t metered-dose inhalers, 848–849t, 848f nutrition for older adults, 1164t pain monitoring in the home setting, 1128t pelvic floor muscle exercises (Kegels), 1215t physical activity, guidelines and minimal requirements for, 1045t poisoning, preventing, 683t postural hypotension, controlling, 1079t safety measures throughout the life span, 673–674t skin integrity, 868t skin problems and care, 710t sleep, promoting, 1103t STIs and HIV, preventing transmission of, 975t teaching tools for children, 481t testicular self-examination, 974f, 974t tooth decay prevention, 717t tube feedings, 1192t urinary elimination in the home care setting, 1213t walkers, using, 1083t wound care, teaching plan for, 477t written teaching aids, developing, 475t Clients data sources, 187 empowering, 429 home health care, perspectives on, 147 illness, impact on, 299 knowing, 428–429 loss of property, as potential liability in nursing, 92 metaparadigm for nursing, 64 Climacteric, defined, 385 Clinical Alert! accurate documentation, 248t alcohol-based hand rubs, 640t

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anti-inflammatory medications and infection, 635t aspirin and acetaminophen, effectiveness of, 1136t assess the client, not the ECG, 1326t avoiding use of word “error” in documentation, 261t back injuries among health care workers, 1059t, 1065t bad systems and errors, 240t base of the lungs and base of the heart, 586t beards and mustaches, shaving, 728t bed rest, effects of, 1048t blood in urine, implications of, 762t bowel movement, different terms for, 1237t CAM modalities, combining, 331t chronic illness and treatment nonadherence, 297t client history regarding physical assessment, 552t client hospital gowns and infection prevention, 649t client identification, 798t client labels on disposable supplies, 652t client situations, discussing, 90t client status, monitoring and documenting, 89t client’s self-report of pain, 1131t client’s stage of change and interventions, 477t clients wishing to administer own enemas, 1253t combining opioid and nonopioid analgesics, 1132t “comfort foods,” 1006t completeness in documentation, 262t consent forms for aspiration or biopsy procedures, 766t constipation with opioids, 1135t correct spelling in documentation, 261t cranial nerves, mnemonic device for, 609t delirium, signs of, with fecal impaction, 1242t diabetes, clients with, 711t document behavior, not descriptive labels, 942t documentation and legal issues, 262t double-checking dosage of insulin or heparin, 821t encouraging clients to write down questions, 479t enteral feedings, starting postoperatively, 1186t ethical behavior, contextual nature of, 106t falls, risks for, 676t fecal impaction removal, and cardiac disease, 1256t flow-rate control devices used for older adults or pediatric clients, 1376t frequently asked questions to suggest to clients, 480t gamma hydroxybutyrate (GHB), 1100t “giving” or “popping” sensation in the incisional area, 918t helping the client be in control of pain management, 1146t high-quality care for unresponsive clients, 1028t immobility and thrombi, 1049t incontinence pad use for incontinence, 1214t infiltration with electronic IV infusion devices, 1375t inflammation, signs of, 633 inner cannulas of tracheostomy tubes, 1293t insulin, mixing in one syringe, 817t insurance companies paying for preventive health care activities, 115t intraoperative positioning of older adults, 906t IV push medications and blood or parenteral nutrition infusion, 833t kidney function, relation to cardiac output, 758t language on consent forms, 80t language used in neurologic examination, 608t lateral assist devices, 1060t lead poisoning, 674t “left” and “right” refer to client’s left or right side, 518t legislators, informing about nursing, 74t lice in excessively matted hair, 726t literacy level, determining, 81t loss and grief felt by those experiencing deaths of many significant others, 1028t low client literacy levels, 474t management levels, nurses moving through, 492t medication errors, avoiding, 89t medication orders, double-checking, 787t meditation, biofeedback, and imagery, techniques for, 330t metered-dose inhaler use, 847t

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Index

Clinical Alert!—Cont. MRSA and hand hygiene, 638t noise level and sensory overload, 934t noncompliance, perception of, 476t normal saline to be used with blood transfusions, 1386t nurses and student nurses, responsibilities of, 96t nurses’ duties, 88t nurse’s duty with client falls, 678t nurses using smart phones or PDAs, 155t older adults requiring different levels of care, 118t oral health of long-term care residents, 716t orientation of the client, 607t overlap in providers performing health care activities, 121t oxygen, careful prescription for, 1272t pain, tolerating, to maximize recovery, 1132t passive ROM progressing to active-assistive ROM exercises, 1077t perineal care, cleaning from “clean to dirty,” 708t peripheral-short IV catheters placed in an emergency situation, 1364t physical health assessment, preparation for, 548t plastic IV bags, not writing directly on, 1366t potassium given intravenously, guidelines for, 1347t pressure on both carotid arteries, 514t professional negligence, 88t recording temperature from electronic thermometers, 510t religious beliefs, sharing, 985t respiratory rate of sleeping adults, 523t Rosenbaum eye chart, using, 563t sanguineous exudate, 862t SBAR model of communication, 459t sex, discussing with clients, 973t signs of infection in older adults, 909t skin breakdown in clients confined to wheelchairs, 1072t skin lesions, photographing, 553t sleep apnea and snoring, 1100t sleep deprivation and negative temperament in clients, 1094t sleep deprivation in hospitalized clients, 1094t spiritual care, offering, 982t stressors, perception of, 953, 953t substance abuse, knowing risk factors for, 84t surgery to reconnect ends of the bowel, 1244t tablets, crushing, 803t “teach back” technique, 474t teaching while performing nursing care, 480t testicular self-examination, teaching, 974t timed urine specimens, collecting, 761t transdermal patches, keeping track of, 838t transdermal patches, using gloves for, 837t treatments once considered folk treatments, 309t TVs and computers in bedrooms affecting amount of sleep, 1095t two nurses to check information with blood transfusions, 1388t Clinical decision support systems, 160–161 Clinical judgment, 173–174 Clinical Manifestations colorectal cancer, 1240t common chronic pain syndromes, 1115t fever, 506t hypothermia, 507t impending death, signs of, 1025t insomnia, 1099t malnutrition, 1175t sensory deprivation, 932t sensory overload, 932t sexually transmitted infections, 963t sleep deprivation and sleep problems in teens, 1096t spiritual needs, 982t stress, 1002t Clinical model of health, 290 Clinical nurse leaders, 37

Clinical nurse specialists, 42t Clinical practice, and nursing theory, 65–66 Clinical reasoning Chapter Highlights, 179t communication, 176t components of client condition changes, responding to, 176 clinical reasoning-in-transition, 176 cognitive and metacognitive processes, 175 learning how to act, 176 priorities, setting, 175, 176t rationales, developing, 176 reflection, 176 concept mapping, 177, 177f, 177t critical thinking, integration with, 176–177 Critical Thinking Checkpoint, 178t defined, 170 medication administration, 801t medication administration safety, 178t nursing process, 185, 186f Clinical Simulation in Nursing, 158 Clinton, William J., 85 Closed airway (in-line) suctioning system, 1298, 1298f, 1301t Closed awareness, defined, 1024 Closed questions for interviews, 190, 191t Closed system, defined, 271 Closed-wound drainage system, 921, 921f, 922f, 922t Closing stage of an interview, 192–193 Clostridium botulinum, 672t Clostridium difficile body reservoirs, in, 632t disinfectants and antiseptics, 643 hand hygiene, 640 nosocomial infections, 630 Clostridium species, 629t Clotting factors, transfusion of, 1385t Clubbing of nails, 556, 556f Cluster (Biot’s) respirations, 1273 CMS. See Centers for Medicare and Medicaid Services (CMS) CMV (cytomegalovirus), 629 CO. See Cardiac output (CO) Coagulase-negative staphylococci, 630t Coagulation disorders, 893t Coanalgesic, described, 1136–1137 Cocaine herbal medicine, 324 sexual function, 970t Cochlea, 565f, 566 Cochrane Library, 157t Code for Nurses (ANA), 104–105 Code of ethics defined, 104 nursing codes, purposes of, 105 nursing codes of ethics, establishment of, 104–105, 104t professional status, aspect of, 43 Code of Ethics for Nurses (ANA) accountability, defined, 103 passive euthanasia and assisted suicide, 108 professional boundaries, 444 purposes of, 105 withdrawing or withholding food and fluids, 109 Codeine fecal elimination, 1240–1241 pain management, 1134 Codeine and acetaminophen, 1132, 1132t, 1133t Cogentin. See Benztropine mesylate Cognitive abilities and aging cognitive ability, 404 learning, 404 memory, 404 perception, 403–404 Cognitive development adolescents, 373 defined, 345

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middle-aged adults, 385 newborns and infants, 359 Piaget’s theory of cognitive development, 345, 345f, 346t, 347t preschoolers, 366 school-age children, 369, 369f toddlers, 363 young adults, 381 Cognitive dimension of health described, 293–294, 294t healthy lifestyle choices, 293t Cognitive domain learning, 466 stress, 1003–1004 Cognitive processes, and clinical reasoning, 175 Cognitive skills cognitive awareness, and safety, 667 exercise, benefits of, 1047 impairment, and communication, 453–454, 454t implementing phase of nursing process, 234 Cognitive theory, and learning, 467 Cognitive-behavioral interventions, 1144–1145, 1144t Cohabiting families, 414 Coinsurance, 126–127 Coitus, 966 Colace. See Docusate sodium Colchicine, 1160t Cold applications cold packs, 885, 886f compresses and soaks, 886 contraindications for, 884, 885t cooling sponge baths, 887 ice bags, gloves, and collars, 886, 886f indications for, 884, 884t local effects, 882–883 pain management, 1144 physiological effects, 882, 883t rebound phenomenon, 883–884, 884t systemic effects, 883 thermal receptors, 883, 884t thermal tolerance, 883, 883t Collaboration collaborative health care, 137–139, 138t competencies for, 138–139 defined, 138 nurse as a collaborator, 138, 138t Collaboration for Homecare Advances in Management and Practice, 151 Collaborative care plans, 220 Collaborative interventions, 227 Collaborative problems diagnostic statements, 209, 210t nursing diagnoses, differentiating from, 203–204, 204t, 207, 208f Collagen, 861 Collagen dressings, 873t Collective bargaining, 47, 79 Colloid osmotic pressure (oncotic pressure), 1337 Colloids, 1336 Cologuard test, 756 Colonics (colon therapy), 332 Colonization, defined, 629 Colonoscopy, 764 Colorectal cancer risk factors and symptoms, 1239, 1240t screening, 541t, 757t Colostomy. See also Ostomy defined, 1244 irrigation of, 1262 Coma, 931t Comfort, postoperative, 909, 924 Commission on Collegiate Nursing Education, 35, 47, 77 Commitment, in nursing, 425t Committee on the Grading of Nursing Schools (1934), 36

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Index Commode, 1249, 1249f Common law, 74, 74f Communicable disease, 629 Communication. See also Reporting ability, and safety, 667 acute sensory impairments, 937, 940, 941t barriers to, 445, 448t Chapter Highlights, 460–461t client records, 248 clinical reasoning, 176t collaborative health care, 139 communication process message, 438, 438f receiver, 438–439, 438f response, 438f, 439 sender, 438, 438f Critical Thinking Checkpoint, 460t culturally responsive nursing care health care agencies, requirements for, 309–310 nonverbal communication, 311–312, 311f verbal communication, 310, 310t, 311t defined, 437 enhancement of, 455 factors influencing boundaries, 444 congruence, 444 developmental stage, 442, 443t environment, 444 gender, 442 interpersonal attitudes, 444 personal space, 442–443, 443f roles and relationships, 443–444 territoriality, 443 values and perceptions, 442 family health, 416 group communication group dynamics, 451, 452t types of health care groups, 451–453, 453t health professionals, among disruptive behaviors bullying, 458 incivility, 457–458, 458t lateral violence, 458 responding to, 458–459, 459t nurse-physician communication assertive communication, 460 communication styles, 459, 459t emotional intelligence, 460 nonassertive communication, 460 helping relationship characteristics of, 449, 449t described, 445, 449 developing, 451 phases of, 449–451, 450t interviews, 193t medication orders, 787–788, 787t, 788f modes of electronic, 439, 441–442 nonverbal, 439, 440–441, 440f, 441f verbal, 439–440 nurse communication, evaluation of, 456–457, 456–457t nurse managers, skill of, 493 Nursing Management assessing impairments to communication, 453–454, 454t style of communication, 454 diagnosing, 454–455 evaluating client communication, 455 nurse communication, 456–457, 456–457t implementing client and support persons, educating, 455 communication enhancement, 455

environment, manipulating, 455 support, providing, 455 planning, 455 nursing process and, 453 self-talk, 437, 438f spirituality, conversing about, 988, 988t, 989t therapeutic communication attentive listening, 445, 445f barriers to, 445 described, 444–445 techniques for, 445, 446–447t visibly tuning in, 445, 446t Communicator, nurse as, 41 Communities of interest, 134 Community community health, planning, 134–135 community-based frameworks, 135–136, 136f community-based settings, 136–137 data for assessment of, 134, 135t defined, 134 functions of, 134, 134t healthy, characteristics of, 134, 134t older adults, care settings for, 394, 394f safety, 668 subsystems, assessment of, 134, 135t teaching in, 465 Community colleges, 36 Community health nursing community-based nursing, differentiated from, 137t computers in nursing practice, 163, 163f defined, 134 Community nursing and care continuity Chapter Highlights, 142t community health, 134–137, 134t, 135t, 136f community-based health care, 133–134, 133f community-based nursing, 137–139, 137t, 138t, 139t continuity of care, 139–141, 140t, 141t Critical Thinking Checkpoint, 141t health care movement to the community, 131–133, 133f, 133t primary health care and primary care, 132–133, 133f, 133t Community nursing centers, 136 Community-based health care, 133–134, 133f Community-based nursing (CBN) collaborative health care, 137–139, 138t community health nursing, differentiated from, 137t competencies for, 137, 138t defined, 137 Compact states, defined, 35 Comparative analysis, 57 Compassion, in nursing, 425t, 429 Compassion fatigue, 83t Compensation, 1350 Compensatory, defined, 271 Competence, in nursing, 425t, 429–430 Complaint, defined, 75, 76f Complementary and alternative healing modalities Assessment Interview, 323t basic concepts balance, 322 energy, 322 healing environments, 322–323 holism, 322 humanism, 322 spirituality, 322 botanical healing aromatherapy, 324f, 325, 326t herbal medicine, 324–325, 325t homeopathy, 324f, 325–326 naturopathy, 326 types of, 324, 324f Chapter Highlights, 333t combining, 331t Critical Thinking Checkpoint, 333t health care, approaches to, 321–322, 322t

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manual healing methods acupuncture, acupressure, and reflexology, 327, 327f, 328f chiropractic, 326–327 hand-mediated biofield therapies, 327–328, 328t massage, 327, 327f, 333t mind-body therapies biofeedback, 330, 330t guided imagery, 329–330, 330t hypnotherapy, 329 meditation, 329, 329t, 330t pilates, 330 qi gong, 330 t’ai chi, 330 yoga, 328–329 miscellaneous therapies animal-assisted therapy, 332 bioelectromagnetics, 332 detoxifying therapies, 332 horticultural therapy, 332 humor and laughter, 331–332 music therapy, 331, 331f, 331t nutritional therapy, 326 self-healing for nurses, 323t spiritual therapy, 330–331 systematized health care practices Ayurveda, 323 curanderismo, 324 Native American healing, 324 traditional Chinese medicine, 323–324 Complementary and alternative medicine (CAM). See also Complementary and alternative healing modalities defined, 321–322, 322t health beliefs and practices, 309 Complementary medicine, defined, 321. See also Complementary and alternative healing modalities Complete bed baths, 701 Complete blood count (CBC) biocultural considerations, 747t blood, composition of, 748f described, 745, 747 fluid, electrolyte, and acid–base balance, 1357 normal levels and clinical implications, 746–747t preoperative, 895t Complete proteins, 1154 Completely in-the-canal (ITC) hearing aids, 331, 331f Completeness in documentation, 262, 262t Compliance arteries, 513 lungs, 1271 Compliance with learning, 466 Complicated grief, 1016–1017 Comportment, in nursing, 425t Comprehensive Drug Abuse Prevention and Control Act (1970), 778t Compresses, warm or cold, 886 Compromised host, in the chain of infection, 631f, 632–633 Computed tomography (CT), 764 Computer-assisted instruction (CAI) acronym, 156t described, 158 Computer-based patient records confidentiality of, 248 described, 160, 160f Computerized axial tomography (CAT), 764 Computerized nursing care plans, 220 Computerized provider order entry (CPOE), 156t, 163 Computers documentation, used for, 253–254, 255f, 256t teaching strategy, 479t, 481–482 Concept maps critical reasoning and clinical reasoning, 177 defined, 177 nursing care plans, 218, 220f, 231t types of concept maps, 177, 177f, 177t

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Index

Concept Maps acute pain, 1149f altered bowel elimination, 1264f deficient fluid volume, 1392f disuse syndrome, risk for, 1088f grieving client, 1030f growth and development theories and theorists, 344f, 347f, 350f ineffective airway clearance, 231t, 1309f ineffective coping, 1012f nutrition, 1196f sensory-perception disturbance, 945f sleep, 1108f spiritual distress, 994f Conceptual framework, defined, 64 Conceptual model, defined, 64 Conceptual models or frameworks for data organization, 193, 195–196, 196t Concrete operations phase of Piaget’s theory of cognitive development described, 345, 345f, 346t, 347t school-age children, 369 Concurrent audit, defined, 242 Conduction of heat, 504 Conductive hearing loss, 566 Condyloid joints, 1040f, 1040t Condyloma acuminatum, 963t Confidence critical thinking, 175 six C’s of caring in nursing, 425t Confidence interval, defined, 57 Confidentiality, 60 Conflict, managing, 493 Confusion assessment tools, 942–943 described, 931t sensory perception functioning, 941–943, 942t, 943f, 943t therapeutic environment for, 943t Confusion Assessment Method test, 942 Congenital hypothyroidism, 749 Congruent communications, 444 Conjunctivitis, 559 Conscience, in nursing, 425t Conscious sedation, 905, 905t Consequence-based (teleological) theories of morality, 102 Constant data, 187 Constant fever, 505 Constipation causes and factors, 1241 defined, 1241, 1241t diet and fluid intake, 1248 opioids, 1135t postoperative phase, 911t Constitutional law, 74, 74f, 75t Constructive surgery, 892t Consumers defined, 39 demands, influencing nursing practice, 45 Contact lenses, 729 Contact precautions, 645t, 646 Contaminated wounds, 855 Contemplation stage of health behavior change, 278, 285f Content analysis, defined, 57 Continuing education, purpose of, 38–39 Continuity of care care across the life span, 139, 141t defined, 139 discharge planning, 140, 140t home health care teaching, 140–141 medication reconciliation, 140 referrals, 140t, 141 Continuity theory, 401 Continuous infusion, intraspinal, 1139

Continuous local anesthetics, 1140 Continuous positive airway pressure (CPAP) described, 1287–1288, 1287f sleep apnea, 1100 Continuous subcutaneous infusion of opioids, 1137–1138 Contraception methods of, 975, 975f, 976t Sanger, Margaret Higgins, 33 Contract collective bargaining, 79 defined, 78 required features, 78 roles, responsibilities, and rights of nurses citizen, 79, 79t employee or contractor for service, 78–79, 79t provider of service, 78, 79t Contract law, 74, 75t Contractility, cardiac, 1317, 1317t Contractual obligations, 78 Contractual relationships, 78 Contracture, defined, 1048 Contralateral stimulation, for pain management, 1144 Controlled substances, 83, 778, 779f Contusions, 855t Convection, and body temperature, 504 Conventional level of Kohlberg’s theory of moral development adolescents, 373 described, 347, 348t, 350t school-age children, 369 Conventional medicine, 321 Coordinating/coordinator home health care nurse as, 147 management function, 492 Coordination of movement, 1038 COPD (chronic obstructive pulmonary disease), 1280t Coping Chapter Highlights, 1013t defined, 1004 ineffective strategies, effects of, 1004, 1004t Lifespan Considerations, 1010t Nursing Management assessing, 1005, 1005t Concept Map, 1012f diagnosing, 1005–1006 evaluating, 1009, 1009–1011t, 1012f implementing anger, mediating, 1007, 1007t anxiety, minimizing, 1007, 1007t crisis intervention, 1008, 1008t health promotion strategies, 1006–1007, 1006t relaxation techniques, 1007–1008 stress management for nurses, 1008–1009 Nursing Care Plan, 1010–1011t planning, 1006, 1006t Coping mechanism defined, 1004 family health, 416 pain management, 1145 Coping strategy, defined, 1004 Copper, and wound healing, 893t Core self-concept, 950 Core temperature, described, 504, 504f Corn, defined, 711 Coronary arteries, 1314, 1315f Coroner, 87 Corrections nursing, 137 Correctol. See Bisacodyl Cortisone, 1001f Corynebacterium xerosis, 629t Costal (thoracic) breathing, 522 Cost-benefit analysis, 57 Cotton applicators, 543t

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Coudé urinary catheters, 1218, 1219f Cough. See also Deep breathing and coughing nonproductive, 524t productive, 524t Cough medications, using, 1281t Cough reflex, 1269, 1269t Coumadin. See Warfarin Counseling health promotion, 284 nursing function, 41 Countershock phase of GAS, 999, 1001f Covert change, 497 CPAP (continuous positive airway pressure), 1100, 1287– 1288, 1287f CPOE (computerized provider order entry), 156t, 163 CPR (cardiopulmonary resuscitation), 1330–1331 Crackles (rales), 582t Cranial nerves neurologic system assessment, 607, 609t, 616t type, functions, and assessment methods, 616t C-reactive protein (CRP), 1320t, 1322 Cream, medical, 777t Creatine kinase (CK) circulation, 1326 normal levels and clinical implications, 749, 750t Creatinine, urinary, 1173 Creatinine clearance, 1210 Creatinine level described, 747 preoperative, 895t Creativity, 171 Credentialing accreditation of nursing education programs, 77 certification, 77 defined, 75 licensure, 75, 77, 77t Credé’s maneuver, 1217 Credibility, in verbal communication, 440 Crepitation, 1053 Crime criminal actions, 74–75 criminal law, 74, 75t defined, 88 reporting, 95, 95t Crimean War, 29, 32 Crises characteristics of, 1008t crisis centers, 119 defined, 1008 Crisis intervention, 1008, 1008t Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response (IOM), 668 Critical analysis, defined, 171–172 Critical Pathway, wound management, 869t Critical pathways case management documentation, 254, 256f, 256t defined, 125 described, 220 Critical theory, defined, 65 Critical thinking attitudes that foster, 174–175 Chapter Highlights, 179t clinical reasoning, integration with, 176–177 concept mapping, 177, 177f, 177t Critical Thinking Checkpoint, 178t defined, 170 Lifespan Considerations, 178t nurse managers, skill of, 492 nursing practice, applying to, 173–174 nursing process, 185, 185t, 186f purpose of, 170–171, 171f, 172t skills for, 170 techniques in, 171–173, 172t, 173t

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Index Critical Thinking, Applying implementing and evaluating, 244t planning, 230t Critical Thinking Checkpoints asepsis, 663t assessing, 198t blind client, signing consent for, 96t caring, 434t circulation, 1331t communication, 460t complementary and alternative healing modalities, 333t critical thinking and clinical reasoning, 178t culturally responsive nursing care, 318t diagnosing, 211t diagnostic testing, 773t documenting and reporting, 265t electronic health records and information technology, 166t family health, 419t growth and development, 351t health, wellness, and illness, 299t health assessment, 624t health promotion, 285t health promotion from conception through adolescence, 375t home care, 152t hygiene, 741 leading, managing, and delegating, 498t loss, grieving, and death, 1030t medications, 850t nurses taking an active role in influencing the direction of health care, 141t older adults, 408t pain management, 1147t perioperative nursing, 925t research study, evaluation of, 60t safety, 692t self-concept, 958t sensory perception, 944t sexuality, 977t skin integrity and wound care, 888t spirituality, 992t teaching, 485t vascular bypass surgery or amputation, 110t vital signs, 536t weight loss with AIDS-defining illness, 71t young adults, 387t Critical values of nursing, 44, 44t Critique defined, 58 research reports, 58, 59t Cross contamination, 736t Cross-dressing, 965–966 Crossing the Quality Chasm: A New Health System for the 21st Century (IOM), 240 Cross-linking theory of aging, 395t CRP (C-reactive protein), 1320t, 1322 Crust, skin, 551t Crutches crutch stance (tripod position), 1084, 1084f gaits four-point alternate gait, 1084–1085, 1084f overview, 1083–1084 swing-through gait, 1085 three-point gait, 1085, 1085f two-point alternate gait, 1085, 1085f getting into and out of a chair, 1085, 1086f measuring clients for, 1083, 1083f overview of, 1082–1083, 1084t stairs, going up and down, 1086, 1086f Cryoprecipitate, 1385t Crystalloids, 1336 CT (computed tomography), 764

Cues clusters of, and nursing diagnoses, 205, 206–207t defined, 198 Cultural broker, 310 Cultural care deprivation, 931 Cultural competence, defined, 306 Cultural deprivation, 931 Cultural Diversity in Health and Illness (Spector), 313t Culturally congruent care, 425 Culturally Responsive Care biocultural considerations in CBCs, 747t blood and blood products, 1384t blood samples, drawing, 745t body piercing and dermal implants, 901t clients in pain, 1130t cultural views of older adults, 392t cultures that value family inclusion in client teaching, 483t ethnopharmacology, 783t families, 317t gender and race disparities in clients with cardiovascular disease, 1323t health care interpreter, working with, 82t leadership, management, and delegation, 497t moral principles, 103t nutritional practices, 1158t pain, responses to, 1119t personal space, 192t providing culturally and linguistically appropriate services, 81t self-concept. assessing, 953t social support, cultural aspects of, 281t therapeutic movement modalities from Eastern cultures, 1045f, 1045t Culturally responsive care, defined, 302 Culturally responsive nursing care Chapter Highlights, 318t communication style health care agencies, requirements for, 309–310 nonverbal communication, 311–312, 311f verbal communication, 310, 310t, 311t, 440 concepts related to culture, 302 discrimination, 304 diversity, 303 ethnicity, 303 ethnocentrism, 304 generalizations, 304 multicultural, 303 nationality, 303 prejudice, 304 race, 303, 303f racism, 304 religion, 303–304 stereotyping, 304 subculture, 303 Critical Thinking Checkpoint, 318t cultural knowledge, resources for, 313, 313t cultural models of nursing care competencies for, 306 cultural competence model, 306 HEALTH traditions model, 306–307, 307f, 307t culturally responsive care, defined, 302 demographics, 305 family patterns, 309 health beliefs and practices, 308–309, 308f, 309t health disparities, 304–305 immigration, 305–306 international adoption, 306t Nursing Management assessing, 314–315, 315f, 316t cultural sensitivity, conveying, 313–314, 314t diagnosing, 315 evaluating, 317

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implementing, 315–317, 317t planning, 315, 317t self-awareness, developing, 313 nutritional patterns, 312–313 space orientation, 312 time orientation, 312 Culture death-related practices, 1023–1024 defined, 302 growth and development, 339 health status, beliefs, and practices, 294 hygienic practices, 696t informed consent, 80, 81, 81t, 82t learning, 469, 469t learning needs, 471, 471t loss and grief responses, 1019 medication action, 783, 783t nonverbal communication, 311–312, 311f, 440 nutrition, 1158, 1158t pain experience, 1118–1119, 1119t self-concept, 952, 952f, 953, 953t sensory function, 931 sexuality, influencing, 966–967 transcultural teaching, 482–484, 483t Culture care, defined, 69 Culture Care Diversity and Universality: A Theory of Nursing (Leininger), 69 Culture care diversity and universality theory (Leininger), 69, 425 Cultures (laboratory tests), 637 Cumulative effect, defined, 780 Cumulative Index to Nursing and Allied Health Literature (CINAHL), 58t, 157t Curanderas, 324 Curanderismo, 324 Curanderos, 324 Curiosity, in critical thinking, 175 Cutaneous stimulation for pain, 1142–1143t, 1142–1144 CVADs (central venous access devices), 834, 1365, 1365f, 1365t, 1367t Cyanosis, 549, 1274 Cyclosporine, 1160t Cystoscope, 764 Cystoscopy, 764 Cysts, skin, 550f Cytomegalovirus (CMV), 629 Cytotoxic T cells, 634

D Dacryocystitis, 559 Dalmane. See Flurazepam Damages, legal, 88 Dancing (stepping or walking) reflex, 358t Dandruff, 724 Dangling a client, 1069–1070t DAR (Data, Action, Response) progress notes, 252 Darvon. See Propoxyphene Darwin, Charles, 64 Data analyzing, for diagnostic process clustering cues, 205, 206–207t gaps and inconsistencies, identifying, 205 standards, comparing with, 204–205, 205t analyzing, for research, 56–57, 57t, 165 collecting, for research, 56, 165 data collection described, 185–186 methods for, 189–193, 190t, 191t, 192t, 193t, 194–195f nursing health history, 186, 188t sources of data, 187–189 types of data, 186–187, 189t data organization conceptual models/frameworks, 193, 195–196, 196t

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Data—Cont. nonnursing models, 197 wellness models, 196–197 data validation, 197, 198t defined, 185 evaluating, in nursing process data collection, 237, 237f data comparison with desired outcomes, 237–238, 237f technology collection and analysis, 165 standardization and classifications, 161 Data warehousing, 158 Database defined, 156t, 186 POMR, 250 research literature, 58, 58t Date, on medication orders, 787, 787t Datril. See Acetaminophen Day care centers, 119 Daydreaming (fantasy), 1003t, 1004 Death. See also Dying and death advance health care directives, 85, 86f autopsies, 85 certification of death, 85 defined, 1023 do-not-resuscitation orders, 85, 87 dying with dignity, 1026, 1026t euthanasia, 87 facing, by older adults, 403 family health, 419 impending, signs of, 1025t inquests, 87 legal aspects, 85–87, 86f organ donation, 87 religious beliefs, 985 signs of, 1023 sleep and mortality of elderly Hispanics, 399t Death with Dignity Act (1997), 87 Debridement, 872 Decision, legal, 75 Decision making, in collaborative health care, 139 Decision trees, 495–496f Decode, defined, 438 Decongestants, 1098t Decubitus ulcers, 855. See also Pressure ulcers Deductive reasoning, 172–173 Deep breathing and coughing oxygenation, 1278, 1278t, 1279t, 1280t postoperative care, 913–914 teaching about, 898–899t Deep palpation, 543, 544, 544f Deep sleep, 1093–1094 Deep vein thrombosis (DVT), 1327–1330, 1328–1329t, 1328f, 1330t Defamation, 91–92, 91f Defecation, 1237–1238, 1237t. See also Fecal elimination Defendants, 75, 76f Defense mechanisms Freud’s theory of psychosexual development, 341 stress, 1003, 1003t Defensive, being, 448t Defining characteristics, in nursing diagnosis, 203 Dehiscence postoperative phase, 911t sign of, 918t wound healing, 862 Dehydration described, 1346 pulse, 513 Delayed grief, 1016 Delegation Chapter Highlights, 499t Critical Thinking Checkpoint, 498t

cultural considerations, 497t defined, 493 five “rights” of, 494 implementation of interventions, 228 legal aspects of, 82–83 LVN/LPNs and RNs, to, 497 supervising care, 235f, 236 UAPs, to, 493, 494, 494t, 495–496f, 497t Delirium (acute confusion). See also Confusion described, 941–943, 942t, 943f, 943t older adults, 406 signs of, with fecal impaction, 1242t Delirium Index test, 943 Delivering Culturally Competent Nursing Care (Kersey-Matusiak), 313t Delta sleep, 1093–1094 Deltoid site for IM injections, 826, 826f Demand feeding, 1161 Dementia bathing clients, 707, 707t described, 941, 942t older adults, 406, 406t Demerol. See Meperidine Democratic leader, 489–490, 490t Demography health care delivery, factors affecting, 124 nursing practice, influencing, 46 older adults, 390, 391f race and ethnicity, 305 Demonstrations, as teaching strategy, 479t Denial Kübler-Ross’s stage of grieving, 1017t stress, 1003t Dental caries caries, defined, 572 defined, 715 toddlers, 364 Dentists, 120 Dentures, 718, 720–721t, 901t Denuded area of skin, 856 Denver Developmental Screening Test (DDST-II), 361 Deontological (principles-based) theories of morality, 102 Dependence, defined, 1130 Dependent functions, 203 Dependent interventions, 227 Dependent t -test, 57t Dependent variable, defined, 56 Depression Kübler-Ross’s stage of grieving, 1017t postoperative phase, 911t reading rehabilitation and central vision loss, 939t stress, indication of, 1003 Dermal implants, 901t Dermatology Nurses’ Association, 887t Descending colostomy, 1244, 1244f Descriptive statistics, 57, 57t Desire phase of the sexual response cycle, 967 Desired effect of drugs, 778–779, 779t Detoxification complementary and alternative therapies, 332 medications, 781 Detrusor muscle, 1201, 1203f Development, defined, 338. See also Growth and development Developmental Assessment Guidelines adolescents, 375t infants, 362t middle-aged adults, 387t older adults, 407t preschoolers, 368t school-age children, 370t toddlers, 365t young adults, 383t Developmental screening tests, 361

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Developmental stages biologic dimension of health, 293 communication process, 442, 443t defecation, 1238–1239, 1240t defined, 341 Erikson’s theory, 341–342, 342f, 344t health promotion theories, 274 hygienic practices, 696t learning, 467 medication action, 782–783 nutrition, 1158 pain experience, 1119, 1120t, 1121t safety, 666, 667t self-concept, 952 sensory function, 931 urination, affecting, 1202–1203, 1204t wound healing, 862, 863t Developmental stressors, 998, 999t Developmental tasks defined, 342 Havighurst’s theory of developmental tasks, 342, 343t, 344t Dextromethorphan, 1117 Diabetes mellitus cardiovascular risk factor, 1320t, 1321 diabetes type 2, 374 diet modifications, 1177 foot hygiene, 710t, 711t maturity-onset diabetes of the young (MODY), 374 surgical risk, 893t Diagnosing. See also under Nursing Management Chapter Highlights, 213t Critical Thinking Checkpoint, 211t defined, 201 diagnostic process data, analyzing, 204–205, 205t, 206–207t diagnostic reasoning, avoiding errors in, 209–211 diagnostic statements, formulating, 208–209, 208t, 209t, 210t health problems, risks, and strengths, identifying, 205, 206, 206–207t, 208f evaluation checklist, 239, 239t NANDA nursing diagnoses accuracy and prevalence, factors influencing, 202t collaborative problems, differentiating from, 203–204, 204t components of, 202–203, 203t definitions, 201–202 medical diagnoses, differentiating from, 203, 204t, 207, 208f status of, 202 nursing diagnoses, ongoing development of, 211, 211t, 212f nursing process, step in, 201, 202f nursing process in action, 182–183f nursing process purpose and activities, 181, 184t, 185f Diagnosis, defined, 201 Diagnosis-related groups client records, 248 defined, 127 Diagnostic and Statistical Manual of Mental Disorders (DSM), 161 Diagnostic labels, 201 Diagnostic reasoning, avoiding errors in, 209–211 Diagnostic statements, formulating basic three-part statements, 208–209, 209t basic two-part statements, 208, 208t collaborative problems, 209, 210t evaluating quality of, 209, 210t one-part statements, 209 variations of basic formats, 209 Diagnostic surgery, 892t Diagnostic testing. See also Health tests and screenings; individual tests aspiration/biopsy tests abdominal paracentesis, 767–768, 767f, 768t, 771t

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Index bone marrow biopsy, 769, 769f, 769t, 771–772t consent forms, 766t liver biopsy, 769–770, 770f, 772t lumbar puncture, 766–767, 766f, 767f, 767t, 770t thoracentesis, 768–769, 768f, 769t, 771t blood tests (See Blood tests) Chapter Highlights, 773–774t computerized, 162, 162f, 163f Critical Thinking Checkpoint, 773t fecal elimination, 1241 Lifespan Considerations, 773t phases of intratest, 745, 745t nursing diagnoses, 745 post-test, 745, 745t pretest, 744–745, 745t specimen collection and testing clients in isolation, 651–652 Home Care Considerations, 763t nursing responsibilities, 754–755 sputum specimens, 762–763, 763f, 763t stool specimens, 755–757, 756f, 756t, 757t throat culture, 763, 763f, 763t urine specimens (See under Urine tests) urinary elimination, 1205 visualization procedures cardiopulmonary disorders, 764, 765f computed tomography, 764 gastrointestinal disorders, 763–764, 764f magnetic resonance imaging, 765, 765f, 765t nuclear imaging studies, 765–766, 766f urinary disorders, 764 Dial-A-Flo in-line gravity control devices, 1375–1376, 1376f Dialysis, 1206 Diaper rash, 697t Diaphragmatic (abdominal) breathing, 522 Diarrhea causes and physiological effects, 1243t defined, 1242 diet and fluid intake, 1248–1249, 1249t medications for, 1252, 1252t Diastole cardiac cycle, 1314–1315, 1315t heart sounds, 587, 587f, 587t Diastolic pressure, defined, 525 Diazepam conscious sedation, 905 mouth dryness, 716 nutrition, 1160t respiratory function, 1273 Dickens, Charles, 31, 31f Diclofenac, 1137 Diet and nutrition. See also Nutrition defecation, 1239–1240 fecal elimination, 1248–1249, 1249f, 1249t indwelling catheters, 1224 medication action, affecting, 783 postoperative care, 914 religious beliefs, 984 sleep, 1098 special diets, assisting with, 1175, 1177–1178, 1177t urinary elimination, 1204–1205 Diet as tolerated, 1177 Diet history, 1173–1174 Dietary Guidelines for Americans, 1163, 1165–1166, 1165t, 1166f Dietitians and nutritionists, 120, 120f Differential count, 746–747t Differentiated practice, 125 Diffusion defined, 1271, 1337, 1337f gases in the blood, 1273–1274, 1274t oxygen and carbon dioxide, 1271, 1272

Digestive system, 1155t. See also Gastrointestinal system Digital (electronic) sphygmomanometers, 527, 528f, 532t Digitalis glycosides, 1280 Digoxin circulation, 1327 Drug Capsule, 522t herbal medicine, 324 Dilantin. See Phenytoin Dilaudid. See Hydromorphone Dimensional analysis for dosage calculation, 792–793 Diphenoxylate hydrochloride, 1252t Diphtheria, tetanus, acellular pertussis (DTaP) vaccine infants, 361t preschoolers, 367t toddlers, 364t Diploma programs for registered nurses, 36 Dipstick urine testing, 761, 761f Direct auscultation, 545 Direct percussion, 544, 544f Direct transmission of microorganisms, 632 Directing, as management function, 492 Directive interview, 190 Dirty, in medical asepsis, 629 Dirty wounds, 855 Disabilities, and access to health care services, 125t Disaccharides, 1154 Disaster planning, 668–669 Discharge planning continuity of care, 140, 140t described, 215–216 Discharge summaries, 257–258 Discipline, personal, 1004 Discovery defined, 75, 76f teaching strategy, 479t, 482 Discrimination, defined, 304 Discussion defined, 247 teaching strategy, 479t Disease defined, 297, 629 medication action, affecting, 783 Disease prevention, defined, 274 Disease-specific isolation precautions, 644 Disenfranchised grief, 1016 Disengagement theory, 401 Dishes, soiled, disposal of, 652 Disinfectants, 643, 644t Disoriented, described, 931t Displacement, 1003t Dissociation, 1003t Distance learning, 158 Distractibility, 345t Distraction, for pain management, 1144, 1144t Distribution of a medication, 781 Disuse syndrome, risk for, 1087t Ditropan XL. See Oxybutynin ER Diuresis, 1205. See also Polyuria Diuretics circulation, 1327 hypokalemia, 1347, 1347t, 1348t sexual function, 970t surgical risk, 893 urinary elimination, 1205 Diurnal variations (circadian, or biologic rhythms) blood pressure, 526 body temperature, 505, 505f learning, barrier to, 469t sleep, 1092–1093 Diversity, defined, 303 Divided colostomy, 1245, 1245f Dix, Dorothea, 30, 30f DNR (do-not-resuscitate) orders, 85, 87

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Dobutamine, 1280 Dock, Lavinia L., 33, 33f Doctoral degree nursing programs, 37–38, 54t Doctor’s handmaiden, nurse as, 31 Documenting Chapter Highlights, 266t client records, purpose of, 248–249, 248t Critical Thinking Checkpoint, 265t data, of, 198 defined, 247 documentation systems case management, 254–255, 256f, 256t charting by exception, 253, 253f, 254f, 255f computerized documentation, 253–254, 255f, 256t focus charting, 252 PIE model, 252 problem-oriented medical record, 250–252, 251f, 252f source-oriented record, 249, 249t, 250f, 250t ethical and legal considerations, 247–248, 248t guidelines for accepted terminology, 260–261, 260t, 261t accuracy, 261, 261t, 262f appropriateness, 262 completeness, 262, 262t conciseness, 262 date and time, 259, 259f frequency of documentation, 259 legal issues, 258, 262, 262t legibility, 259 permanence, 259 sequence of events, 261 signature, 261 spelling, 261, 261t home care documentation, 258, 259t informed consent, 82 legal protection for nurses, 94, 94f long-term care documentation, 258, 258t, 259t medication administration, 799–800, 799t nursing activities, 235f, 236, 255–258, 257t pain documentation, 1124, 1124f Practice Guidelines, 262t teaching process, 484 wound assessment, 864, 865f Docusate calcium, 1242t, 1251t Docusate sodium, 1242t, 1251t Doe v. Bolton, 85 Dolophine. See Methadone Dolor, defined, 633t Domestic partner policies, 414 Domestic violence, 676 Donepezil, 406t Do-not-resuscitate (DNR) orders, 85, 87 “Do-not-use” abbreviations, 241, 261, 261t Doppler ultrasound stethoscopes blood pressure measurement, 527 pulse measurement, 514, 514f, 517t Dorsal position, 1063 Dorsal recumbent position, 542t, 1063, 1063f, 1063t Dorsalis pedis artery, 513f, 514, 514t, 517t Dorsiflexion, 1042f, 1042t Dorsogluteal site for IM injections, 824–825 Dosage of drugs calculation methods basic formula, 791 dimensional analysis, 792–793 fractional equation method, 792 individualized dosages, 793 ratio and proportion method, 791–792 rounding, guidelines for, 790, 791t medication orders, 787, 787t Dosha, defined, 323 Double-barreled colostomy, 1245, 1245f

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Drains postoperative assessment, 912 surgical wounds, 921, 921f, 922f, 922t Draping the client, 542 Dress/dressing functional levels of self-care, 697t religious beliefs, 984–985, 985f Dressings postoperative assessment, 909, 912 purposes of, 872 securing, 874, 875f surgical, 918, 918–920t, 921t types of, 872–874, 873t Drop factor, 1374 Droplet nuclei, 632 Droplet precautions, 645–646, 645t Drug, defined, 777. See also Medication Drug abuse, defined, 780. See also Substance abuse Drug abuse and misuse by older adults, 405–406 Drug allergy described, 779–780, 779t medication administration, 794 Drug Capsule albuterol, 1280t azithromycin, 643t digoxin, 522t docusate calcium and docusate sodium, 1242t donepezil, 406t enoxaparin, 1330t ferrous sulfate, ferrous gluconate, 1163t fluticasone, 1281t furosemide, 1347t midazolam, 905t oxybutynin ER, 1211t oxycodone, oxycodone/acetaminophen/ oxycodone/ aspirin, 1135t sertraline HCl, 1009t sildenafil citrate, tadalafil, and vardenafil, 971t travoprost, 937t zolpidem, 1106t Drug dependence, 780 Drug habituation, 780 Drug half-life, 780, 781 Drug interaction, 780 Drug tolerance, 780 Drug toxicity, 779 Dry powder inhalers (DPIs), 847 Dry skin described and nursing implications, 697t skin problems and care, 710t DTaP. See Diphtheria, tetanus, acellular pertussis (DTaP) vaccine Dulcolax. See Bisacodyl Dullness (percussion sound), 545, 545t Dunn’s high-level wellness grid, 291–292, 291f Durable medical equipment (DME) company, 146 Durable power of attorney for health care, 85, 86f Duragesic. See Fentanyl Duration of sound with auscultation, 545 Durkham-Humphrey Amendment (1952), 778t Duty, 88, 88t, 91f DVT (deep vein thrombosis), 1327–1330, 1328–1329t, 1328f, 1330t Dying and death. See also Death Chapter Highlights, 1031t concept of death, by age, 1022, 1022t Critical Thinking Checkpoint, 1030t death, definitions and signs of, 1023 death-related religious and cultural practices, 1023–1024, 1024f Nursing Management assessing, 1024–1025, 1025t diagnosing, 1025 evaluating, 1029, 1029t

implementing family, supporting, 1028–1029, 1028t helping clients die with dignity, 1026, 1026t hospice and palliative care, 1026–1027, 1027f physiological needs of the dying client, 1027, 1028t postmortem care, 1029 spiritual support, 1027–1028 planning, 1025–1026, 1025t responses to, 1022–1023, 1023t Dying clients, nurses caring for, 40 Dying Person’s Bill of Rights, 1025, 1025t Dynamic (isotonic) exercise, 1044 Dysesthesia, 1115, 1115t Dysmenorrhea, 962 Dyspareunia, 970 Dysphagia, 1177–1178 Dyspnea defined, 524t, 1273 physiological aging, 399 Dysrhythmia, 515 Dysuria, 1206t, 1207

E Early adulthood Havighurst’s age period and developmental tasks, 343t loss and grief responses, 1019 Early childhood, 343t Early Hearing Detection and Intervention Tracking and Surveillance System, 935–936 Early morning care, 695 Ears and hearing cleaning, 730 data collection, 190t distracters and older adult drivers, 940t ear infections, 364t hearing aids Home Care Considerations, 732t removing, cleaning, and inserting, skill for, 731–732t types of, 730–731, 730f, 731f newborns and infants, 357, 362t physical assessment ear anatomy, 565–566, 565f Home Care Considerations, 569t Lifespan Considerations, 569t overview of, 565–566, 565f skill for, 566–569t preschoolers, 365, 368t school-age children, 368, 370t sensory perception disturbances, 936–937, 941t Eastern medicine, 321 Eating disorders adolescents, 374 young adults, 382–383 Ebola virus, 672t EBP. See Evidence-based practice (EBP) Eccrine glands adolescents, 371 defined, 696 ECF (extracellular fluid), 1335–1336, 1335f ECG. See Electrocardiogram (ECG) Echinacea, 325t Echocardiogram, 764 Ecologic systems theory of Bronfenbrenner, 346, 347t, 348t Ecomaps, 415, 417f Economic factors. See also Socioeconomic status health care delivery, factors affecting, 122 learning needs, 471 physiological and psychosocial aging, 402 Ectoderm, 354 Edema fluid volume excess, 1345–1346, 1346f skin assessment, 549

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EDTA (ethylene diamine tetraacetic acid), 332 Educational Resources Information Center (ERIC), 157t Educator, home health care nurse as, 147 EEG (electroencephalogram), 1102 Effective coping, 1004 Effectiveness, defined, 493 Efficacy, defined, 493 Ego, 340 Ego defense mechanisms Freud’s theory of psychosexual development, 341 stress, indication of, 1003, 1003t Ego differentiation versus work-role preoccupation, 342, 344t Ego integrity versus despair task of Erikson’s theory of psychosocial development, 401 Ego transcendence versus ego preoccupation, 342, 344t Egocentricity, insight into, 174 E-health Internet and health information, 469 physiological and psychosocial aging, 402 EHRs. See Electronic health records (EHRs) Ejaculation, 371 Elastomeric IV infusion pumps, 1376, 1376f Elbow joint movements, 1040f, 1040t Elbow restraints, 691f, 691t Elderspeak, 444 Elective surgery, 892 Electra complex, 366 Electric shock defined, 684 safety, 684, 684f, 685t Electrocardiogram (ECG) circulation, 1326 defined, 764 preoperative, 895t Electrocardiography, defined, 764 Electroencephalogram (EEG), 1102 Electrolytes. See also Fluid, electrolyte, and acid–base balance; individual electrolytes body fluid, in, 1335, 1336f fluid, electrolyte, and acid–base balance, 1356–1357, 1356t, 1357f imbalances calcium, 1347, 1349t, 1350, 1350f chloride, 1350 magnesium, 1349t, 1350 phosphate, 1350 potassium, 1347, 1347t, 1348t sodium, 1346–1347, 1346f, 1348t oral supplements, 1361–1362 preoperative, 895t regulation of bicarbonate, 1341t, 1342 calcium, 1340–1341, 1341t chloride, 1341t, 1342 magnesium, 1341, 1341t overview, 1339–1340, 1341t phosphate, 1341t, 1342 potassium, 1340, 1341t sodium, 1340, 1341t serum, described and normal levels, 747, 748f, 748t Electromyogram (EMG), 1102 Electronic communication advantages, 441 defined, 439 disadvantages, 442 guidelines for, 442 Electronic Health Record Incentive Program (CMS), 160 Electronic health records (EHRs) computerized documentation, 253–254, 255f, 256t described, 160, 160f pain documentation, 1124, 1124f Electronic health records and information technology Chapter Highlights, 166t

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Index computer systems hospital information systems, 157, 157f management information systems, 156–157 computer terminology, 156t computer use by children and adults, 165t computer-related acronyms, 156t Critical Thinking Checkpoint, 166t general concepts, 155–156, 155t, 156t Lifespan Considerations, 165t nursing administration, 164 nursing education, technology in, 157–158, 157t nursing practice, technology in Electronic IV infusion devices, 1375, 1375f, 1375t Electronic Preventive Services Selector, 295–296 Electronic (digital) sphygmomanometers, 527, 528f, 532t Electronic thermometers, 508, 508f Electro-oculogram (EOG), 1102 Elimination. See also Fecal elimination; Urinary elimination newborns and infants, 361t older adults, 408t prenatal development, 355 preoperative care, 900 preschoolers, 367t school-age children, 370t toddlers, 364t Elimination half-life, 780, 781 Elixir, 777t E-mail advantages, 441 defined, 441 disadvantages, 442 guidelines for, 442 Embolus/emboli immobility, 1049 postoperative phase, 910t, 914 Embryonic phase of prenatal development, 354–355 Emergency assessment, 185, 187t Emergency medical personnel, 121 Emergency surgery, 892 Emergency System for Advance Registration of Volunteer Health Professionals, 669 EMG (electromyogram), 1102 EMLA cream. See Lidocaine/prilocaine Emmetropic, defined, 364 Emotional component of wellness, 289, 290f Emotional intelligence, 460 Emotional support, 1021–1022 Emotions learning, 468, 469t safety, 667 stress, 1098 Empathy helping relationships, 450 therapeutic communication, 445, 446t Emphysema, 1272 Empirical knowing, 427, 428f Employees competitive job market, preparing for, 46–47, 47t nurses as, 78–79, 79t performance, enhancement of, 493 Enabling, defined, 429 Encoding, defined, 438 End (terminal) colostomy, 1244, 1244f Endocardium, 1313, 1314f Endocrine system exercise, benefits of, 1046 older adults, 397t Endocrine theory of aging, 395t Endoderm, 354 End-of-life care, 1027 End-of-life issues advance directives, 108 ethical aspects, 108–109

euthanasia and assisted suicide, 108 termination of life-sustaining treatment, 108–109 withdrawing or withholding food and fluids, 109 Endogenous. defined, 630 Endotracheal tubes described, 1292, 1292f extubation, current research study on, 54t nursing interventions, 1292t suctioning, 1299–1301t Enema administering, skill for, 1253–1255t commonly used solutions, 1252t defined, 1252 Home Care Considerations, 1256t Lifespan Considerations, 1256t types of, 1252–1253, 1253t Energy complementary and alternative healing modalities, 322 personal, and hygienic practices, 696t Engel’s stages of grieving, 1017, 1017t Enhancement interventions, 228 Enoxaparin Drug Capsule, 1330t subcutaneous injection, 822t Enteral nutrition administering client assessment, 1191t gastrostomy or jejunostomy feeding, skill for, 1189–1190t guidelines for, 1186, 1191, 1192t Home Care Considerations, 1191t infusion pumps, 1185–1186, 1185f Lifespan Considerations, 1190t skill for, 1186–1189t starting postoperatively, 1186t clogged feeding tubes, 1191–1192 enteral, defined, 1180 enteral access devices, 1180, 1180f fluid and electrolyte replacement, 1359, 1361–1362, 1361t gastrostomy and jejunostomy tubes, 1184, 1184f, 1185f nasoenteric tubes, 1184, 1184f nasogastric tubes, insertion of, 1180–1183t, 1180–1184 nasogastric tubes, removing, 1192–1193t testing feeding tube placement, 1185 Enterobacter species, 630t Enterobacteriaceae species, 629t Enterococcus species, 630, 630t Entoderm, 354 Enuresis described, 1101t, 1206t, 1207 school-age children, 1202–1203 Environment agent-host-environment model of health, 291, 291f body alignment and activity, 1043 body temperature, 505 communication, 444, 455 growth and development, 339 healing, in complementary and alternative healing modalities, 322–323 health status, beliefs, and practices, 294 hygiene beds, making occupied beds, 739–740, 739–740t overview of, 734, 735t unoccupied beds, 734–738, 735f, 736–738t footboard or footboot, 734 hospital beds, 733, 734t hygienic practices, influencing, 696t intravenous rods, 734 mattresses, 733 noise, 733 overview of, 732–733 room temperature, 733

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side rails, 733–734, 734t ventilation, 733 infection prevention, 638t learning, 468, 469t medication action, affecting, 783 metaparadigm for nursing, 64 pain experience, 1119–1120 preparing, for physical health assessment, 541–542 respiratory function, 1272 restful, for sleep, 1104, 1104t safety bioterrorism, 668 community, 668 disaster planning, 668–669 health care setting, 667–668 home, 668 workplace, 668 sensory perceptual functioning, 933–934, 934t sleep, 1097 wellness, 289, 290f Enzymes, 1154 EOG (electro-oculogram), 1102 Eosinophils, 747t, 748f Epicardium, 1313, 1314f Epidural route of administration anesthesia, 905 described, 785 opioids, 1138, 1138f, 1139, 1139t Epinephrine, 999, 1001f Episcopalians, and health-related information, 990t Equal Employment Opportunity Commission, 84 Equianalgesia, 1135–1136, 1136t Equilibrium, 271 Equipment equipment-related accidents, 685 physical health assessment, 542, 543t Erectile dysfunction (ED), 970, 971t Erikson, Erik H., 341, 344t Erikson’s theory of psychosocial development adolescents, 371 described, 341–342, 342f, 344t middle-aged adults, 385t nonnursing developmental model, 197 preschoolers, 365 psychosocial aging, 401 school-age children, 368 self-concept, 949, 949t toddlers, 362 young adults, 380t Erosion, skin, 551t “Error,” avoiding use of, in documentation, 261t Errors bad systems, 240t medication errors, 88–89, 89t, 794–795 transfusion errors, 1386t Erythema, 549, 697t Erythrocytes oxygen transport, 1271 red blood cell (RBC) count, 746t, 747, 747t, 748f Erythromycin, 1159 Eschar, 861 Escherichia coli body reservoirs, in, 632t feces, in, 1238 nosocomial infections, 630, 630t physiological barrier to, 633 resident flora, 628, 629t UTIs, 1051, 1212 Essential amino acids, 1154 Essential oils, 325, 326t Estimated average requirement (EAR), 1166, 1167t Eszopiclone, 1105t

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Index

“Ethic of justice,” 381 Ethical knowing, 427, 428f Ethics Chapter Highlights, 110t defined, 101 documenting and reporting, 247–248, 248t ethical issues abortion, 106 AIDS, 106 allocation of scarce health resources, 109 end-of-life issues, 108–109 organ and tissue transplantation, 108 personal health information, management of, 109 Ethics committees, 103–104, 104f Ethmoid sinuses, 570f, 843, 844f Ethnicity defined, 303 family health, 417–418 medication action, 783, 783t nutrition, 1158, 1158t older adults, 391, 391t pain experience, 1118–1119, 1119t Ethnocentrism, 304 Ethnography, 55 Ethnopharmacology, 783, 783t Ethyl alcohol, 644t Ethylene diamine tetraacetic acid (EDTA), 332 Etiologic agent, in the chain of infection, 631, 631f, 639t Etiology defined, 201, 297 nursing diagnoses, 203 Eubacterium species, 629t Eucalyptus, 326t Eudaimonistic model of health, 290 Eupnea, 523, 1273 European heritage, people with adolescent families, 413 biocultural considerations in CBCs, 747t blood pressure, 526 cardiovascular disease, 1323t older adults, 391t Eustachian tube, 565f, 566 Euthanasia ethical issues, 108 legal aspects of, 87 Evaluating. See also under Nursing Management Chapter Highlights, 244t Critical Thinking, Applying, 244t described, 236–237 evaluation checklist, 239t Lifespan Considerations, 242t nursing care plan, 242–244t nursing process, phase of, 237, 237f nursing process in action, 182–183f nursing process purpose and activities, 181, 184t, 185f process of continuing, modifying, or terminating nursing care plan, 237f, 238–240, 239t data collection, 237, 237f data comparison with desired outcomes, 237–238, 237f drawing conclusions about problem status, 237f, 238, 238f relating nursing activities to outcomes, 237f, 238 quality of nursing care, 240–242, 240t Evaluating Internet Health Information Tutorial, 156 Evaluation statement, 237–238 Evaporation, and body temperature, 504 Eversion, 1038t, 1042f, 1042t Evidence-Based Practice attitudes on aging and well-being, 392t authentic nurse leader, requirements for, 491t bedside shift-to-shift reports and outcomes, 264t Bible reading and management of stressful life events, 991t black pepper essential oil for IV catheter insertion, 1364t

breathing exercises for clients with COPD, 1280t cardiovascular disease and metabolic syndrome, 1322t chronic conditions and disabilities and access to health care services, 125t clients’ values, clarifying, 103t clinical reasoning and medication administration, 801t clinical reasoning and medication administration safety, 178t colorectal cancer screening, improving use among medically underserved populations, 757t community health nurses and risks of cardiovascular disease, 139t continuous quality improvement project, 240t coping strategies used by nurses working in dialysis units, 1005t depression, reading rehabilitation, and central vision loss, 939t documentation of pressure ulcers on EHRs and paper-based records, 162t domestic violence in pregnant military women, 382t double- and single-gloving, 651t early mobilization of critically ill clients, 1078t effectiveness and safety in nasogastric and PEG tubes, 1190t fatigue and decision regret among critical care nurses, 1099t healing touch for clients undergoing knee replacement, 328t health belief model and injury prevention practices, 296t health care–associated infections and chlorhexidine gluconate baths, 702t health literacy knowledge of student nurses, 473t hearing impairment, distracters, and older adult drivers, 940t home care nurses’ views of their practice, 152t Internet as an effective public health intervention, 280t knowledge for caregivers, 418t Levine’s conservation model of nursing and care of preterm infants, 70t mortality rates in mothers and fetal alcohol spectrum disorders, 356t nurse residency programs for new graduates, 47t nurse-physician relationships, perceptions of, 458t nurses’ and clients’ perspectives about nurses’ cultural competence, 314t nurses’ demographic information and knowledge regarding pain assessment and management, 1126t nursing actions to provide death with dignity, 1026t nursing diagnoses, factors influencing prevalence and accuracy, 202t ostomy care instruction, methods of, 1243t poor sleep and national health, 1095t preoperative education, 896t professional negligence claims, 90t pulse oximetry on a restrained arm, 534t risk factors for pressure ulcers, 861t role strain experienced by African American grandmothers raising grandchildren, 952t safety of older clients and restraints, 687t sleep and mortality of elderly Hispanics, 399t socioeconomic status and outcome of child’s mental and physical health, 348t student nurses developing ethical caring, 433t ultrasound bladder scanner and UTIs, 1210t women’s attraction to other women and feelings of wellbeing, 963t Evidence-based practice (EBP) Chapter Highlights, 61t components of, 53f defined, 52 practice change, steps in, 52–53, 53t research, reliance on, 53 research process, 57, 58f Evisceration postoperative phase, 911t sign of, 918t wound healing, 862 Exacerbation, defined, 297 Exaggerated grief, 1016 Examining, as data collection method, 193, 194–195f

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Excitement phase of the sexual response cycle, 968, 968t, 969f Excoriation pressure ulcers, 856 skin lesion, 551t Excretion of a medication, 781 Exercise. See also Activity and exercise adolescents, 375t benefits of, 1046–1047, 1047f blood pressure, 526 body temperature, 505 Eastern cultures, 1045f, 1045t fecal elimination, 1249 intensity, measurement of, 1044 middle-aged adults, 387t older adults, 408t pulse, 513 self-care for nurses, 430, 430f stress and coping, 1006 thinking of as physical activity, 281t types of, 1044, 1044f, 1045t young adults, 384t Exhalation (expiration), 522, 523f Ex-Lax. See Senna Exogenous, defined, 630 Exophthalmos, 558 Exosystem level, in Bronfenbrenner’s ecologic systems theory, 346, 347t Expectorants, 1279–1280, 1281t Expectorate, defined, 762, 1278 Experienced Faith stage, in Westerhoff ’s theory of spiritual development, 349, 350t Experimental research design, 56 Expert witnesses, nurses as, 75 Expiration (exhalation), 522, 523f Expiratory reserve volume (ERV), 1276f, 1276t Explanations, as teaching strategy, 479t Express consent, 80 Extended care facilities. See Long-term care facilities Extended family, 412 Extension (movement), 1038t, 1039–1042f, 1039–1042t External auditory meatus, 565 External standards of care, 78 External stressors, 998 External urinary drainage devices, 1215, 1215–1217t Externals, in health locus of control model, 295 Extracellular fluid (ECF), 1335–1336, 1335f Extracts, 777t Extraneous variables, 54 Extravasation, 1378t, 1383, 1383t Exudate defined, 633 response to inflammation, 633–634 wound healing, 862 Eye hygiene care, overview of, 728 Nursing Management assessing nursing history, 728, 728t physical assessment, 728–729 diagnosing, 729 evaluating, 730 implementing contact lens care, 729 eye care, 729, 729t eyeglass care, 729 planning, 729 Eyeglasses, 729 Eyeglasses hearing aids, 331 Eyes and vision. See also Eye hygiene fluid, electrolyte, and acid–base imbalance, 1354t physical assessment common problems, 559–560 eye anatomy, 559, 559f

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Index Home Care Considerations, 565t Lifespan Considerations, 564–565t overview of, 559–560, 559f skill for, 560–564t, 565t Eyewear, as personal protective equipment, 647–649t, 651 EZ Lift, 1059f

F Fabiola, 28 Face masks oxygen therapy, 1286–1287, 1286f, 1288–1289t personal protective equipment, 647–649t, 649, 650t, 651 Face tents for oxygen therapy, 1287, 1287f, 1288–1289t Facial expression, in nonverbal communication, 441, 441f Facial nerve (CN VII), 616t Facilities management, 164 Factual statements, 173, 173t Fad, 1158 Fahrenheit to Celsius conversion, 509 Failure to observe and take appropriate action, 89 Failure to thrive, 359 Fair-mindedness, in critical thinking, 174 Faith, as a complementary and alternative modality, 330 Faith Community Nursing: Scope and Standards of Practice (ANA), 137 Falls Home Care Considerations, 680t preventing, 676–678, 677t, 678t risk factors and preventive measures, 676, 676t, 677t safety monitoring devices, 678, 678–680t unintentional torts, 89, 89t False imprisonment, 90, 91f Family culturally responsive care, 317t defined, 412 growth and development, 338–339 health beliefs and practices, 309 health status, beliefs, and practices, 294 history of illness, 188t illness, impact on, 299 self-concept, 952, 952f sexuality, influencing, 966–967, 966f structure, influencing nursing practice, 45 supporting, for dying clients, 1028 Family Assessment Guide, 415t Family Confusion Assessment Method test, 942 Family health Chapter Highlights, 420t Critical Thinking Checkpoint, 419t functions of the family, 412, 413f Nursing Management assessing ecomap, 415, 417f family assessment guide, 415, 415t family communication patterns, 416 family coping mechanisms, 416 family violence, 417 genogram, 415, 416f health beliefs, 415–416 knowledge for caregivers, 418, 418t risk for health problems, 417–418 diagnosing and planning death of a family member, 419 health crisis, 418–419, 419t nurse’s role, 419 implementing and evaluating, 419 theoretical frameworks structural-functional theory, 414–415 systems theory, 414 types of families adolescent family, 413 blended family, 414 cohabiting family, 414

foster family, 413–414 gay and lesbian family, 414 intragenerational family, 414 overview of, 412–413 single adults living alone, 414 single-parent family, 413 traditional family, 413, 413f two-career family, 413 Family-centered nursing, 412 Fantasy (daydreaming), 1003t, 1004 Fasciculation, muscular, 603 FASD. See Fetal alcohol spectrum disorders (FASD) “Fast track” BSN programs, 37 Fats defined, 1155t dietary, reducing, 1165, 1165t Fat-soluble vitamins, 1156 Fatty acids, 1155–1156 Faxing confidential information, 248t FDA. See U.S. Food and Drug Administration (FDA) Fear pain, 1132 stress, indication of, 1002 Febrile, defined, 505 Febrile transfusion reaction, 1385t Fecal elimination Anatomy & Physiology Review, 1246f bowel diversion ostomies anatomic location, 1244, 1244f permanence, 1244, 1244t stoma, surgical construction of, 1244–1245, 1244f, 1245f Chapter Highlights, 1265t defecation, physiology of defecation, process of, 1237–1238, 1237t feces, 1238, 1239t large intestine, 1236–1237, 1237f, 1246f rectum and anal canal, 1237, 1237f, 1238f factors affecting activity, 1240 age and development, 1238–1239, 1240t anesthesia and surgery, 1241 defecation habits, 1240 diagnostic procedures, 1241 diet, 1239–1240 fluid intake and output, 1240 medications, 1240–1241 pain, 1241 pathologic conditions, 1241 psychological factors, 1240 Nursing Management assessing diagnostic studies, 1246 feces, examining, 1246 nursing history, 1246, 1247t physical examination, 1246 Concept Map, 1264f diagnosing, 1247 evaluating, 1262 implementing bowel training programs, 1257 enemas, administering, 1252–1256, 1252t, 1253–1255t, 1253t, 1256t fecal impaction, removing, 1256–1257, 1256t fecal incontinence pouch, 1257–1258, 1257f flatulence, decreasing, 1252 medications, 1249, 1251–1252, 1251t, 1252t ostomy management, 1258–1262, 1258f, 1259–1261t, 1259f, 1262t regular defecation, promoting, 1247–1249, 1248t, 1249f, 1249t, 1250–1251t, 1250f Nursing Care Plan, 1262–1263t planning, 1247, 1248t problems bowel incontinence, 1242–1243

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constipation, 1241, 1241t diarrhea, 1242, 1243t fecal impaction, 1241–1242, 1242t flatulence, 1243 Lifespan Considerations, 1245t Fecal impaction defined, 1241–1242, 1242t digital removal of, 1256–1257, 1256t medication for, 1242t Fecal incontinence described, 1242–1243 fecal incontinence pouch, 1257–1258, 1257f pressure ulcers, 856 Feces defined, 1236 described, 1238 fluid output, 1338t, 1339 normal and abnormal, characteristics of, 1239t Feedback communication process, 439 defined, 271, 271f, 272f learning, 468 Feet. See Foot hygiene Feldene. See Piroxicam Felony, defined, 88 Female genitals and inguinal area, assessment of Lifespan Considerations, 618t, 718f overview of, 615, 619, 619f pubic hair development, 618f, 618t skill for, 617–618t Female orgasmic disorder, 970 Female sexual arousal disorder, 970 Femoral artery, 513f, 514, 514t, 516t Fencing (tonic neck) reflex, 358t Fentanyl conscious sedation, 905 epidural route of administration, 1138, 1139 oral route of administration, 1137 pain management, 1132, 1132t, 1134 PCA, 1140 transdermal route of administration, 1137 transmucosal route of administration, 1137 Feosol. See Ferrous sulfate Fergon. See Ferrous gluconate Ferrous gluconate, 1163t Ferrous sulfate, 1163t Fetal alcohol spectrum disorders (FASD) mortality rates in mothers, 356t prenatal development, 356 Fetuses fetal phase of prenatal development, 355 safety hazards, 667t urinary elimination, 1204t Fever, 505, 513. See also Pyrexia Fever spike, 505 Feverfew, 325t Fiber, dietary, 1154 Fibrin, 861 Fibrinogen, 748f Fibromyalgia, 1115t Fidelity, as moral principle, 103 Fifth vital sign, pain as, 1121 Filter needle or straw, 811, 812f Filtration, defined, 1337, 1338f Filtration pressure, 1337, 1338f Finance, technology use in, 164 Finger counting test, 565t Fire extinguishers, 682, 682f Firearms adolescents, 374 safety, 684–685 school-age children, 369f young adults, 381

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1474

Index

Fires health care agencies, 682, 682f home fires, 682–683 First intention healing, 860 First-level managers, 491, 492t Fissures foot hygiene, 711 skin, 551t FIT (fecal immunochemical test), 755, 756, 756t Fixation, defined, 341 FLACC (Facial expression, Leg movement, Activity, Cry, Consolability) pain rating scale, 1123 Flaccid, defined, 1048, 1217 Flashlights, 543t Flat position for hospital beds, 734t Flatness (percussion sound), 545, 545t Flatulence decreasing, 1252 described, 1243 diet and fluid intake, 1249 medications for, 1252 Flatus, defined, 1237 Fleet enemas, 1252, 1252t, 1253t Flexion (movement), 1038t, 1039–1042f, 1039–1042t Fliedner, Theodor, 29 Flovent. See Fluticasone Flow sheets documentation in, 257 PIE documentation, 252 Flowchart concept maps, 177f, 177t Flow-control devices, 1375–1376, 1375t, 1376f, 1376t Flow-oriented spirometer, 1281f, 1282 Fluid, electrolyte, and acid–base balance acid–base balance buffers, 1342, 1342f renal regulation, 1343, 1343t respiratory regulation, 1342–1343, 1343t acid–base imbalances metabolic acidosis, 1351, 1352t metabolic alkalosis, 1352, 1352t overview, 1350 respiratory acidosis, 1351, 1351f, 1352t respiratory alkalosis, 1351, 1351f, 1352t body fluids and electrolytes body fluid, composition of, 1335–1336, 1336f body fluids, distribution of, 1335, 1335f body fluids, regulating, 1338–1339, 1338t, 1340f electrolytes, regulating, 1339–1342, 1341t movement of, 1336–1338, 1337f, 1338f Chapter Highlights, 1392t electrolyte imbalances calcium, 1347, 1349t, 1350, 1350f chloride, 1350 magnesium, 1349t, 1350 phosphate, 1350 potassium, 1347, 1347t, 1348t sodium, 1346–1347, 1346f, 1348t factors affecting age, 1343–1344, 1343t environmental temperature, 1344 gender and body size, 1344 lifestyle, 1344 fluid imbalances, 1344–1346, 1345t, 1346f homeostasis, 1334 imbalances, risk factors for, 1353, 1353t Nursing Management assessing clinical measurements, 1353–1356, 1355f, 1356t components of, 1352–1353 laboratory tests, 1356–1357, 1356t, 1357f, 1358t nursing history, 1353, 1353t physical assessment, 1353, 1354t Concept Map, 1391f

diagnosing, 1358–1359 evaluating, 1389 implementing blood transfusions (See Blood transfusions) enteral fluid and electrolyte replacement, 1359, 1361–1362, 1361t parenteral fluid and electrolyte replacement (See Intravenous (IV) route of administration) wellness, promoting, 1359 Nursing Care Plan, 1389–1390t planning, 1359, 1359t, 1360t Fluid intake facilitating, 1359, 1361t fecal elimination, 1248–1249, 1249t indwelling catheters, 1224 prenatal development, 355 preoperative phase, 899–900 restricting, 1361, 1361t urinary elimination, 1204–1205, 1212 wound healing, 869 Fluid intake and output (I & O) body fluid regulation, 1338–1339, 1338t, 1355–1356, 1356t fecal elimination, 1240 postoperative assessment, 909 records of, 257, 1355f Fluid volume deficit (FVD) Concept Map, 1391f described, 1344, 1345t Nursing Care Plan, 1389–1390t Fluid volume excess (FVE), 1345–1346, 1345t, 1346f Fluoride fluoridated water, 715 supplements infants, 361t toddlers, 364t treatments, for school-age children, 370t Fluoxetine, 1134 Flurazepam, 1105t Fluticasone, 1281t Fly larvae, 872 Foam swabs for oral care, 718, 718f Focus charting, 252 Focused interview, 190 Focusing, in therapeutic communication, 447t Folate/folic acid supplements, 355, 1162 Foley (indwelling, or retention) urinary catheters, 761, 761f, 1218, 1219f, 1224–1225 Folk medicine, 308–309, 309t Fontanels fluid, electrolyte, and acid–base imbalance, 1354t newborns and infants, 357, 357f Food, Drug, and Cosmetic Act (1938), 778t Food diary, 1173 Food frequency record, 1173 Food Guide Pyramid, 1165, 1166f Foot drop, 1048, 1048f Foot hygiene clients with diabetes, 710t, 711t developmental variations, 710 Nursing Management assessing clients at risk, identifying, 712, 712t nursing history, 710, 711t physical assessment, 710–712, 711t diagnosing, 712 evaluating, 714 implementing foot care, providing, 713–714t overview of, 712 planning, 712 Footboards/footboots, 734, 1061t Forensic nurses, 42t Formal leaders, 488

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Formal nursing care plan, defined, 216 Formal operations stage of Piaget’s theory of cognitive development adolescents, 373 described, 345, 346t, 347t young adults, 381 Foreseeability, 88, 91f Foster families, 413–414 Four Topic (Box) method for ethical decision making, 106 4 C’s of Culture model of culturally responsive care, 314 4 A’s (Ask, Affirm, Assess, Act) to Rise Above Moral Distress, 105–106 Fowler, James, 349, 350t Fowler’s position, 734t, 1062–1063, 1062f, 1062t Fowler’s theory of spiritual development adolescents, 373 described, 349, 350t middle-aged adults, 386 preschoolers, 366 school-age children, 369 toddlers, 363 young adults, 381 Fractional equation method of dosage calculation, 792 Fracture (slipper) bedpans, 1249, 1250f Francisella tularensis, 672t Free-radical theory of aging, 395t Fremitus, 583t Frequency of administration of medication, 787, 787t Frequency of documentation, 259 Freud, Sigmund, 340, 344t Freud’s theory of psychosexual development described, 197, 340–341, 341t, 344t newborns and infants, 358–359 preschoolers, 365–366 school-age children, 368 toddlers, 362 young adults, 380t Friction on skin, 856 Friction rub, 582t Frigid, defined, 970 Frontal sinuses, 570f, 843, 844f Frontier Nursing Service, 34, 34f Full consciousness, 931t Full liquid diet, 1177, 1177t Full thickness wounds, 855t Functional method framework for care, 125 Functional reserve capacity (FRC), 1276f, 1276t Functional strength, defined, 1044 Functional urinary incontinence, 1211t Fungi disinfectants and antiseptics, 644t infection, cause of, 629 Funnel chest (pectus excavatum), 580, 581f Furosemide Drug Capsule, 1347t sensory function, 932 Fusobacterium species, 629t The Future of Nursing (IOM), 37 The Future of Nursing: Leading Change, Advancing Health (IOM), 45 FVD. See Fluid volume deficit (FVD) FVE (fluid volume excess), 1345–1346, 1345t, 1346f

G Gabapentin coanalgesic, 1136 pain management, 1132t Gait assessment of, 1052–1053, 1052f, 1054f crutches four-point alternate gait, 1084–1085, 1084f overview, 1083–1084 swing-through gait, 1085

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Index three-point gait, 1085, 1085f two-point alternate gait, 1085, 1085f neurologic assessment, 610t nonverbal communication, 441 Gait belts assisting a client to ambulate, 1080t described, 1070–1071, 1071f Gamma hydroxybutyrate (GHB), 1100t Gamma-glutamyl transferase (GGT), 750t Gamp, Sairy, 31, 31f Gardasil. See Human papillomavirus (HPV) vaccine Garlic, 325t GAS (general adaptation syndrome), 999–1000, 1001f Gas sterilization, 643 Gas-permeable contact lenses, 729 Gastrocolic reflex, 1239 Gastrointestinal disorders, and stress, 1000f Gastrointestinal system digestive system anatomy and physiology, 1155t exercise, benefits of, 1046 immobility, effects of, 1051, 1055t middle-aged adults, 384t older adults, 397t, 400 pharmacokinetics of an oral medication, 782f postoperative care, 914 visualization procedures, 763–764, 764f Gastrostomy, defined, 1244 Gastrostomy tubes. See also Enteral nutrition defined, 806 gastrostomy feeding, administering, 1189–1190t medication administration, 806, 806t placement of, 1184, 1184f skin-level gastrostomy tube, 1184, 1185f Gate control theory of pain, 1117–1118, 1117f Gauge of the needle shaft, 809–810, 809f Gay defined, 965 gay families, 414 Gebbie, Kristine, 201 Gel, described, 777t Gel flotation pads, 871t Gender biologic dimension of health, 293 blood pressure, 526t cardiovascular risk factor, 1320, 1320t communication process, 442 family health, 417 fluid, electrolyte, and acid–base balance, 1344 loss and grief responses, 1020 medication action, 783 nutrition, 1158 pulse, 513 Gender dysphoria, 965 Gender identity sexual health, 964 types of, 965–966, 965f Gender identity disorder, 965 Gender-role behavior, 964–965, 964f General adaptation syndrome (GAS), 999–1000, 1001f General anesthesia, 904 Generalizations, 304 Generation X, 379 Generation Y (Millennials), 379 Generativity, defined, 385 Generativity versus stagnation Erikson’s theory of developmental stages, 341, 344t middle-aged adults, 385 self-concept, 949t Generic name, 777 Genetic theory of aging, 395t Genetics. See also Heredity biologic dimension of health, 293 growth and development, 338 medication action, 783, 783t

Genital intercourse, 966 Genital stage of Freud’s theory of psychosexual development described, 341, 341t, 344t young adults, 380t Genital warts adolescents, 372 clinical manifestations, 963t Genitals. See also Female genitals and inguinal area; Male genitals and inguinal area older adults, 397t, 400–401 perineal-genital care, 707–708, 708–709t, 708t Genogram, 415, 416f Geragogy, 466 Geriatrics, defined, 392 Gerontological nursing development of, 392–393 nurses, roles of, 393 Gerontology, defined, 392 Gesell, Arnold, 339–340 Gestures, in nonverbal communication, 441 Gilligan, Carol, 102, 348–349, 350t Gilligan’s theory of caring and relationships described, 348–349, 350t older adults, 404 young adults, 381 Ginger aromatherapy, 326t herbal medicine, 325t Gingiva, 715 Gingivitis, 572, 716, 716t Ginkgo, 325t Ginseng, 325t Glasgow Coma Scale, 607, 607t, 609t Glaucoma, 559t, 936, 937t, 938–939f Gliding joints, 1042f, 1042t Global self, defined, 949 Global self-esteem, 951 Globulins, 748f Glomerulus, 1200, 1201f Glossitis, 572, 716t Glossopharyngeal nerve (CN IX), 616t Gloves personal protective equipment, 646–647, 647–649t, 651t physical health assessment, 543t sterile applying and removing (closed method), 659–661t applying and removing (open method), 658–659t described, 658 Glucocorticoids, 1279, 1281t Glucose level. See also Capillary blood glucose blood glucose meters, 749, 749f fasting, preoperative, 895t urine testing, 762 Glycerides, 1156 Glycogen, 1154 Glycopyrrolate preoperative preparation, 901 urinary retention, 1205t Goals/desired outcomes, for nursing care plans defined, 223, 223f evaluation checklist, 239, 239t guidelines for writing, 225 nursing diagnoses, relationship to, 224 Nursing Outcomes Classification, 223–224, 223t purpose of, 224 short-term and long-term goals, 224 statements, components of, 224–225, 224t, 225t, 226t Goldmark Report (1923), 36 GoLYTELY. See PEG-ES Goniometer, 605t Gonorrhea clinical manifestations, 963t young adults, 382 Good Samaritan acts, 93

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Gordon’s typology of 11 functional health patterns, 195 Gould, Roger, 343, 344t Gould’s theory of adult development, 343–344, 343f, 344t Governance, defined, 43 Gowns personal protective equipment, 647–649t, 649 sterile, applying and removing (closed method), 659–661t Graduate nursing education, 37–38, 37f. See also Nursing education Gram, 789 Grand theories, defined, 64 Grandparenting physiological and psychosocial aging, 402 role strain in raising grandchildren, 952t Granulation tissue inflammatory response, 634 wound healing, 861 Graphic records, 257 Grief Chapter Highlights, 1031t Concept Map, 1030f Critical Thinking Checkpoint, 1030t defined, 1016 grief responses, factors influencing, 1018–1020, 1019f grief responses, types of, 1016–1017 grieving by older adults, 403 manifestations of, 1018 Nursing Management assessing, 1020, 1020t diagnosing, 1020–1021 evaluating, 1022 implementing emotional support, providing, 1021–1022 grief work, facilitating, 1021 planning, 1021, 1021t stages of grieving, 1017–1018, 1017t, 1018t Grief work, facilitating, 1021 Gross negligence, 88 Grounded theory, 55 Group, defined, 451 Group communication group dynamics, 451, 452t types of health care groups overview, 451–452 self-awareness and growth groups, 453 self-help groups, 452–453, 453t task groups, 452 teaching groups, 452 therapy groups, 453 work-related social support groups, 453 Group dynamics, 451, 452t Group teaching, 481 Growth, defined, 338 Growth and development body alignment and activity, 1038, 1043 Chapter Highlights, 351t concepts, applying to nursing practice, 349–350 Critical Thinking Checkpoint, 351t factors influencing culture, 339 environment, 339 family, 338–339 genetics, 338 health, 339 nutrition, 339 temperament, 338 principles of, 338, 339f, 339t stages of, by age, 339, 340t theories attachment theory (Bowlby), 345 behaviorist theory (Skinner), 345, 347t biophysical theory (Gesell), 339–340, 347t cognitive theory (Piaget), 345, 345f, 346t, 347t

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Index

Growth and development—Cont. Concept maps, 344t, 347t, 350t ecologic systems theory, 346, 347t, 348t moral development definitions, 346–347 Gilligan, 348–349, 350t Kohlberg, 347–348, 348t, 350t psychosocial theories Erikson, 341–342, 342f, 344t Freud, 340–341, 341t, 344t Gould, 343–344, 343f, 344t Havighurst, 342, 343t, 344t Peck, 342, 344t social learning theories Bandura, 346, 347t Vygotsky, 346, 347t spiritual development Fowler, 349, 350t Westerhoff, 349, 350t temperament theory (Chess and Thomas), 344–345, 345t Growth groups, 453 Guaiac test defined, 757 performing, 755–756, 756f, 756t Guarana, 1100 Guardian angel, nurses as, 31 Guide to Clinical Preventive Services (U.S. Preventive Services Task Force), 295 Guide to Community Preventive Services (CDC), 295 Guided imagery described, 329–330, 330t self-care for nurses, 431 Guns. See Firearms Gurgles (rhonchi), 582t Gustatory, defined, 930

H Habit training, for incontinence, 1214 Habits of the mind and critical thinking skills, 170 Haemophilus influenzae type B (HIB) vaccine, 361t, 364t Hahnemann, Samuel, 325 Hair loss of, 724 physical assessment Home Care Considerations, 555t Lifespan Considerations, 555t overview of, 554 skill for, 555t Hair hygiene developmental variations, 724 Nursing Management assessing nursing history, 724, 724t physical assessment, 724–725 diagnosing, 725 evaluating, 728 implementing beard and mustache care, 728, 728t brushing and combing, 725–727, 726f, 726–727t Lifespan Considerations, 727t shampooing, 727, 727f planning, 725 overview of, 723–724 HAIs. See Health care–associated infections (HAIs) Halcion. See Triazolam Haley’s M-O. See Mineral oil Halitosis, 716t Hand hygiene Home Care Considerations, 642t overview of, 638, 638t, 640, 640t skill for performing, 640–642t Hand movements test, 565t

Hand (mitt) restraints, 688, 688f Hand rolls, 1061t Hand-mediated biofield therapies, 327–328, 328t “Handoff ” communication, 263–264, 263t, 264t Hard contact lenses, 729 Harm, described, 88, 91f Harris flush, 1253 “Hat” container for urine, 1208, 1209f Haustra, 1236 Haustral churning, 1237 Havasupai Arizona Indian tribe study, 59 Havighurst, Robert, 342, 344t Havighurst’s activity theory, 401 Havighurst’s age periods and developmental tasks, 197 Havighurst’s theory of developmental tasks described, 342, 343t, 344t middle-aged adults, 385t young adults, 380t Hawaiian heritage, and older adults, 391t HbA1C (hemoglobin A1C), 749 Hct. See Hematocrit (Hct) HDL-C (high-density lipoprotein cholesterol), 751t Head circumference newborns and infants, 356, 357, 357f toddlers, 361, 365t inflicted traumatic brain injury, 360 lymph nodes, 576t molding, in newborns and infants, 357, 357f physical assessment ears and hearing (See Ears and hearing) eyes and vision (See Eyes and vision) mouth and oropharynx (See Mouth and oropharynx) nose and sinuses (See Nose and sinuses) skull and face (See Skull and face, assessment of) Headache, 1115t Healing, and religious beliefs, 984 Healing touch, 328, 328t Health Chapter Highlights, 300t Critical Thinking Checkpoint, 299t defined, 288 growth and development, 339 health belief models locus of control model, 295 purpose of, 294–295 Rosenstock and Becker’s model, 295–296, 296t health care adherence, 296–297, 296t, 297t health status, beliefs, and practices differentiation of, 292, 292t external variables, 294 internal variables, 293–294, 293t, 294t hygienic practices, 696t metaparadigm for nursing, 64 models of adaptive, 290 agent-host-environment model, 290–291, 291f clinical model, 290 eudaimonistic, 290 health-illness continua, 291–292, 291f, 292f role performance model, 290 nurses promoting, 39–40 nurses restoring, 40 nutrition, 1159 older adults, 391 personal definitions, 288–289, 289f, 289t surgical risk, 892, 893t Health assessment abdomen (See Abdomen, physical assessment of) anus (See Anus) axillae (See Axillae, assessment of) breasts (See Breasts) cardiovascular system (See Cardiovascular system)

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Chapter Highlights, 624t Critical Thinking Checkpoint, 624t female genitals and inguinal area (See Female genitals and inguinal area) general survey appearance and mental status, 545, 546–547t height and weight, 548, 548f Home Care Considerations, 549t Lifespan Considerations, 549t preparation for assessment, 548t vital signs, 548 head ears and hearing (See Ears and hearing) eyes and vision (See Eyes and vision) mouth and oropharynx (See Mouth and oropharynx) nose and sinuses (See Nose and sinuses) skull and face (See Skull and face, assessment of) integumentary system (See Hair; Nails; Skin) male genitals and inguinal area (See Male genitals and inguinal area) musculoskeletal system (See Musculoskeletal system) neck (See Neck) neurologic system (See Neurologic system) peripheral vascular system (See Peripheral vascular system) physical assessment cancer screenings, 541, 541t client, preparing, 541, 541t draping, 542 environment, preparing, 541–542 equipment, 542, 543t examination methods, 542–545, 543f, 544f, 544t, 545f, 545t order of assessment, 540, 540t positioning, 542, 542t purposes of, 540 specific assessments, 540, 540t thorax and lungs (See Thorax and lungs, assessment of) Health assessment and promotion adolescents, 374, 375t infants, 360–361, 360t, 361t, 362t middle-aged adults, 386, 387t older adults, 407, 408t school-age children, 370, 370t toddlers, 364, 364t, 365t young adults, 383, 384t Health behaviors, 292t Health beliefs and practices family health, 415–416 health beliefs, defined, 292t health promotion, 281–282 learning needs, 471, 471t nursing health history, 188t Health care delivery systems Chapter Highlights, 129t Critical Thinking Checkpoint, 129t frameworks for care case management, 125, 125t case method, 125 differentiated practice, 125 functional method, 125 managed care, 124–125 primary nursing, 126 team nursing, 125–126 health care agencies and services ambulatory care centers, 117 crisis centers, 119 day care centers, 119 extended (long-term) care facilities, 118, 118f, 118t fires, 682, 682f home health care agencies, 119 hospice services, 119 hospitals, 117–118, 117f mutual support and self-help groups, 119 needs of, identified with client records, 248–249

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Index occupational health clinics, 117, 117f physicians’ offices, 117 public health, 116, 116f rehabilitation centers, 118–119, 119f retirement and assisted living centers, 118 rural care, 119 subacute care facilities, 118 health care delivery, factors affecting demographic changes, 124 economics, 122 health insurance, access to, 123–124 HIPAA, 124, 124t homelessness and poverty, 124, 124t older adults, increasing numbers of, 122 technology advances, 122 uneven distribution of services, 123, 123f women’s health, 122–123 health care financing CHIP, 127 group insurance plans, 128 Medicare and Medicaid, 126–127, 126f private insurance, 127 prospective payment system, 127 Supplemental Security Income, 127 WIC, 127 health care providers alternative (complementary) care providers, 120 case managers, 120, 120f dentists, 120 dietitians and nutritionists, 120, 120f emergency medical personnel, 121 nurses, 120, 120f occupational therapists, 120, 120f overlap of activities, 120f, 121t paramedical technologists, 121 pharmacists, 120f, 121 physical therapists, 120f, 121 physician assistants, 121 physicians, 120f, 121 podiatrists, 121 respiratory therapists, 120f, 121 social workers, 121 spiritual support personnel, 121 unlicensed assistive personnel, 121 health care services, types of primary prevention, 115, 115t secondary prevention, 115–116 tertiary prevention, 116 older adults’ functional levels, assessing, 128t safety, 667–668, 676 Health Care Financing Administration, 258 Health care personnel communication among disruptive behaviors bullying, 458 incivility, 457–458, 458t lateral violence, 458 responding to, 458–459, 459t nurse-physician communication assertive communication, 460 communication styles, 459, 459t emotional intelligence, 460 nonassertive communication, 460 data sources, 189 infection prevention, 662, 662t teaching, 465 Health care proxy defined, 85 sample form, 86f Health care reform, 45. See also Patient Protection and Affordable Care Act (ACA) Health care system, defined, 115 Health care–associated infections (HAIs) chlorhexidine gluconate baths, 702t

defined, 630 risk for, reducing, 630t Health disparities defined, 304 efforts to reduce, 304–305 factors contributing to, 304 Health education. See Client and family education; Client Teaching Health equity defined, 304 efforts to provide, 304–305 Health examinations. See also Health assessment, physical assessment adolescents, 375t newborns and infants, 361t preschoolers, 367t school-age children, 370t toddlers, 364t Health informatics, 155 Health insurance access to, as factor affecting health care delivery, 123–124 group plans, 128 private insurance, 127 Health Insurance Portability and Accountability Act (HIPAA) computer records, confidentiality of, 248 continuity of care, 139 data, 187 health care delivery, factors affecting, 124, 124t hospital information systems, 157 personal health information, management of, 109 physical examination information, 541 privacy of clients’ health information, 92, 92t protected health information, 247 Health literacy defined, 80t, 81, 473 health literacy knowledge of student nurses, 473t low client literacy levels, 474t, 476t Newest Vital Sign health literacy test, 473, 474f, 475f “teach back” technique, 474, 474t written teaching aids, developing, 475t Health Literacy Universal Precautions Toolkit, 474 Health maintenance organizations (HMOs), 128 Health on the Net Foundation, 156 Health Professions Education: A Bridge to Quality (IOM), 45 Health promotion activities, sites for, 275–276 Chapter Highlights, 286t Critical Thinking Checkpoint, 285t defined, 274 defining health protection, differentiating from, 274–275, 275t prevention levels, 274, 275t topics, by age, 275, 276t health behavior change, 278–279, 284–285, 285f Health Promotion Model, 276–278, 277f, 277t Healthy People 2020, 274, 274t individual health assessing, 272 holism, 270–271 homeostasis, 271–272, 271f, 272f individuality, 270 Internet as an effective health intervention, 280t Lifespan Considerations, 282t nurse’s role, 279–280, 279t Nursing Management assessing, 280–282, 280t, 281t, 282t diagnosing, 282–283 evaluating, 285 implementing, 284–285, 285f planning, 283–284, 283t nursing process, 280 stress and coping, 1006–1007, 1006t

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theoretical frameworks developmental stage theories, 274 needs theories, 273–274, 273f overview, 272–273 Health promotion from conception through adolescence adolescents cognitive development, 373 health assessment and promotion, 374, 375t Health Promotion Guidelines, 375t health risks, 373–374, 373f moral development, 373 physical development, 371, 375t psychosocial development, 371–373, 372f, 375t puberty, 370–371 spiritual development, 373 Chapter Highlights, 376t conception and prenatal development elimination, 355 maternal factors of impaired development, 355t nutrition and fluids, 355 oxygen, 355 safety, 355–356, 356t sleep and activity, 355 stages of, 354–355 temperature maintenance, 355 Critical Thinking Checkpoint, 375t neonates and infants cognitive development, 359 Developmental Assessment Guidelines, 362t head and chest circumference, 356–357, 357f head molding, 357, 357f health assessment and promotion, 360–361, 360t, 361t, 362t Health Promotion Guidelines, 361t health risks, 359–360, 360f hearing, 357, 362t length, 356, 356f moral development, 359 motor development, 358, 358f, 359t, 362t psychosocial development, 358–359, 359t, 362t reflexes, 358, 358t smell and taste, 358 touch, 358 vision, 357, 362t weight, 356 preschoolers cognitive development, 366 Developmental Assessment Guidelines, 368t health assessment and promotion, 367, 367t, 368t Health Promotion Guidelines, 367t health risks, 367 moral development, 366–367 physical development, 364–365, 365f, 368t psychosocial development, 365–366, 366f, 368t spiritual development, 367 school-age children cognitive development, 369, 369f Developmental Assessment Guidelines, 370t health assessment and promotion, 370, 370t Health Promotion Guidelines, 370t health risks, 369–370, 369f moral development, 369 physical development, 367–368, 370t psychosocial development, 368–369, 370t spiritual development, 369 toddlers cognitive development, 363 Developmental Assessment Guidelines, 365t health assessment and promotion, 364, 364t, 365t Health Promotion Guidelines, 364t health risks, 363–364, 363f moral development, 363 physical development, 361–362, 362f, 365t psychosocial development, 362–363, 362t, 365t spiritual development, 363

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Health Promotion Guidelines adolescents, 375t infants, 361t middle-aged adults, 387t older adults, 408t preschoolers, 366t school-age children, 370t toddlers, 364t young adults, 384t Health promotion in older adults. See Older adults Health promotion in young and middle-aged adults. See Middle-aged adults; Young adults Health Promotion Model assumptions of, 276, 277t behavioral outcome, 278 behavior-specific cognitions and affect, 277–278 competing demands and preferences, 278 described, 276, 277f individual characteristics and experiences, 276–277 plan of action, commitment to, 278 Health promotion nursing diagnosis, defined, 282 Health protection, defined, 274–275, 275t Health resources, allocation of, 109 Health Resources and Services Administration, 132 Health risk assessment (HRA), 281 Health risks adolescents, 373–374, 373f middle-aged adults alcoholism, 386 cancer, 386 cardiovascular disease, 386 injuries, 386 mental health alterations, 386 obesity, 386 preschoolers, 366 school-age children, 369–370, 369f young adults eating disorders, 382–383 hypertension, 382 injury and violence, 381–382, 382t malignancies, 383 sexually transmitted infections, 382 substance abuse, 382 suicide, 382 Health Source, 58t Health status defined, 292t respiratory function, 1273 safety, 666 Health System Reform Agenda (ANA), 131 Health tests and screenings. See also Diagnostic testing middle-aged adults, 387t older adults, 408t young adults, 384t HEALTH traditions model described, 306–307, 307t symbolic examples, 307, 308f Healthcare Integrity and Protection Data Bank, unprofessional conduct by nurses, 93 Healthy People 2020 activity and exercise objectives, 1036–1037 cardiovascular risk factors, 1321, 1322 dietary recommendations, 1165 eating disorders in young adults, 382 folic acid and neural tube defects, 355 health care reform, 132 health disparities, 305 health promotion, 274, 274t injuries and violence, 381 older adults, 391 pressure ulcers, rate of, 855 Hearing. See Ears and hearing Hearing aids Home Care Considerations, 732t

removing, cleaning, and inserting, skill for, 731–732t types of, 730–731, 730f, 731f Heart physical assessment heart sounds, 587, 587f, 587t, 1315t Lifespan Considerations, 591t overview, 586–587, 586t, 587f, 587t precordium, 586–587, 587f skill for, 588–591t pumping action, and blood pressure, 526 Heart attack (myocardial infarction), 1323, 1323t Heart failure, 1323, 1323t Heart rate, 1317, 1317t Heart sounds, 587, 587f, 587t, 1315t Heart-lung death, defined, 1023 Heat applications aquathermia pad, 885, 885f compresses and soaks, 886 contraindications, 884, 885t electric heating pads, 886 hot packs, 885, 886f hot water bags, 884–885, 885f indications for, 884, 884t local effects, 882 pain management, 1144 physiological effects, 882, 883t rebound phenomenon, 883–884, 884t sitz baths, 886, 887f systemic effects, 883 thermal receptors, 883, 884t thermal tolerance, 883, 883t Heat balance, 504, 504f Heat exhaustion, 505 Heat stroke, 506 Heave (lift), 586 Heel guard boots, 1063t Heel protectors, 871f, 871t Height measuring, 548 preschoolers, 364, 368t school-age children, 367, 370t toddlers, 361, 365t Heimlich maneuver, 684, 684f Heimlich valve for chest tubes, 1305–1306, 1306f Helix, defined, 565 Helper T cells, 634 Helping relationships characteristics of, 449, 449t described, 445, 449 developing, 451 phases of, 449–451, 450t Hematocrit (Hct) blood pressure, 526 described and normal levels, 745, 746t, 747, 747t fluid, electrolyte, and acid–base balance, 1357 oxygen transport, 1271 Hematoma, 862 Hemoccult test, 755–756, 756f, 756t Hemodynamic studies, 1326 Hemoglobin (Hgb) described and normal levels, 745, 746t, 747, 747t functions of, 1319 level, and nutrition, 1172 oxygen saturation, 533 oxygen transport, 1271 Hemoglobin A1C (HbA1C), 749 Hemolytic transfusion reaction, 1384, 1385t Hemoptysis, 524t, 762 Hemorrhage postoperative phase, 909, 910t wound healing, 862 Hemostasis, 861 Hemothorax, 1305 Hemovac, 921, 921f, 922f

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Henderson, Virginia, 39, 66–67 Henry Street Settlement, 33, 33f Heparin enoxaparin, 822t, 1330t shaving beards and mustaches, 728 subcutaneous injections, 817, 821t, 822t Hepatitis A vaccine infants, 361t preschoolers, 367t toddlers, 364t Hepatitis A virus (HAV), 632t Hepatitis B vaccine adolescents, 375t infants, 361t preschoolers, 367t toddlers, 364t young adults, 384t Hepatitis B virus (HBV) body reservoirs, in, 632t postexposure protocol, 662t Hepatitis C virus (HCV), 662t Herbal medicine, 324–325, 325t Herbert, Sidney, 29 Heredity. See also Genetics cardiovascular risk factor, 1320, 1320t family health, 417 infection, susceptibility to, 635 Heritage, defined, 303 Heritage Assessment Interview, 314–315, 315f, 316t Heritage consistent, defined, 314–315, 315f, 316t Heritage inconsistent, defined, 314 Hernia, 619 Heroines, nurses as, 31 Herpes genitalis clinical manifestations, 963t young adults, 383 Herpes simplex virus type 2, 632t Hgb. See Hemoglobin (Hgb) HIB (Haemophilus influenzae type B) vaccine, 361t, 364t Hibiclens. See Chlorhexidine gluconate Hierarchical concept maps, 177f, 177t High-density lipoprotein cholesterol (HDL-C), 751t Higher brain death, defined, 1023 High-Fowler’s position, 1062, 1062t High-risk behaviors, 373–374, 373f HIndus, and health-related information, 990t Hinge joints, 1040f, 1040t, 1041f, 1041t, 1042f, 1042t Hip joint movements, 1041f, 1041t HIPAA. See Health Insurance Portability and Accountability Act (HIPAA) Hirschberg test, 563t Hirsutism described and nursing implications, 697t hair hygiene, 725 Hispanic/Latino heritage, people with adolescent families, 413 cultural health-related practices, 317t culture that values family inclusion in client teaching, 483t older adults, 391, 391t, 392t pain, responses to, 1119t sleep and mortality of elderly Hispanics, 399t social support, cultural aspects of, 281t History, for nursing health history, 188t History of present illness, 188t HIV. See Human immunodeficiency virus (HIV) HMO (health maintenance organizations (HMOs), 128 Holism complementary and alternative healing modalities, 322 described, 270–271 Holistic health belief, defined, 308 Holy days, 982 Home care Chapter Highlights, 153t client advocacy, 109–110

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Index computers in nursing practice, 163, 163f Critical Thinking Checkpoint, 152t defined, 144 documentation, 258, 259t future of, 151 home care clients, perspectives of, 147 home care nurses roles of, 146–147, 147f views of their practice, 152t home health care system durable medical equipment companies, 146 home health agencies, 145–146 private duty agencies, 146 referral process, 145, 145t reimbursement, 146 home health nursing caregiver support, 149 client safety, 147–148, 148f, 148t factors contributing to growth of, 144–145 infection prevention, 148–149 nurse safety, 148 unique aspects of, 145 infections, 637, 637t, 638t Lifespan Considerations, 152t nursing practice in the home health issues, establishing, 150 initial home visit, 149–150, 150f planning and delivering care, 150, 150f, 150t, 151f resources for, 151 older adults, care setting for, 394 Home care, planning for activity and exercise, 1056, 1057t dying and death, 1026 fecal elimination, 1247, 1248t fluid, electrolyte, and acid–base balance, 1359, 1359t, 1360t loss and grieving, 1021, 1021t nutrition, 1174–1175, 1176t oxygenation, 1276–1277, 1277t pain management, 1128, 1128t postoperative phase, 912, 913t preoperative phase, 895t sensory perceptual functioning, 935, 935t skin hygiene, 699, 699f, 699t stress and coping, 1006, 1006t urinary elimination, 1211, 1212t, 1213t Home Care Assessment fecal elimination, 1248t fluid, electrolyte, and acid–base balance, 1359t grieving, 1021t home hazard appraisal for adults, 148t hygiene, 699f, 699t infection, 637t mobility and activity problems, 1057t oxygenation, 1277t pain, 1128t sensory perception disturbances, 935t stress and coping, 1006t surgical clients, 913t urinary elimination, 1212t wound care and prevention of pressure ulcers, 868t Home Care Considerations abdomen, assessment of, 603t administering medications, 805 antiemboli stockings, 904t assisting a client to ambulate, 1081t bandages and binders, applying, 883t blood pressure, 533t body temperature, 512f, 512t capillary blood glucose, 754t catheterization, 1223t changing an ostomy appliance, 1262t closed-wound drainage system, 922t communication and clinical reasoning, 176t

ear and hearing assessment, 569t enema, administering, 1256t eye and vision assessment, 565t GI suction, 917t hair assessment, 555t hand hygiene, 642t health assessment general survey, 549t hearing aids, 732t home care oxygen equipment, 1290–1290t, 1290f hygiene, 706t intradermal injection, administering, 819t IV push antibiotics, administering, 837t metered-dose inhalers, 848t mouth and oropharynx assessment, 575t musculoskeletal system assessment, 606t nail assessment, 557t nutrition, 1176t oral hygiene, 723t pain management, 1146t PCA pump, 1141t peripheral vascular system assessment, 594t positioning, moving, and turning clients, 1070t postoperative instructions, 913t pulse, 521t pulse oximetry, 535t respirations, 525t restraints, applying, 691t safety monitoring devices, 680t seizure precautions, 682t sequential compression devices, 1330t skin assessment, 554t sleep, 1102t specimen collection, 763t standard precautions and personal protective equipment, 649t sterile field, 657t stool specimens, 757t subcutaneous injections, 822t suctioning, 1297t suctioning a tracheostomy or endotracheal tube, 1301t sutured wound, cleaning, 921t sutures or staples, removing, 924t temperature measurement, 512f, 512t tracheostomy care, 1305t transferring from bed to a chair, 1076t tube feeding, administering, 1191t urine specimen collection, 760t wound care, 879t Home health care agencies, described, 119, 145–146 Home Health Care Classification, 161 Home health care nursing, defined, 144 Home health care teaching, 140–141 Home Health Quality Improvement National Campaign, 151 Homelessness families, 412–413 health care delivery, factors affecting, 124, 124t Homeopathy, 324f, 325–326 Homeostasis defined, 271 fluid, electrolyte, and acid–base balance, 1334 physiological, 271, 271f, 272f psychological, 272 Homes fires, 682–683 hazard appraisal, 669 safety, 668 Homicide, 381 Homocysteine, 1320t, 1322 Homosexuality adolescents, 372–373 defined, 965 HONcode Site Evaluation Form, 156 Honesty, in caring, 424 Hordeolum (sty), 559

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Hormones body temperature, 505 fluid and electrolyte balance, 1339, 1340f Horticultural therapy, 332 Hospice described, 1026–1027, 1027f health care agency, 119 hospice nursing, defined, 144 older adults, 393 Hospital information system (HIS), 157, 157f Hospital-acquired conditions (HACs), 127 Hospitals, 117–118, 117f Host, in agent-host-environment model of health, 291, 291f Hour of sleep (PM) care, 695–696 Household system of measurement, 789, 790, 790t HPV vaccine. See Human papillomavirus (HPV) vaccine Hub of the needle, 809, 809f Huff coughing, 1278, 1279t Human dignity, 100, 100t Human Genome Project, 303 Human immunodeficiency virus (HIV). See also Acquired immunodeficiency syndrome (AIDS) body reservoirs, in, 632t postexposure protocol, 662t Human papillomavirus (HPV) vaccine adolescents, 372, 375t school-age children, 370t young adults, 383, 384t Human resources, technology use in, 164 “Human response patterns,” 211, 211t Humanist, defined, 322 Humanistic learning theory, 467 Humidifiers oxygen therapy, 1283–1284, 1284f oxygenation, 1278 Humility, in caring, 424 Humor complementary modality, 331–332 verbal communication, 440 Humoral (antibody-mediated) immunity, 634, 634t Hunger and Homelessness Survey, 412–413 Hydralazine nutrition, 1160t urinary retention, 1205t Hydration oxygenation, 1278 postoperative care, 914 Hydrocodone pain management, 1132, 1132t, 1133t, 1134 urinary retention, 1205t Hydrocolloid dressings, 873t, 874 Hydrogel dressings, 873t Hydrogen peroxide, 644t Hydromorphone pain management, 1132, 1132t, 1134 PCA, 1140 Hydrostatic pressure, 1337, 1338f Hydrotherapy, 332 Hygiene beds, making occupied beds, 739–740, 739–740t overview of, 734, 735t unoccupied beds, 734–738, 735f, 736–738t Chapter Highlights, 741t Critical Thinking Checkpoint, 741t defined, 695 ears, 730 environment footboard or footboot, 734 hospital beds, 733, 734t intravenous rods, 734 mattresses, 733 noise, 733 overview of, 732–733

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Index

Hygiene—Cont. room temperature, 733 side rails, 733–734, 734t ventilation, 733 eyes (See Eye hygiene) factors influencing, 695, 696t feet (See Foot hygiene) hair (See Hair hygiene) Home Care considerations, 706t hygienic care, types of, 695–696 mouth (See Mouth hygiene) nails (See Nails, nail hygiene) nose, 732 preoperative care, 900–901 skin (See Skin hygiene) Hyperalgesia, 1114, 1115t Hypercalcemia, 1347, 1349t, 1350 Hypercapnia, 1273 Hypercarbia, 1273 Hyperchloremia, 1350 Hyperextension, 1038t, 1039–1042f, 1039–1042t Hyperinflation, with suctioning, 1298 Hyperkalemia, 1347, 1348t Hypermagnesemia, 1349t, 1350 Hypernatremia, 1346–1347, 1346f, 1348t Hyperopia, defined, 559 Hyperopic, defined, 364 Hyperoxygenation, with suctioning, 1298 Hyperpathia, 1114 Hyperphosphatemia, 1350 Hyperpyrexia, 505, 506f Hyperresonance, 545, 545t Hypersomnia, 1099 Hypertension cardiovascular risk factor, 1320t, 1321 classification of, 526, 527t defined, 526 management guidelines, 526–527 young adults, 382 Hyperthermia, 505. See also Pyrexia Hypertonic, defined, 1336 Hypertonic enema solutions, 1252, 1252t, 1253t Hypertonic IV solutions, 1362, 1362t Hypertrophy of muscles, 1046 Hyperventilation defined, 523, 524t described, 1273 suctioning, 1297 Hypervolemia, 1345 Hypnotherapy, 329 Hypoactive sexual desire disorder, 969 Hypocalcemia, 1347, 1349t, 1350, 1350f Hypochloremia, 1350 Hypodermic route of administration, 784t, 785. See also Subcutaneous injections; Subcutaneous route of administration Hypodermic syringe, 806 Hypoglossal nerve (CN XII), 616t Hypokalemia, 1347, 1347t, 1348t Hypomagnesemia, 1349t, 1350 Hyponatremia, 1346, 1346f, 1348t Hypophosphatemia, 1350 Hypotension, 527 Hypothermia Clinical Manifestations, 507t complications, 506–507 defined, 506 nursing interventions, 507, 507t older adults, 405 temperature range, 506f Hypothesis, defined, 56 Hypotonic, defined, 1336–1337 Hypotonic enema solutions, 1252–1253, 1252t Hypotonic IV solutions, 1362, 1362t

Hypoventilation, 523, 524t, 1273 Hypovolemia described, 1344 postoperative phase, 909, 910t pulse, 513 Hypovolemic shock, 910t Hypoxemia, 1273–1274 Hypoxia, 1274, 1274t

I I & O. See Fluid intake and output (I & O) Iatrogenic disease, 780 Iatrogenic infections, 630t Ibuprofen dysmenorrhea, 962 inflammatory response, 635t pain management, 1132, 1132t, 1133 pain transduction, 1116 postoperative care, 913 ICF (intracellular fluid), 1335, 1335f, 1336, 1336f ICN. See International Council of Nurses (ICN) Id, defined, 340 Ideal body weight, 1157, 1157t Ideal self, defined, 950 Identification preschoolers, 366 stress, 1003t Identity versus role confusion adolescents, 371 self-concept, 949t Idiosyncratic effect, 780 Ileal conduit, 1228, 1229f Ileostomy, 1244, 1244f Ileus current research studies, 54t postoperative phase, 911t Illicit drugs, defined, 780. See also Substance abuse Illiteracy, defined, 80t. See also Literacy Illness. See also Health acute and chronic, 297–298 Chapter Highlights, 300t Critical Thinking Checkpoint, 299t defined, 297 effects on the client and family, 299 family health, 418–419, 419t illness behaviors, 298–299, 298f learning, barrier to, 469t medication action, affecting, 783 models of Dunn’s high-level wellness grid, 291–292, 291f illness-wellness continuum, 292, 292f nurses preventing, 40 religious beliefs, 984 self-concept, 953 sensory function, 932 sleep, 1097 urinary elimination, 1205 Illness behavior defined, 298 rights and obligations of the sick role, 298 stages of dependent client role, 298–299 medical care contact, 298 recovery or rehabilitation, 299 sick role, assumption of, 298, 298f symptom experiences, 298 Illness-wellness continuum, 292, 292f Imagery, 329–330, 330t Imagination, 366 Imitation, 466 Immigration, 305–306 Immobility cardiovascular system, 1048–1049, 1049f, 1049t, 1055t disuse syndrome, risk for, 1087t, 1088f

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gastrointestinal system, 1051, 1055t integumentary system, 1051, 1055t metabolic system, 1050, 1055t musculoskeletal system, 1048, 1048f, 1055t overview, 1047–1048, 1048t pressure ulcers, 856 problems related to, 1055, 1055t psychoneurologic system, 1051, 1055t respiratory system, 1049–1050, 1049f, 1055t urinary system, 1050–1051, 1050f, 1055t Immobilization, for pain management, 1144 Immune system exercise, benefits of, 1046 infection, 633 older adults, 397t stress, 1000f Immunity, defined, 634 Immunizations. See also specific vaccines adolescents, 375t infants, 361t infection, susceptibility to, 635 preschoolers, 367t school-age children, 370t toddlers, 364t vaccines, 817 Immunoglobulins (antibodies), 1384, 1384t blood transfusions, 1383–1384, 1384t described, 634, 634t immunoglobulin A (IgA), 634 immunoglobulin D (IgD), 634 immunoglobulin E (IgE), 634 immunoglobulin G (IgG), 634 immunoglobulin M (IgM), 634 Immunologic theory of aging, 395t Imodium. See Loperamide hydrochloride Imodium Advanced. See Simethicone/loperamide Impaired nurse defined, 83 legal aspects, 83–84, 83t, 84t warning signs, 84t Implanted vascular access devices (IVADs), 1365, 1366f Implementing. See also under Nursing Management Chapter Highlights, 244t Critical Thinking, Applying, 244t defined, 234 evaluation checklist, 239t, 240 nursing care plan, 242–244t nursing process, phase of, 234, 235f nursing process in action, 182–183f nursing process purpose and activities, 181, 184t, 185f process of delegated care, supervising, 235f, 236 documenting nursing activities, 235f, 236 nurse’s need for assistance, determining, 235, 235f nursing interventions, implementing, 235–236, 235f, 236f reassessing the client, 235, 235f skills for, 234–235 Implied consent, 80 Impregnated nonadherent dressings, 873t Imprint magazine, 48 Impulse conduction, 930, 931f Inactivated polio vaccine (IPV) infants, 361t preschoolers, 367t toddlers, 364t Incentive spirometers Client Teaching, 1282t types of, 1281f, 1282 uses for, 1280 Incident reports, 94–95 Incisions, 855t Incivility between health professionals, 457–458, 458t Incompetent valves in veins, 1324, 1324f

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Index Incomplete proteins, 1154 Incus, 565f, 566 Independence adolescents, 372 critical thinking, 174 physiological and psychosocial aging, 403 Independent functions, 203 Independent interventions, 226–227 Independent practice associations, 128 Independent t -test, 57t Independent variable, defined, 56 Indicators, defined, 223 Indirect auscultation, 545 Indirect percussion, 544–545, 545f Indirect transmission of microorganisms, 632 Individualized care plans, 216 Individualized exercise prescriptions, 1043 Individuals assessing the health of, 272 individuality, concept of, 270 Individuating-reflexive stage of Fowler’s theory of spiritual development described, 349, 350t young adults, 381 Indocin. See Indomethacin sodium trihydrate Indomethacin sodium trihydrate, 1132t Inductive reasoning, 172 Industry versus inferiority Erikson’s theory of developmental stages, 341, 344t school-age children, 368 self-concept, 949t Indwelling (Foley, or retention) urinary catheters, 761, 761f, 1218, 1219f, 1224–1225 Ineffective coping, 1004 Infants abdomen, assessment of, 603t anus, assessment of, 623t average daily urine output, 1205t bathing, 706t biologic dimension of health, 293 blood pressure, 532t body alignment and activity, 1038 body temperature, 512f, 512t breast and axilla assessment, 597t capillary blood glucose, 754t catheterization, 1223t cognitive development, 359 colic, 359–360 communication with, 443t death, concept of, 1022t defecation, 1238 Developmental Assessment Guidelines, 362t ear and hearing assessment, 569t enema, administering, 1256t eye and vision assessment, 564t female genitalia and inguinal area assessment, 618t fluid, electrolyte, and acid–base balance, 1343, 1343t hair assessment, 555t hair care, 727t Havighurst’s age period and developmental tasks, 343t health assessment and promotion, 360–361, 360t, 361t, 362t health assessment general survey, 549t health care decisions, 178t Health Promotion Guidelines, 361t health promotion topics, 276t health risks, 359–360, 360f heart and central vessels, assessment of, 591t IM injections, 829t male genitalia and inguinal area assessment, 622t medication administration, 800 moral development, 359 mouth and oropharynx assessment, 574t musculoskeletal system assessment, 606t nail assessment, 557t

nasogastric tube, inserting, 1183t neck assessment, 578t neurologic system assessment, 615t normal sleep patterns and requirements, 1095 nose and sinus assessment, 571t nutrition, 1161 ophthalmic medications, administering, 841t oral health, 717 oral hygiene, 723t oral medications, 805t otic medications, administering, 843t oxygen delivery equipment, 1290t pain experience, 1119, 1120t pain management, 1146t peripheral vascular system assessment, 593t physical development head and chest circumference, 356–357, 357f head molding, 357, 357f hearing, 357, 362t length, 356, 356f motor development, 358, 358f, 359t, 362t reflexes, 358, 358t smell and taste, 358 touch, 358 vision, 357, 362t weight, 356 positioning, moving, and turning clients, 1070t pressure ulcer and wound care, 879t psychosocial development, 358–359, 359t, 362t pulse, 520t pulse and respiration average and normal range, 513t pulse oximetry, 535f, 535t rectal medications, administering, 846t respirations, 525t respiratory development, 1272, 1274t restraints, 691f, 691t safety, 671, 673t safety hazards, 667t sexual development, 960, 961t skin assessment, 554t skull and face assessment, 558t sputum and throat specimens, 763t stool specimens, 757t stress and coping, 1010t suctioning, 1297t suctioning a tracheostomy or endotracheal tube, 1301t surgical risk, 892 temperature measurement, 512f, 512t thorax and lungs, assessment of, 586f, 586t tracheostomy care, 1305t transferring clients, 1076t tube feeding, administering, 1190t urinary elimination, 1202, 1204t urine specimen collection, 760t Infected wounds, 855 Infection. See also Asepsis body’s defenses nonspecific defenses anatomic and physiological barriers, 633 inflammatory response, 633–634, 633t specific defenses antibody-mediated defenses, 634, 634t cell-mediated defenses, 634 chain of infection, 630–633, 631f, 632t Chapter Highlights, 663–664t Critical Thinking Checkpoint, 663t defined, 628 Drug Capsule, azithromycin, 643t Lifespan Considerations, 636t microorganisms that cause infections, 629 nosocomial and health care–associated, 630, 630t Nursing Management assessing laboratory data, 636–637

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nursing history, 635, 636t physical assessment, 635–636 diagnosing, 637 evaluating, 663 implementing chain of infection, breaking, 637, 639t disinfecting and sterilizing, 643–644, 644t hand hygiene (See Hand hygiene) host, supporting defenses of, 642–643 infection prevention and control, 644–646, 645t infection prevention for health care workers, 662, 662t infection prevention nurse, role of, 662–663 isolation practices (See Isolation practices) nosocomial infections, preventing, 637–638 sterile technique (See Sterile technique) planning goals for, 637 home care, for, 637, 637t, 638t overview of, 628–629, 629t postoperative phase, 911t signs of, in older adults, 909t susceptibility factors for, 634–635, 635t types of, 629–630 wound healing, 862 Infection control, 638t Infection prevention client teaching, 638t health care workers, 662, 662t home health nursing, 148–149 wound healing, 869, 870t Infection prevention nurses, 662–663 Infectious agent, defined, 628 Inferences, defined, 197 Inferential statements, 173, 173t Inferential statistics, 57, 57t Infiltration, described, 1375t, 1378t, 1383, 1383t Inflammation defined, 633 inflammatory phase of wound healing, 861 inflammatory response exudate production, 633–634 reparative phase, 634 vascular and cellular responses, 633 signs of inflammation, 633, 633t Inflicted traumatic brain injury, 360 Influence, defined, 491 Influenza vaccine infants, 361t middle-aged adults, 387t older adults, 408t preschoolers, 367t school-age children, 370t toddlers, 364t Informal leaders, 488–489 Informal nursing care plan, 216 Informatics, defined, 155 Information nursing practice, influencing, 46 therapeutic communication, 447t Information technology, 155 Informed consent aspiration or biopsy procedures, 766t cultural issues, 80, 81, 81t, 82t defined, 79–80 elements of, 60t, 80 exceptions to, 81 express or implied, 80 literacy, 80–81, 80t, 81t rights of research participants, 59, 60f, 60t Infrared thermometers, 509, 509f Infusion Nurses Society, 1363 Ingestion, defined, 1236 Ingrown toenails, 712 Inhalation (inspiration), 522, 522f

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Index

Inhalation route of administration described, 784t, 785 metered-dose inhalers, 847, 847f, 847t, 848f, 848–849t nebulizers, 846, 847t Inhibited grief, 1016 Inhibiting effect, defined, 780 Initial assessment, 185, 187t Initiative versus guilt Erikson’s theory of developmental stages, 341, 344t preschoolers, 365 self-concept, 949t Injury middle-aged adults, 386 older adults, 405 toddlers, 363, 363f unintentional tort, 88, 91f young adults, 381 Innovar, 901 Input, defined, 271, 271f Inquest, defined, 87 Insensible fluid losses, 1338t, 1339 Insensible heat loss, 504 Insensible water loss, 504 In-service education, 39 Insomnia, 1098–1099, 1099t Inspection technique, described, 543 Inspiration (inhalation), 522, 522f Inspiratory capacity, 1276f, 1276t Inspiratory reserve volume (IRV), 1276f, 1276t Institute for Healthcare Improvement, 241 Institute for Safe Medication Practices, 786, 786t Institute of Medicine (IOM) Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response, 668 Crossing the Quality Chasm: A New Health System for the 21st Century, 240 electronic health records, 160 To Err is Human: Building a Safer Health System, 45, 240, 667, 669 The Future of Nursing: Leading Change, Advancing Health, 45 Health Professions Education: A Bridge to Quality, 45 Keeping Patients Safe - Transforming the Work Environment of Nurses, 668 RN baccalaureate programs, 37 safe patient handling and mobility standards, 1058 Institutional discrimination, 304 Institutional racism, 304 Institutional Review Boards, 59 Instrumental activities of daily living, 128t Insulin high-alert medication, 817t mixing in one syringe, 817t subcutaneous injections, 817, 820, 821t Insulin pens, 807–808, 807f Insulin syringe, 807, 807f Intake and output. See Fluid intake and output (I & O) Integrated delivery system, 128 Integrated health care system, 135–136, 136f Integrative (integrated) medicine, 321 Integrity, in critical thinking, 175 Integrity versus despair Erikson’s theory of developmental stages, 341–342, 342f, 344t self-concept, 949t Integumentary system immobility, effects of, 1051, 1055t older adults, 395, 396t, 397 Intellectual component of wellness, 289, 290f Intellectual humility, 174 Intellectualization, 1003t Intensity, in the temperament theory of Chess and Thomas, 345t Intensity of sound with auscultation, 545 Intention tremor, 603 Intentional torts, 89–92, 90t, 91f

Intercostal retraction, 524t Intermittent fever, 505 Intermittent IV infusion devices/locks, 833–834, 834f, 1366, 1368, 1369f, 1382–1383t Intermittent IV infusion of medications, 831–832, 832f, 833f Internal standards of care, 78 Internal stressors, 1008 Internals, in the health locus of control model, 295 International Classification for Nursing Practice, 161 International Classification of Diseases (ICD), 161 International Classification of Primary Care, 161 International Classification of Sleep Disorders, 1101 International Council of Nurses (ICN) described, 48 International Classification for Nursing Practice, 161 nurses’ code of ethics, 104, 104t International Health Terminology Standards Development Organization, 161 International Journal of Nursing Terminologies and Classifications, 211 International Nurses Society on Addictions, 1131 International Nursing Association for Clinical Simulation and Learning, 158 International Nursing Review, 48 International Orem Society, 67 International Red Cross, 32 Internet defined, 156t effective public health intervention, 280t health information, 156, 156t, 469–470 Interpersonal relationships, 445. See also Helping relationships Interpersonal skills, 235 Interpreters culturally responsive care, 310, 310t, 311t informed consent forms, 81, 82t Intersex, defined, 965 Intersex Society of North America, 965 Interstate compact, defined, 77 Interstitial fluid, 1335, 1335f, 1336, 1336f Interview children as clients, 193t communication during, 193t defined, 190 interview questions, 190–191, 191t planning the interview and setting, 191–192, 192t stages of, 192–193 types of interviews, 190 In-the-canal (ITC) hearing aids, 331, 331f In-the-ear (ITE) hearing aids, 731, 731f Intimacy, defined, 380 Intimacy versus isolation Erikson’s theory of developmental stages, 341, 344t self-concept, 949t young adults, 380t Intimate distance, defined, 442 Intimate partner violence, 381–382, 382t Intonation, in verbal communication, 439 Intra-arterial route of administration, 785 Intra-articular route of administration, 785 Intracardiac route of administration, 785 Intracellular fluid (ICF), 1335, 1335f, 1336, 1336f Intractable pain, 1115t Intradermal (ID), defined, 784t, 785 Intradermal (ID) injection administering for skin tests, skill for, 818–819t defined, 817 Home Care Considerations, 819t Lifespan Considerations, 819t overview, 817, 823t sites for, 817, 817f Intragenerational families, 414 Intramuscular (IM), defined, 784t, 785 Intramuscular (IM) injections defined, 823

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deltoid site, 826, 826f dorsogluteal site, 824–825 Lifespan Considerations, 829t opioids, 1138 overview, 823, 823f, 823t rectus femoris site, 825, 825f technique for, 826, 827–828t vastus lateralis site, 824, 824f, 825f ventrogluteal site, 823f, 824, 824f Intraoperative phase anesthesia, types of, 904–905, 905t defined, 891 Nursing Management assessing, 905 diagnosing, 905 documentation, 906 evaluating, 906 implementing positioning, 906, 906t, 907f surgical skin preparation, 906 planning, 905–906 Intraosseous route of administration, 785 Intrapleural pressure, 1269 Intrapleural route of administration, 785 Intrapulmonary pressure, 1269 Intraspinal route of administration defined, 785 misconceptions, 1139 opioids, 1138–1139, 1138f, 1139t Intrathecal route of administration defined, 785 opioids, 1138 Intravascular fluid (plasma), 1335, 1335f, 1336f. See also Plasma Intravenous (IV), defined, 784t, 785 Intravenous (IV) push administration described, 833, 833t Home Care Considerations, 837t skill for, 834–837t Intravenous pyelography (IVP), 764 Intravenous rods, 734 Intravenous (IV) route of administration catheter stabilization devices, 1366, 1368f changing an IV catheter to an intermittent infusion lock, 1382–1383t changing IV containers and tubing, 1378, 1379t complications, 1383, 1383t flow rates, 1374–1375, 1375t infusion administration sets, 1366, 1368, 1368f, 1369f infusion control devices, 1375–1376, 1375t, 1376f, 1376t intermittent infusion devices, 833–834, 834f, 1366, 1368, 1369f, 1382–1383t intermittent medication infusions, 831–832, 832f, 833f IV catheters, 1363–1365, 1364t, 1365f, 1365t, 1366f, 1367t IV filters, 1368–1369, 1369f IV infusion, discontinuing, 1380, 1380–1381t IV infusion, starting, 1369, 1370–1374t IV poles, 1369 IV push, 833, 833t, 834–837t IV solutions, 1362, 1362t large-volume infusions, 829, 829–831t monitoring an infusion, skill for, 1376–1378t opioids, 1138 overview, 829 peripheral venipuncture sites, 1363, 1363f, 1363t, 1364t rounding numbers for, 791t solution containers, 1366, 1366t, 1368f volume-control infusions, 833, 833f, 834t, 1366 Introductory phase of the helping relationship, 449, 450t Introjection preschoolers, 366 stress, 1003t Intuition, 173–174

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Index Intuitive project stage of Fowler’s theory of spiritual development, 349, 350t Intuitive thought phase of Piaget’s theory of cognitive development, 345, 346t, 347t Intuitive-projective stage of Fowler’s theory of spiritual development, 366 Invasion of privacy, 90–91, 90t, 91f Inversion, 1038t, 1042f, 1042t Iodophors, 644t IOM. See Institute of Medicine (IOM) Ions, 1335 Iowa Intervention Project, 228 IPV. See Inactivated polio vaccine (IPV) Iron deficiency anemia, 1161 Iron intake nutrition, 1162, 1163t wound healing, 893t Iron supplements fecal elimination, 1241 fecal occult blood testing, 756 timing affecting, 784 Irrigation bladder, 1225, 1226–1227t colostomy, 1262 defined, 849 irrigation syringes, 808, 808f syringes for, 849, 849f Ischemia defined, 1324 pressure ulcers, 855 Isocarboxazid, 1160t Isokinetic (resistive) exercises, 1044 Isolation practices isolation, defined, 644 personal protective equipment eyewear, 647–649t, 651 face masks, 647–649t, 649, 650t, 651 gloves, 646–647, 647–649t, 651t gowns, 647–649t, 649 Home Care Considerations, 649t psychosocial needs of isolation clients, 652 soiled equipment and supplies, disposal of, 651–652, 652t transporting clients with infections, 652 Isometric (static or setting) exercises, 1044, 1044f Isoniazid, 1160t Isopropyl alcohol, 644t Isotonic, defined, 1336 Isotonic enema solutions, 1252t, 1253 Isotonic (dynamic) exercise, 1044 Isotonic IV solutions, 1362, 1362t IVADs (implanted vascular access devices), 1365, 1366f Ivermectin, 725 IVP (intravenous pyelography), 764

J Jackson-Pratt drains, 921, 921f Jasmine, 326t Jaundice, 549 Jehovah’s Witnesses blood and blood products, 1384t health-related information, 990t Jejunostomy, defined, 1244 Jejunostomy tubes. See also Enteral nutrition jejunostomy feeding, administering, 1189–1190t placement of, 1184, 1184f Jewish faith health-related information, 990t nutritional practices, 1158t, 1159 Joint Commission abbreviations, 786, 786t accreditation, technology use in, 164 bioterrorism preparation, 685 CAUTI incidence, reducing, 1217t

central line-associated infections, preventing, 1365t client identification, 797t diagnostic tests, timely reporting of, 745t disaster planning, 669 documentation requirements, 247 “do-not-use” list of abbreviations, 261, 261t durable medical equipment for home care, 146 ethics committees, 103 fall risks, 676 health care–associated infections, reducing, 630t medication reconciliation, 140, 795, 795t, 796t medication safety, 145, 145t National Patient Safety Goals, 668, 669, 671t nursing care plan documentation, 256 pain management, 1128–1129 Patient and Family Education standards, 464 pressure ulcers, prevention of, 855t safety, 667 sentinel events, 241 sleep apnea, 893 transfusion errors, eliminating, 1386t Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery, 902, 902t Joints assessment of, 1053 movements, 1038, 1038t, 1039–1042f, 1039–1042t Journal of Nursing Scholarship, 48 Journal of Transcultural Nursing, 69 Judgmental statements communication barrier, 448t described, 173, 173t Jugular venous distention (JVD), 588, 591t Justice, 103, 381

K Kaiserswerth School, 29, 32 Kalish, Richard, 273 Kalish’s hierarchy of needs, 273 Kaolin-pectin preparations, 1252t Kaopectate. See Kaolin-pectin preparations Kardex, 256–257 Keeping Patients Safe - Transforming the Work Environment of Nurses (IOM), 668 Kefauver-Harris Amendment (1962), 778t Kegel exercises, 1215, 1215t Keloids skin lesion, 551t wound healing, 861 Kennedy Krieger Institute study, 59 Kenney, Elizabeth, 31 Ketamine, 1117 Ketones, urinary, 762 Ketorolac pain management, 1132t postoperative care, 913 Kidneys acid–base balance, 1343, 1343t anatomy and physiology, 1200–1201, 1201f fluid and electrolyte balance, 1339 kidney function, relation to cardiac output, 758t pharmacokinetics of an oral medication, 782f Kidneys/ureters/bladder (KUB) x-ray, 764 Kilocalorie (Kcal, large calorie, or Calorie), 1156 Kilojoule (kJ), 1156 Kinesthetic, defined, 930 King, Imogene, and goal attainment theory, 67–68, 67f, 68f Knees joint movements, 1041f, 1041t replacement surgery, 328t Knights of Saint Lazarus, 29, 29f Knowing, in caring, 424 Knowledge, and professional status, 43 Kock pouch, 1229, 1229f

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Kohlberg, Lawrence, 102, 347, 350t Kohlberg’s theory of moral development adolescents, 373 described, 197, 347–348, 348t, 350t middle-aged adults, 385–386 older adults, 404 school-age children, 369 toddlers, 363 young adults, 381 Koilonychia (spoon-shaped nails), 554, 556, 556f Korean heritage, and views of older adults, 392t Korotkoff ’s sounds, 529, 529f, 529t K-pads (aquathermia pads), 885, 885f KUB (kidneys/ureters/bladder) x-ray, 764 Kübler-Ross’s stages of grieving, 1017, 1017t Kussmaul’s breathing, 1273 Kwell. See Lindane Kyphosis, 398, 580, 581t

L Lacerations, 855t Lactobacillus species, 629t Lactose intolerance, 1159 Lactulose, 1251t Ladder programs in nursing education, 36 Laissez-faire (permissive) leader, 490, 490t Language interviews, 192 learning, 469t neurologic system assessment, 606–607, 608t Language barriers culturally responsive care, 310, 310t, 311t deficits, as impairment to communication, 453 informed consent, 80, 81t, 82t Lanoxin. See Digoxin Lanugo, 355, 724 Large calorie (Calorie, kilocalorie, Kcal), 1156 Large intestine Anatomy & Physiology Review, 1246f defecation, 1236–1237, 1237f Large-volume IV infusions, adding medication to, 829, 829–831t Laryngoscopy, 764 LAS (local adaptation syndrome), 999–1000, 1001f Lasix. See Furosemide Latency stage of Freud’s theory of psychosexual development described, 341t, 344t school-age children, 368 Lateral flexion, 1039f, 1039t, 1042f, 1042t Lateral position, 1063–1064, 1064f, 1064t, 1067–1068t Lateral violence, 458 Latex allergy, 646–647 Latter-Day Saints, and health-related information, 990t Laughter, 331–332 Lavage defined, 849 irrigation syringes for, 849, 849f Lavender, 326t Lavin, Mary Ann, 211 Law, defined, 73. See also Legal aspects of nursing Law of similars, 325 Laxatives described, 1249, 1251, 1251t fecal elimination, 1239, 1241 nutrition, 1160 LDH test, 895t LDL (low-density lipoprotein), 751t Lead poisoning, 674t Leaders defined, 488 nurses as, 41, 488, 489f roles, compared to manager roles, 489t

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Index

Leadership authentic leaders, 491t Chapter Highlights, 499t Critical Thinking Checkpoint, 498t cultural considerations, 497t effective leadership, 491, 491t formal and informal, 488–489 theories classic, 489–490, 490t contemporary, 490–491 Leadership style, defined, 489 Leading questions for interviews, 191 LEAP (Lower Extremity Amputation Prevention) program, 608 LEARN (Listen, Explain, Acknowledge, Recommend, Negotiate) model of culturally responsive care, 314 Learning Chapter Highlights, 485t Critical Thinking Checkpoint, 485t defined, 465 evaluating, 484 factors affecting active involvement, 468, 468f age and developmental stage, 467, 469t barriers to, 468, 469t cultural aspects, 469, 469t emotions, 468, 469t environment, 468 feedback, 468 motivation, 467 nonjudgmental support, 468 physiological events, 468–469 psychomotor ability, 469 readiness, 467 relevance, 468 repetition, 468 simple to complex learning, 468 timing, 468, 469t learning domains, 466 learning outcomes, setting, 477–478, 478t older adults, 404 overview of, 465–466, 466t theories of behaviorism, 466 cognitivism, 467 humanism, 467 Learning needs, 465 Learning style, 471, 471t Leg exercises postoperative care, 914 teaching about, 897–898t Legal aspects of nursing Chapter Highlights, 96–97t client records, 248 contractual arrangements in nursing, 78–79, 79t Critical Thinking Checkpoint, 96t documentation, 262, 262t documenting and reporting, 247–248, 248t drug administration, 778, 778t, 779f general concepts civil judicial process, 75, 76f functions of the law in nursing, 73–74 law, sources of, 74, 74f, 74t laws, types of, 74, 75t legal actions, kinds of, 74–75 nurses as witnesses, 75 legal protections competent nursing care, providing, 94, 95t documentation, 94, 94f Good Samaritan acts, 93 incident reports, 94–95 physician’s orders, carrying out, 94 professional liability insurance, 93–94 legal responsibilities of students, 96, 96t

nursing practice, legal aspects of abortions, 85 Americans with Disabilities Act, 83, 83t consent, exceptions to, 81 controlled substances, 83 death and related issues, 85–87, 86f delegation, 82–83 euthanasia, 87 impaired nurses, 83–84, 83t, 84t informed consent, 79–81, 80t, 81t inquests, 87 nurse’s role, 81–82, 82f, 82t organ donation, 87 sexual harassment, 84 violence, abuse, and neglect, 83 nursing practice, regulation of, 75, 77–78, 77t potential liability crimes and torts, 88–92, 88t, 89t, 90t, 91f loss of client property, 92 overview of, 87 privacy of client information, 92, 92t social media, 92 unprofessional conduct, 92–93 reporting crimes, torts, and unsafe practices, 95, 95t restraints, 686, 686t, 687t Legibility of documentation, 259 Legislation (statuary law), 46, 74, 74f, 74t, 75t Leininger, Madeleine, and culture care diversity and universality theory, 69, 425 Length of newborns and infants, 356, 356f Lesbians defined, 965 lesbian families, 414 Leukocytes defined, 747 inflammation, 633 normal values and functions, 748f WBC count, 746t, 747, 748f, 1173 Leukocytosis, 633 Leukotriene modifiers, 1279 Level of consciousness neurologic system assessment, 607, 607t, 609t postoperative assessment, 909 Levin tube, 1180, 1180f Levine’s conservation model of nursing, 70t Levitra. See Vardenafil Levodopa, 1205t Liability, defined, 78 Libel, 91, 91f Libido, 341 Lice (pediculosis) excessively matted hair, 726t hair hygiene, 724–725 License criteria for, 77 defined, 75 mutual recognition model, 77, 77t Licensed practical nurses (LPNs), 36, 120, 497 Licensed vocational nurses (LVNs), 36, 120, 497 Lichenification, 551t Lidocaine fecal impaction removal, 1256 topical route of administration, 1137 Lidocaine/prilocaine, 1137 Lidocaine/tetracaine, 1137 Lidoderm, 1132t, 1136 Lifespan Considerations abdomen, assessment of, 603t abdominal paracentesis, 768t antiemboli stockings, 904t anus, assessment of, 623t assessing older adults’ functional levels, 128t assessment, 193t assisting a client to ambulate, 1081t

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bandages and binders, applying, 882t bathing, 706t blood pressure, 532f, 532t body temperature, 512f, 512t bone marrow biopsy, 769t breast and axilla assessment, 597t capillary blood glucose, 754t catheterization, 1223t circulation, 1320t communication with children, 443t computer use, 165t death, responses to, 1029t diagnosing, 211t diagnostic testing, 773t ear and hearing assessment, 569t enema, administering, 1256t evaluating, 242t eye and vision assessment, 564–565t factors in potential bowel elimination problems, 1245t falls, preventing, 667t female genitalia and inguinal area assessment, 618f, 618t fluid and electrolyte imbalance, 1343t hair assessment, 555t hair care, 727t health assessment general survey, 549t health care decisions, 178t health care delivery, 141t health promotion and illness prevention, factors affecting, 282t health promotion topics, 276t heart and central vessels, assessment of, 591t home care, 152t IM injections, 829t infections, 636t international adoption, 306t intradermal injection, administering, 819t liver biopsy, 772t long-term care, 258t lumbar puncture, 767t male genitalia and inguinal area assessment, 622t massage, uses of, 333t medication nonadherence, 297t metered-dose inhalers and nebulizers, administering, 847t musculoskeletal system assessment, 606t nail assessment, 557t nasogastric tube, inserting, 1183t neck assessment, 578t neurologic system assessment, 615t nose and sinus assessment, 571t nursing care plan, 229t nutrition, 1164–1165t older adults, communication with, 454t ophthalmic medications, administering, 841t oral hygiene, 723t oral medications, 805t otic medications, administering, 843t oxygen delivery equipment, 1290t pain, 1121t pain management, 1146t PCA pump, 1141t peripheral vascular system assessment, 593–594t positioning, moving, and turning clients, 1070t postoperative care, 912t preoperative teaching, 899t pressure ulcer and wound care, 879t pulse, 520t pulse oximetry, 535f, 535t rectal medications, administering, 846t respirations, 525t respiratory development, 1274t restraints, 691f, 691t seizure precautions, 681t self-esteem, enhancing, 956–957t, 956f, 957f sensory perception, 939t

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Index sequential compression devices, 1330t skin assessment, 554t skull and face assessment, 558t sleep disturbances, 1097t spiritual development, 983t sputum and throat specimens, 763t stool specimens, 757t stress and coping, 1010t suctioning, 1297t suctioning a tracheostomy or endotracheal tube, 1301t teaching considerations, 472t temperature, 512f, 512t thoracentesis, 769t thorax and lungs, assessment of, 586f, 586t tracheostomy care, 1305t transferring clients, 1076t tube feeding, administering, 1190t urine specimen collection, 760t voiding, factors affecting, 1204t Lifestyle cognitive dimension of health, 293–294, 293t, 294t family health, 418 fluid, electrolyte, and acid–base balance, 1344 health promotion, 281 nursing health history, 188t nutrition, 1159 respiratory function, 1272 safety, 666 sleep, 1098 wound healing, 862–863 Life-sustaining treatment, termination of, 108–109 Lift (heave), 586 Lifting clients, 1059, 1059f, 1060f Light palpation, 543 Light perception test, 565t Limb restraints, 688, 688f Limited English proficiency. See Language barriers Lindane, 725 Line of gravity, 1037, 1037f Linens, soiled, disposal of, 651 Linezolid, 1160t Liniment, 777t Lipids digestion, 1156 elevated levels, as cardiovascular risk factor, 1320–1321, 1320t metabolism, 1156 types of, 1155–1156 Lipoproteins, 1156 Liquid medication, administering, 803t Liquid oxygen, 1290t Liter, 789 Literacy. See also Health literacy definitions, 80t informed consent, 80–81, 80t, 81t Literature access and retrieval, 157–158, 157t research literature, review of, 58, 58t, 165 review of, as data source, 189 Lithotomy position, 542t Litigation, 75 Liver biopsy client positioning, 770, 770f Lifespan Considerations, 772t procedure, 769–770, 772t site for, 769, 770f disease as surgical risk, 893t pharmacokinetics of an oral medication, 782f Living wills, 85 Livor mortis, defined, 1029 LMX4. See Lidocaine Lobule of the ear, 565, 565f Local adaptation syndrome (LAS), 999–1000, 1001f

Local anesthesia pain management, 1132t, 1140, 1145 perioperative nursing, 905 Local infection, 629 Locus of control, defined, 295 Logical positivism, 54 Logrolling a client, 1068–1069t Lomotil. See Diphenoxylate hydrochloride Long-term care facilities bathing, 707, 707t documentation, 258, 258t, 259t health care agencies, 118, 118f, 118t older adults, 393 oral health of long-term care residents, 716t Long-term coping strategies, 1004 Long-term memory, 404 Look-alike/sound-alike medications, 241 Loop colostomy, 1245, 1245f Loperamide hydrochloride, 1252t Lorazepam insomnia, 1105t preoperative preparation, 901 respiratory function, 1273 Lordosis, 1052 Lortab. See Hydrocodone Loss Chapter Highlights, 1031t Critical Thinking Checkpoint, 1030t defined, 1015 Nursing Management assessing, 1020, 1020t diagnosing, 1020–1021 evaluating, 1022 implementing emotional support, providing, 1021–1022 grief work, facilitating, 1021 planning, 1021, 1021t significance of, 1019 types and sources, 1015–1016 Lotion, 777t Lovenox. See Enoxaparin Low back pain, 1115t Low literacy, defined, 80t Low-density lipoprotein (LDL), 751t Lower Extremity Amputation Prevention (LEAP) program, 608 Loyalties, conflicting, 105 Lozenges, 777t LPNs (licensed practical nurses), 36, 120, 497 Lubricant laxatives, 1251t Luer-Lok syringe tips, 808, 808f Lumbar puncture client positioning, 766–767, 767f defined, 766 equipment, 766f, 767, 767f Lifespan Considerations, 767t procedure, 767, 770t site for, 766, 766f Lunesta. See Eszopiclone Lung recoil, 1271 Lung scan, 764 Lungs. See also Thorax and lungs acid–base balance, 1342–1343, 1343t base of, 586t compliance of, 1271 LVNs (licensed vocational nurses), 36, 120, 497 Lymph nodes, 575–576, 576f, 576t, 577–578t Lymphocytes, 746t, 748f Lyrica. See Pregabalin

M Maceration, 856 Macrominerals, 1156

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Macronutrients, 1153 Macrosystem level, in Bronfenbrenner’s ecologic systems theory, 346, 347t Macule, 550f Maggots, 872 Magico-religious health belief, 308 Magnesium imbalances, 1349t, 1350 normal values, 748f, 748t, 1356t regulation of, 1341, 1341t Magnesium citrate, 1251t Magnet Recognition Program®, 37, 66 Magnetic resonance imaging (MRI), 765, 765f, 765t Mahoney, Mary, 33, 33f Maintenance stage of health behavior change, 279, 285f Major surgery, defined, 892 Maladaptive coping, 1004 Malathion, 725 Male erectile disorder, 970, 971t Male genitals and inguinal area, assessment of Lifespan Considerations, 622t overview of, 619, 619f pubic hair and external genital development, 619, 620t skill for, 620–621t Male orgasmic disorder, 970 Males in nursing, 34–35, 34f, 35f Malleus, 565f, 566 Malnutrition Clinical Manifestations, 1175t defined, 1168, 1169 surgical risk, 893t Malpractice, 88, 91f Managed care, described, 124–125 Management Chapter Highlights, 499t Critical Thinking Checkpoint, 498t cultural considerations, 497t functions of, 492 levels of, 491–492, 492t principles of, 492 skills and competencies for, 492–493 Management information systems, 156–157 Manager defined, 488 nurses as, 41, 488, 489f roles, compared to leader roles, 489t Mandala design, 1047, 1047f Mandated reporter, nurse as, 83 Manometer, for lumbar puncture, 767, 767f Manslaughter, 88 Manual healing methods acupuncture, acupressure, and reflexology, 327, 327f, 328f chiropractic, 326–327 hand-mediated biofield therapies, 327–328, 328t massage, 327, 327f, 333t Manubrium, 580, 580f MAOIs. See Monoamine oxidase inhibitors (MAOIs) MAP (mean arterial pressure), 525–526 MAR. See Medication administration record (MAR) Marburg virus, 672t Marijuana, 970t Marplan. See Isocarboxazid Martin Chuzzlewit (Dickens), 31, 31f Martocchio’s clusters of grief, 1018 Mary Mahoney Award, 33 Maslow, Abraham, 273 Maslow’s hierarchy of needs data organization, 197 health promotion, 273, 273f Mass peristalsis, 1237 Massage, for pain management, 1142, 1142–1143t Massage therapy described, 327, 327f Lifespan Considerations, 333t

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Index

Masses, characteristics of, 543, 544t Master’s degree nursing programs, 37, 37f, 54t Mastoid, 565 Masturbation, 960 Mattresses, 733, 871t, 1061t Maturation, defined, 339–340 Maturation phase of wound healing, 861 Maturity family health, 417 middle-aged adults, 383 Maturity-onset diabetes of the young (MODY), 374 Maxillary sinuses, 570f, 843, 844f Mayeroff, Milton, 424 MCH (mean corpuscular hemoglobin), 746t MCHC (mean corpuscular hemoglobin concentration), 746t MDI. See Metered-dose inhaler (MDI) MDS (Minimum Data Set), 258 Meals, assisting clients with, 1178–1179, 1179f, 1179t Meals-on-Wheels, 1179–1180 Mean, defined, 57t Mean arterial pressure (MAP), 525–526 Mean corpuscular hemoglobin (MCH), 746t Mean corpuscular hemoglobin concentration (MCHC), 746t Measles-mumps-rubella (MMR) vaccine adolescents, 375t infants, 361t preschoolers, 367t school-age children, 370t toddlers, 364t Measurement systems apothecaries’ system, 789 converting units of weight and measure, 789–790, 790t dosage calculation methods, 790–793, 791t, 794f household system, 789 metric system, 788–789, 789f Measures of central tendency, 57, 57t Measures of variability, 57, 57t Meatus, urinary, 1202 Mechanical debridement, 872 Mechanical phlebitis, 1383 Meconium, 1238 Median, defined, 57t Medicaid described, 127 reimbursement for home care, 146 Medical alert bracelets and necklaces, 148, 148f Medical asepsis, 629 Medical diagnoses, differentiating from nursing diagnoses, 203, 204t, 207, 208f Medical examiners, 87 Medical Library Association, 156 Medical records nursing administration, technology use in, 164 technology bedside data entry, 159–160, 1360 clinical decision support systems, 160–161 computer-based client records, 160, 160f data standardization and classifications, 161 overview, 159 tracking client status, 161, 161f, 162t Medical Reserve Corps, 669 Medicare client records, 248 described, 126–127, 126f durable medical equipment for home care, 146 reimbursement for home care, 146 required data for home nursing plan of care, 150, 150t Medicare Rural Hospital Flexibility Program, 119 Medication actions of drugs on the body, 780–782, 780f, 782f altered sexual function, 969, 970t blood pressure, 526 Chapter Highlights, 850–851t circulation, 1327

clinical reasoning and medication administration safety, 178t Critical Thinking Checkpoint, 850t defined, 777 drug abuse and misuse by older adults, 405–406 drug misuse, 780 drug monitoring, 747–748 drug standards, 777–778 drugs, effects of, 778–780, 779t fecal elimination, 1240–1241, 1249, 1251–1252, 1251t, 1252t forms of, 777, 777t Home Care Considerations, 805t infection, susceptibility to, 635, 635t inhaled medications metered-dose inhalers, 847, 847f, 847t, 848f, 848–849t, 848f nebulizers, 846, 847t irrigations, 849, 849f legal issues, 778, 778t, 779f measurement systems apothecaries’ system, 789 converting units of weight and measure, 789–790, 790t dosage calculation methods, 790–793, 791t, 794f household system, 789 metric system, 788–789, 789f medication action, factors affecting, 782–784, 783t medication orders abbreviations, 786, 786t communicating, 787–788, 787t, 788f overview, 785, 785t parts of, 786–787, 787f, 787t questioning unusual orders, 787–788 types of, 786 name of, on medication orders, 787, 787t names for, 777 nasogastric and gastrostomy medication, 806, 806t nutrition, 1159, 1160t oral medications administering, skill for, 801–804t Lifespan Considerations, 805t overview, 801 oxygenation, 1278–1280, 1280t, 1281t pain management categories and examples, 1132, 1132t coanalgesics, 1136–1137 continuous local anesthetics, 1140 equianalgesic dosing, 1135–1136, 1136t local anesthetics, 1132t, 1140, 1145 nonopioids and NSAIDs, 1132t, 1133, 1133t, 1134t opiate routes of administration, 1137–1140, 1138f, 1139t opioids, 1132, 1132t, 1133–1135, 1135t patient-controlled analgesia, 1140–1141, 1140f, 1141t WHO three-step analgesic ladder, 1132–1133, 1132t parenteral medications injectable medications, preparing, 810–817, 811f, 812f, 813–814t, 814–815t, 816–817t intradermal injections, 817, 817f, 818–819t, 823t intramuscular injections deltoid site, 826, 826f dorsogluteal site, 824–825 Lifespan Considerations, 829t overview, 823, 823f, 823t rectus femoris site, 825, 825f technique for, 826, 827–828t vastus lateralis site, 824, 824f, 825f ventrogluteal site, 823f, 824, 824f intravenous medications intermittent infusion devices, 833–834, 834f intermittent IV infusions, 831–832, 832f, 833f IV push, 833, 833t, 834–837t large-volume infusions, 829, 829–831t volume-control infusions, 833, 833f, 834t, 1366 needles, 809–810, 809f

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needlestick injuries, preventing, 810, 810f, 810t, 811f subcutaneous injections, 817, 819–820, 820–822t, 820f, 823t syringes, 806–809, 806f, 807f, 808f, 809f, 810, 811f preoperative preparation, 901 pulse, 513 respiratory function, 1273 routes of administration buccal, 784t, 785, 785f inhalation, 784t, 785 oral, 784, 784t parenteral, 784t, 785 rectal, 776, 784t sublingual, 784, 784t, 785f topical, 784t, 785 transdermal, 784t vaginal, 784t, 785 safe administration clinical reasoning processes, 801t developmental considerations, 800–801, 800t medication administration errors, 794–795 medication dispensing systems, 796–797, 796f, 797f medication reconciliation, 795–796, 795t, 796t overview, 793–794 Practice Guidelines, 795t process of administration, 797–800, 797t, 798f, 798t, 799t safety goals, 145, 145t sensory function, 931 sleep, 1098, 1098t, 1105, 1105t, 1106t surgical risk, 893 topical medications nasal medications, 843, 844f ophthalmic medications, 839–841, 839–841t otic medications, 841–843, 841–843t rectal medications, 846, 846f, 846t skin applications, 838–839, 838t transdermal patches, 837–838, 837t, 838f, 838t vaginal medications, 843–846, 844–846t urinary elimination, 1205, 1205t wound healing, 863 Medication administration adjunctive interventions, 799 administration of the drug, 798–799, 798t, 799t client, informing about the medication, 798 client identification, 797, 797t, 798f, 798t, 799t evaluating client’s response, 799t, 800 recording drug administered, 799–800, 799t Medication administration record (MAR) described, 787, 788f documentation, 257 Medication cabinets, 796 Medication carts, 796, 796f, 797f Medication errors, 88–89, 89t, 794–795 Medication history, 794 Medication reconciliation, 140, 795–796, 795t, 796t Medication rooms, 796–797 Medicine wheel, 308, 308f Meditation defined, 984 described, 329 guidelines for, 329t self-care for nurses, 431 techniques for, 330t MEDLINE (National Library of Medicine’s bibliographic database), 58t, 157t Meeting the Standards assessing health, 626t contemporary health care, 168t health beliefs and practices, 336t integral aspects of nursing, 501t integral components of client care, 928t life span development, 422t nature of nursing, 113t nursing process, 268t

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Index physiological health, promoting, 1395t psychosocial health, promoting, 1034t Melatonin, 1105t Meloxicam, 1132t Memory neurologic system assessment, 607, 609t older adults, 404 Memory foam mattresses/pads, 871t Men in Nursing, 34 Menarche, 370–371 Meningococcal vaccine school-age children, 370t toddlers, 364t young adults, 384t Meniscus, defined, 803t Mennonite faith, and health-related information, 990t Menopause, 384 Menstruation defined, 960 disorders, and stress, 1000f Mental health alterations/illness impaired nurses, 84t informed consent, 81 middle-aged adults, 386 young adults, 381 Mental status attention span and calculation, 607, 609t decreased, and pressure ulcers, 856 disability, and learning, 469t language, 606–607, 608t memory, 607, 609t orientation, 607, 607t, 609t sensory perceptual functioning, 933 surgical risk, 893 Mentor, defined, 493 Meperidine, 1135 Mercury-in-glass thermometers, 508, 508t Meridians, 327 Mesoderm, 354 Mesosystem level, in Bronfenbrenner’s ecologic systems theory, 346, 347t Message, in the communication process, 438, 438f Metabolic acidosis, 1351, 1352t Metabolic alkalosis, 1352, 1352t Metabolic syndrome (Met-S) cardiovascular risk factor, 1320t, 1322, 1322t middle-aged adults, 386 Metabolic system exercise, benefits of, 1046 immobility, effects of, 1050, 1055t stress, effects of, 1000f Metabolism defined, 1050, 1156 medication, of, 781 middle-aged adults, 384t Metabolites, 781 Metacognitive processes, 175 Metamucil. See Psyllium hydrophilic mucilloid Metaparadigm for nursing, 64, 65f Meter, 789 Metered-dose inhaler (MDI) Client Teaching, 848–849t, 848f Home Care Considerations, 848t Lifespan Considerations, 847t overview, 847, 847f Methadone, 1132t, 1134, 1135 Methicillin-resistant Staphylococcus aureus (MRSA) hand hygiene, 638t nosocomial infections, 630t Methodology, defined, 56 Methylcellulose, 1251t Methyldopa nutrition, 1160t urinary retention, 1205t

Methylphenidate, 1099 Metoprolol, 1327 Metric system conversion with other systems, 789–790, 790t described, 788–789, 789f Met-S. See Metabolic syndrome (Met-S) Mexican heritage, and nutritional practices, 1158t MI (myocardial infarction), 1323, 1323t Microdrip IV administration sets, 1366, 1368f Microminerals, 1156 Micronutrients, 1153 Microsystem level, in Bronfenbrenner’s ecologic systems theory, 346, 347t Micturition, 1202. See also Urination Mid-arm circumference (MAC), 1172, 1172f, 1172t Mid-arm muscle area (MAMA), 1172, 1172t Midazolam conscious sedation, 905, 905t respiratory function, 1273 Middle-aged adults Chapter Highlights, 388t cognitive development, 385 Critical Thinking Checkpoint, 387t Developmental Assessment Guidelines, 387t Havighurst’s age period and developmental tasks, 343t health assessment and promotion, 386, 387t Health Promotion Guidelines, 387t health promotion overview, 383–384, 384f health risks alcoholism, 386 cancer, 386 cardiovascular disease, 386 injuries, 386 mental health alterations, 386 obesity, 386 loss and grief responses, 1019 moral development, 385–386 nutrition, 1163 physical development, 384–385, 384t, 387t psychosocial development, 385, 385t, 387t safety, 674t, 675 sexual development, 961t, 962 spiritual development, 386 stress and coping, 1010t stressors, 999t Middle-level managers, 491, 492t Midlevel (middle range) nursing theories, 65 “Midlife crisis,” 385 Midstream urine specimens defined, 757 obtaining, 758–760, 758f, 758–760t Midwifery, 34 Mild anxiety, 1001, 1002t Mild pain, 1114 Milk thistle, 325t Millennials (Generation Y), 379 Miller, Steve, 34 Milliequivalent, defined, 1335 Mind mapping, 177. See also Concept mapping Mind-body interactions, 293 Mind-body therapies biofeedback, 330, 330t guided imagery, 329–330, 330t hypnotherapy, 329 meditation, 329, 329t, 330t pilates, 330 qi gong, 330 self-care for nurses guided imagery, 431 meditation, 431 music therapy, 431 storytelling, 431, 431t yoga (See Yoga)

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t’ai chi (See T’ai chi) yoga (See Yoga) Mineral oil, 1251t Minerals, dietary, 1156 Mini-Mental State Examination, 942–943 Minimum Data Set (MDS), 258 Minor surgery, defined, 892 Minors, and informed consent, 81 Minute volume (MV), 1276t Miosis, defined, 560 MiraLAX. See Polyethylene glycol 3350 Misdemeanors, 88 Mist collars for tracheostomy tubes, 1293, 1294f Mitral area of the chest, 587, 587f Mitt (hand) restraints, 688, 688f Mixed hearing loss, 566 Mixed urinary incontinence, 1207 MMR. See Measles-mumps-rubella (MMR) vaccine Mobic. See Meloxicam Mobility defined, 1037 safety, 666 Modafinil, 1100 Mode, defined, 57t Modeling behaviorist theory, 466 health promotion, 285 teaching strategy, 479t Moderate anxiety, 1001, 1002t Moderate pain, 1114 Moderation, and a healthy lifestyle, 430 Modesty draping the client, 542 religious beliefs, 984–985, 985f Moist heat sterilization, 643 Monoamine oxidase inhibitors (MAOIs) narcolepsy, 1100 nutrition, 1160t urinary retention, 1205t Monocytes, 746t, 748f Monosaccharides, 1154 Monounsaturated fatty acids, 1156 Montag, Mildred, 36 Montgomery straps, 874, 875f Mood, in the temperament theory of Chess and Thomas, 345t Moon face, 558 Moral, defined, 346 Moral behavior, 347 Moral development adolescents, 373 defined, 102, 347 middle-aged adults, 385–386 newborns and infants, 359 preschoolers, 366 school-age children, 369 toddlers, 363 young adults, 381 Moral development theories definitions, 346–347 Gilligan, 348–349, 350t Kohlberg, 347–348, 348t, 350t Moral distress, 105, 106t Moral reasoning, by older adults, 404 Moral rules, 102 Morality Chapter Highlights, 110t defined, 101, 346–347 moral development, 102 moral frameworks, 102 moral principles, 102–103, 103t religion, distinguishing from, 101, 101t Mormons, and health-related information, 990t Morning care, 695 Moro reflex, 358t

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Morphine aspirin and acetaminophen, compared to, 1136t fecal elimination, 1240–1241 herbal medicine, 324 intraspinal route of administration, 1138 naloxone, 781 oral route of administration, 1137 pain management, 1132, 1132t, 1134 PCA, 1140 respiratory function, 1273 Mortality. See Death Morticians, 1029 Motivation client teaching, 472–473 learning, 467 sleep, 1098 Motor function neurologic system assessment, 607, 610–613t newborns and infants, 358, 358f, 359t, 362t preschoolers, 365, 365f, 368t school-age children, 368, 370t toddlers, 362, 362f, 365t Motor vehicle crashes, 373, 373f Motrin. See Ibuprofen Mourning, 1016. See also Bereavement Mouth and oropharynx lymph nodes, 576t physical assessment Home Care Considerations, 575t Lifespan Considerations, 574–575t mouth anatomy, 571, 572f overview of, 571–572, 572f skill for, 572–574t Mouth hygiene developmental variations, 715 Nursing Management assessing clients at risk, identifying, 716, 716t nursing interview, 715, 715t physical assessment, 716, 716t diagnosing, 716–717 evaluating, 723 implementing artificial denture care, 718, 720–721t assisting clients with oral care, 718, 718f brushing and flossing teeth, 718, 718–721t Home Care Considerations, 723t Lifespan Considerations, 723t oral health throughout the life span, 717–718, 717t special oral hygiene needs, 721–723, 722–723t planning, 717 teeth, parts of, 715, 715f Movement assessment of, 1053 normal alignment and posture, 1037, 1037f balance, 1038 coordination, 1038 joint mobility, 1038, 1038t, 1039–1042f, 1039–1042t postoperative care, 914 postoperatively, teaching about, 897t Moving and turning clients in bed assisting a client to sit on the side of the bed (dangling), skill for, 1069–1070t guidelines for, 1064–1065, 1065t Home Care Considerations, 1070t Lifespan Considerations, 1070t logrolling a client, skill for, 1068–1069t moving a client up in bed, skill for, 1066–1067t turning a client to the lateral or prone position, skill for, 1067–1068t MRI (magnetic resonance imaging), 765, 765f, 765t MRSA. See Methicillin-resistant Staphylococcus aureus (MRSA)

MS Contin. See Morphine Mucous membranes fluid, electrolyte, and acid–base imbalance, 1354t nonspecific defense against infection, 633 Mucus clearance device (MCD), 1283, 1283f Multicultural, defined, 303 Multidimensional Health Locus of Control Scale, 295 Multidisciplinary care plan, 220 Multidose vials, 812–813 Multiethnic, defined, 303 Multiracial, defined, 303 Mummy restraints, 691f, 691t Musculoskeletal disorders, work-related, 1058–1059, 1059t Musculoskeletal system disorders, and stress, 1000f exercise, benefits of, 1046 immobility, effects of, 1048, 1048f, 1055t middle-aged adults, 384t muscles, assessment of, 1053 physical assessment Home Care Considerations, 606t Lifespan Considerations, 606t overview, 603 skill for, 604–605t Music therapy described, 331, 331f, 331t self-care for nurses, 431 Muslims health-related information, 990t nutritional practices, 1158t, 1159 Mustaches, care of, 728, 728t Mutual pretense, defined, 1024 Mutual recognition model for licensure, 77, 77t Mutual recognition regulatory model, 35 Mycobacterium leprae, 629 Mycobacterium tuberculosis, 632t Mydriasis, 560 Myocardial infarction (MI), 1323, 1323t Myocardium, 1313, 1314f Myoglobin, 749, 751t Myopia, defined, 559 Myopic, defined, 364 MyPlate, 1165, 1166f Mythic-literal stage of Fowler’s theory of spiritual development described, 349, 350t school-age children, 369 Myths, and ageism, 392, 392t

N N95 respirators, 649, 650t Nails nail hygiene Nursing Management assessing, 714, 714t diagnosing, 714 evaluating, 715 implementing, 714–715, 714f planning, 714 overview of, 714 parts of, 554, 556f physical assessment Home Care Considerations, 557t Lifespan Considerations, 557t overview of, 554, 556, 556f skill for, 556–557t Naloxone antagonist, 781 opioid-containing epidural infusion, 1139t Name of the client cultural factors, 309 medication orders, 786–787, 787t NANDA International data standardization and classification, 161

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journal of, 211 nursing diagnoses accuracy and prevalence, factors influencing, 202t collaborative problems, differentiating from, 203–204, 204t, 207, 208f components of, 202–203, 203t definitions, 201–202 medical diagnosis, differentiating from, 203, 204t, 207, 208f status of, 202 Naprosyn. See Naproxen Naproxen, 1132t Narcan. See Naloxone Narcolepsy, 1099–1100, 1100t Narcotics legal issues, 778, 779f oral, administering, 803t preoperative preparation, 901 respiratory function, 1273 sexual function, 970t sleep, 1098t Narrative charting, 249, 250f, 250t Narrow therapeutic index, defined, 1133 Nasal medications, 843, 844f Nasoenteric (nasointestinal) tubes, 1184, 1184f Nasogastric tubes defined, 806, 1180 effectiveness and safety, 1190t inserting Lifespan Considerations, 1183t skill for, 1180–1183t medication administration, 806, 806t removing, skill for, 1192–1193t types of, 1180, 1180f uses for, 1184 Nasopharyngeal airways, 1291–1292, 1291f National Action Plan to Improve Health Literacy, 81 National Alliance of Wound Care, 887t National Association of Pediatric Nurse Practitioners, 48 National Black Nurses Association, 48 National Board of Certification for Medical Interpreters, 310 National Center for Complementary and Alternative Medicine National Institutes of Health, 321–322 treatments once considered folk treatments, 309t National Center on Minority Health and Health Disparities (NIH), 305 National Coordinating Council for Medication Error Reporting and Prevention, 794 National Council Licensure Examination-PN (NCLEX-PN), 36 National Council Licensure Examination-RN (NCLEX-RN), 35, 158 National Council of State Boards of Nursing mutual recognition model, 77, 77t single-state licensure, 46 telemedicine, 162 National Council on Aging, 1170 National Database of Nursing Quality Indicators, 241 National Disaster Medical System, 669 National Dysphagia Diet, 1178 National Formulary, 778 National Health Planning and Resources Development Act (1974), 127 National Healthcare Disparities Report (2011), 304 National Hospice and Palliative Care Organization, 85 National Institute for Occupational Safety and Health (NIOSH) body mechanics, 1058 infection prevention for health care workers, 662 N95 respirators, 649 National Institute of Nursing Research, 53 National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine, 309t, 321–322 National Center for Nursing Research, 53

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Index National Center on Minority Health and Health Disparities, 305 Office of Dietary Supplements, 326 public health agencies, 116 National League for Nursing (NLN) American Society of Superintendents of Training Schools for Nurses in the United States, 33 associate degree, title for, 38t founding, purpose, and publications, 47, 48 Tri-Council for Nursing, 31–32 National Library of Medicine Evaluating Internet Health Information Tutorial, 156 MEDLINE, 58t, 157t National Male Nurses Association, 34 National Minimum Drinking Age Act (1984), 379 National Organ Transplant Act, 87 National Partnership for Action to End Health Disparities, 304–305 National Patient Safety Foundation, 474 National Patient Safety Goals CAUTI incidence, reducing, 1217t central line-associated infections, preventing, 1365t client identification, 797 diagnostic tests, timely reporting of, 745t “do-not-use” list of abbreviations, 261 Joint Commission, 668, 669, 671t medication reconciliation, 796t medication safety, 804t pressure ulcers, prevention of, 855t transfusion errors, eliminating, 1386t Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery, 902t National Quality Forum, 241 National Quality Foundation, 1058 National Sample Survey of Registered Nurses, 305 National Sleep Foundation, 1095, 1096 National Stakeholder Strategy for Achieving Health Equity, 305 National Standards for Culturally and Linguistically Appropriate Serviced in Health Care (CLAS Standards), 305 National Student Nurses Association code of academic and clinical conduct, 44, 44t founding, purpose, and publications, 48 Nationality, defined, 303 Native Americans adolescent families, 413 healing, 324 nutritional practices, 1159 older adults, 391t, 392t pain, responses to, 1119t social support, cultural aspects of, 281t Natroba. See Spinosad Naturalism, 55 Naturopathic medicine, 326 Nausea opioids, 1136t postoperative phase, 911t Navajo heritage, and nutritional practices, 1158t NCLEX-PN (National Council Licensure Examination-PN), 36 NCLEX-RN (National Council Licensure Examination-RN), 35 Nebulizers for inhaled medications, 846, 847t Neck joint movement, 1039f, 1039t physical assessment anatomy of, 575, 575f Lifespan Considerations, 578t lymph nodes, 575–576, 576f, 576t overview of, 575–576, 575f, 576f, 576t skill for, 576–578t NEECHAM Confusion Scale, 943 Needleless injection systems, 811, 811f, 832 Needles for parenteral medications, 809–810, 809f Needlestick injuries, 662, 810, 810f, 810t, 811f Needlestick Safety and Prevention Act (2001), 662 Needs theories of health promotion basic needs, characteristics of, 273–274

Kalish’s hierarchy of needs, 273 Maslow’s levels of needs, 273, 273f Negative feedback, 271 Neglect, legal aspects of, 83 Negligence, 88, 88t, 89t, 90t, 91f Neisseria gonorrhoeae, 632t Neobladder, 1229, 1230f Nephrons, 1200–1201, 1201f Nephrostomy, 1228, 1229f Nerve blocks described, 1145 intraoperative phase of nursing, 905 pain management, 1145 Network, defined, 156t Networking, by nurse managers, 493 Neuman, Betty, and systems model, 68, 69f Neural tube defects, 355 Neurofibromas, 550f Neurogenic bladder, 1207 Neurologic disorders, 893t Neurologic system fluid, electrolyte, and acid–base imbalance, 1354t physical assessment cranial nerves, 607, 609t, 616t level of consciousness, 607, 607t, 609t Lifespan Considerations, 615t mental status attention span and calculation, 607, 609t language, 606–607, 608t memory, 607, 609t orientation, 607, 607t, 609t motor function, 607, 610–613t reflexes, 607, 610t sensory function, 607–608, 613–614t skill for, 608–614t, 616t Neuromuscular system, 396t, 397–398, 398f Neurontin. See Gabapentin Neuropathic pain, 1114, 1115t Neurotransmitters, 1116 Neutral questions for interviews, 191 Neutrophils, 746t, 748f New England Hospital for Women and Children, 32, 33 Newborns body alignment and activity, 1038 cardiovascular system, 1319 cognitive development, 359 defecation, 1238 Developmental Assessment Guidelines, 362t hair, 724 health assessment and promotion, 360–361, 360t, 361t Health Promotion Guidelines, 361t health risks, 359–360, 360f moral development, 359 normal sleep patterns and requirements, 1094–1095 nutrition, 1161 physical development head and chest circumference, 356–357, 357f head molding, 357, 357f hearing, 357, 362t length, 356, 356f motor development, 358, 358f, 359t, 362t reflexes, 358, 358t smell and taste, 358 touch, 358 vision, 357, 362t weight, 356 psychosocial development, 358–359, 359t, 362t pulse and respiration average and normal range, 513t respiratory function, 1272 safety, 671, 673t safety hazards, 667t surgical risk, 892 Newest Vital Sign health literacy test, 473, 474f, 475f Newman, Margaret, 290

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Newman’s model of health, 290 NIC. See Nursing Interventions Classification (NIC) Nifedipine, 1160t Nightingale, Florence biography, 32, 32f Crimean War, 29, 32 environmental theory of nursing, 63, 66 health, defined, 288 Kaiserswerth School, 29, 32 laughter, 331 nursing, definition of, 39 research, 53 vision of nursing, 32 Nightingale Training School for Nurses, 32 NIH. See National Institutes of Health (NIH) NIOSH. See National Institute for Occupational Safety and Health (NIOSH) Nitrates, 1327 Nitrogen balance, 1155 Nix. See Permethrin NLN. See National League for Nursing (NLN) NMDS. See Nursing Minimum Data Set (NMDS) NOC. See Nursing Outcomes Classification (NOC) Nociception defined, 1115–1116 modulation, 1116–1117 perception, 1116 transduction, 1116, 1116t transmission, 1116, 1116f, 1117f Nociceptive pain, 1114, 1115t Nociceptors, 1116 Noctec. See Chloral hydrate Nocturia, 1206, 1206t Nocturnal emissions, 1096 Nocturnal enuresis, 1203 Nocturnal frequency of urination, 1203 Nodule, dermal, 550f Noise excessive, and safety, 684 hygienic environment, 733 sensory overload, 934t Nonassertive communication, 460 Noncompliance, as a diagnostic label, 476, 476t Nondirective interview, 190 Nonessential amino acids, 1154 Nonexperimental research design, 56 Noninvasive positive pressure ventilation, 1287–1288, 1287f Nonjudgmental support, 468 Non-Luer-Lok syringe tips, 808, 808f Nonmaleficence, as moral principle, 102, 103t Nonrebreather oxygen masks, 1286, 1286f Nonspecific defenses against infection anatomic and physiological barriers, 633 defined, 633 inflammatory response exudate production, 633–634 reparative phase, 634 signs of inflammation, 633, 633t vascular and cellular responses, 633 Nonsteroidal anti-inflammatory drugs (NSAIDS) defined, 1133 fecal occult blood testing, 756 pain management, 1132, 1132t, 1133, 1134t Nonsuicidal self-injury, 374 Nonverbal communication altered thought processes, 440 cultural considerations, 311–312, 311f, 440 defined, 439 facial expression, 441, 441f gestures, 441 Nursing Management, 454 observing and interpreting, 440, 440f personal appearance, 440–441 posture and gait, 441

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Norepinephrine, 999, 1001f Norm, described, 204–205, 205t Normal saline to be used with blood transfusions, 1386, 1386t Normocephalic, defined, 557 Normocephaly, 356 North American Nursing Diagnosis Association (NANDA), 201. See also NANDA International Norton’s Pressure Area Risk Assessment Form, 858, 860t Nortriptyline, 1132t Nose and sinuses hygiene, 732 nasal medications, 843, 844f physical assessment Lifespan Considerations, 571t overview of, 570, 570f skill for, 570–571t Nosocomial infections causative microorganisms, 630, 630t defined, 630 preventing, 637–638 Notes on Nursing: What It Is, and What It Is Not (Nightingale), 32, 32f, 63 NPO defined, 801 preoperative guidelines, 900 NREM sleep, 1093–1094, 1094f, 1094t NSAIDs. See Nonsteroidal anti-inflammatory drugs (NSAIDS) Nuclear family, defined, 412 Nuclear imaging studies, 765–766, 766f NuLYTELY. See PEG-ES Numerical pain rating scales, 1123, 1123f Nurse administrators, 42t Nurse anesthetists, 42t Nurse educators, 42t Nurse entrepreneurs, 42t Nurse informaticists, 160 Nurse Licensure Compact, 77 Nurse midwife, 42t Nurse practice acts, 41, 75 Nurse practitioners, 42t Nurse researchers, 42t Nurse residency programs, 47, 47t Nurse-run clinics, 394 Nurses bilingual, serving as interpreters, 311t current nursing shortage, 46–47, 47t educators, as, 470 health care providers, 120, 120f health promotion, role in, 279–280, 279t home care nurses’ views of their practice, 152t informed consent, obtaining, 81–82, 82f, 82t need to analyze own feelings about death, 1023t roles and functions caregiver, 41 case manager, 42 change, 497–498, 498t change agent, 41 client advocate, 41 communicator, 41 counselor, 41 expanded career roles, 42, 42t family health, 419 gerontological nursing, 393 leader, 41 manager, 41 research consumer, 42 teacher, 41 self-healing methods, 323t spiritual self-awareness, 991–992 stress management for, 1008–1009 taking an active role in influencing the direction of health care, 141t unprofessional conduct, 92–93

“Nurses of America” campaign, 32 Nursing critical values of, 44, 44t defined, 64 definitions of, 39 historical perspectives men in nursing, 34–35, 34f, 35f nursing leaders, 32–34, 32f, 33f, 34f religion, 28–29, 29f societal attitudes, 30–32, 31f war, 29–30, 29f, 30f, 31f women’s roles, 28 socialization to, 43–44, 44t Nursing administration, technology use in, 164 Nursing & Allied Health Collection, 157t Nursing and Health Care Perspectives, 48 Nursing associations, 47 Nursing care competent, as legal protection for nurses, 94, 95t quality of, evaluating nursing audit, 241–242 nursing-sensitive indicators, 241 quality assurance, 240 quality improvement, 240–241, 240t teaching while performing nursing care, 480t Nursing care plans continuing, modifying, or terminating, 237f, 238–240, 239t documentation of, 256 documents in, 216, 217f example of, 229–230t guidelines for writing, 221 multidisciplinary care plans, 220 standardized approaches, 216–218, 218f, 219f Nursing Care Plans acute pain, 1147–1148t altered bowel elimination, 1262–1263t deficient fluid volume, 1389–1390t disuse syndrome, risk for, 1087t implementing and evaluating, 242–244t ineffective airway clearance, 1307–1308t ineffective coping, 1010–1011t nutrition, 1194–1195t planning, 229–230t sensory-perception disturbance, 943–944t sleep, 1106–1107t spiritual distress, 992–993t Nursing care summary, 258 Nursing diagnoses accuracy and prevalence, factors influencing, 202t collaborative problems, differentiating from, 203–204, 204t, 207, 208f components of, 202–203, 203t described, 201–202 diagnostic tests, 745 goals/desired outcomes, relationship to, 224 medical diagnosis, differentiating from, 203, 204t, 207, 208f status of, 202 Nursing Diagnosis: The International Journal of Nursing Language and Classification, 211 Nursing education accreditation/approval of programs, 77 continuing education, 38–39 current curricula, 35, 35f entry into practice, issues regarding, 38t graduate level admission requirements, 37 doctoral programs, 37–38 master’s degree, 37, 37f licensed practical (vocational) nursing, 36 nursing theory, 65 nursing theory development, 63–64 overview of, 35, 35f

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registered nursing associate degree, 36 baccalaureate degree, 37, 38t diploma programs, 36 technology student and course record management, 158 teaching and learning, 157–158, 157t testing, 158 types of programs, 35–36 Nursing ethics Chapter Highlights, 110t defined, 101 ethical decisions, making, 105–106, 105t, 106f, 106t, 107–108t ethical decisions and practice, enhancing, 106 ethical problems, origins of, 105 ethics committees, 103–104, 104f nursing codes of ethics, 104–105, 104t Nursing health history components of, 188t database, part of, 186 teaching, 470–471, 471t, 472t Nursing informatics, 155 Nursing interventions consequences of, considering, 227 criteria for, choosing, 227 defined, 215 delegating implementation of, 228 evaluation checklist, 239–240, 239t implementing, 235–236, 235f, 236f individualized, writing, 227–228, 229–230t Neuman’s systems model, 68 Nursing Interventions Classification (NIC), 228, 229t problem status, relationship to, 228 selecting, 225–227 types of, 226–227 Nursing Interventions Classification (NIC) benefits of, 229t data standardization and classification, 161 described, 228 Nursing Management activity and exercise assessing, 1051–1055, 1052f, 1052t, 1054f, 1055t Concept Map, 1088f diagnosing, 1056 evaluating, 1086 implementing ambulating clients (See Ambulation) back injury, preventing, 1060, 1060t body mechanics (See Body mechanics) mechanical aids for walking (See Walking, mechanical aids for) moving and turning clients in bed (See Moving and turning clients in bed) positioning clients (See Positioning clients) ROM exercises, 1076–1077, 1076t, 1077f, 1077t transferring clients (See Transferring clients) Nursing Care Plan, 1087t planning, 1056, 1057t circulation assessing, 1324–1326, 1325t, 1326f, 1326t diagnosing, 1326 evaluating, 1331 implementing cardiopulmonary resuscitation, 1330–1331 circulation, promoting, 1326–1327, 1327t medications, 1327, 1330t venous stasis, preventing, 1327–1330, 1328–1329t, 1328f, 1330t planning, 1326 communication assessing, 453–454, 454t diagnosing, 454–455 evaluating, 455–457, 456–457t

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Index implementing, 455 planning, 455 culturally responsive nursing care assessing, 314–315, 315f, 316t cultural sensitivity, conveying, 313–314, 314t diagnosing, 315 evaluating, 317 implementing, 315–317, 317t planning, 315, 317t self-awareness, developing, 313 dying and death assessing, 1024–1025, 1025t diagnosing, 1025 evaluating, 1029, 1029t implementing family, supporting, 1028–1029, 1028t helping clients die with dignity, 1026, 1026t hospice and palliative care, 1026–1027, 1027f physiological needs of the dying client, 1027, 1028t postmortem care, 1029 spiritual support, 1027–1028 planning, 1025–1026, 1025t eyes assessing, 728–729, 728t diagnosing, 729 evaluating, 730 implementing, 729, 729t planning, 729 family health assessing, 415–418, 415t, 416f, 417f, 418t diagnosing and planning, 418–419, 419t implementing and evaluating, 419 fecal elimination assessing, 1246, 1247t Concept Map, 1264f diagnosing, 1247 evaluating, 1262 implementing bowel training programs, 1257 enemas, administering, 1252–1256, 1252t, 1253–1255t, 1253t, 1256t fecal impaction, removing, 1256–1257, 1256t fecal incontinence pouch, 1257–1258, 1257f flatulence, decreasing, 1252 medications, 1249, 1251–1252, 1251t, 1252t ostomy management, 1258–1262, 1258f, 1259–1261t, 1259f, 1262t regular defecation, promoting, 1247–1249, 1248t, 1249f, 1249t, 1250–1251t, 1250f Nursing Care Plan, 1262–1263t planning, 1247, 1248t fluid, electrolyte, and acid–base balance assessing clinical measurements, 1353–1356, 1355f, 1356t components of, 1352–1353 laboratory tests, 1356–1357, 1356t, 1357f, 1358t nursing history, 1353, 1353t physical assessment, 1353, 1354t Concept Map, 1391f diagnosing, 1358–1359 evaluating, 1389 implementing blood transfusions (See Blood transfusions) enteral fluid and electrolyte replacement, 1359, 1361–1362, 1361t parenteral fluid and electrolyte replacement (See Intravenous (IV) route of administration) wellness, promoting, 1359 Nursing Care Plan, 1389–1390t planning, 1359, 1359t, 1360t foot hygiene assessing, 710–712, 711t, 712t diagnosing, 712

evaluating, 712, 714 implementing, 712–714, 713–714t planning, 712 hair hygiene assessing, 724–725, 724t diagnosing, 725 evaluating, 728 implementing beard and mustache care, 728, 728t brushing and combing, 725–727, 726f, 726–727t Lifespan Considerations, 727t shampooing, 727, 727f planning, 725 health promotion assessing, 280–282, 280t, 281t, 282t diagnosing, 282–283 evaluating, 285 implementing, 284–285, 285f planning, 283–284, 283t infection assessing, 635–637, 636t diagnosing, 637 evaluating, 663 implementing chain of infection, breaking, 637, 639t disinfecting and sterilizing, 643–644, 644t hand hygiene (See Hand hygiene) host, supporting defenses of, 642–643 infection prevention and control, 644–646, 645t infection prevention for health care workers, 662, 662t infection prevention nurse, role of, 662–663 isolation practices (See Isolation practices) nosocomial infections, preventing, 637–638 sterile technique (See Sterile technique) planning, 637, 637t, 638t intraoperative phase assessing, 905 diagnosing, 905 documentation, 906 evaluating, 906 implementing, 906, 906t, 907f planning, 905–906 loss and grieving assessing, 1020, 1020t diagnosing, 1020–1021 evaluating, 1022 implementing emotional support, providing, 1021–1022 grief work, facilitating, 1021 planning, 1021, 1021t nail hygiene assessing, 714, 714t diagnosing, 714 evaluating, 715 implementing, 714–715, 714f planning, 714 nutrition assessing anthropometric measurements, 1170, 1172, 1172f, 1172t biochemical (laboratory) data, 1172–1173 clinical data (physical examination), 1173, 1174f, 1175t dietary data, 1173–1174 nursing history, 1170 nutritional assessment, 1169, 1169t nutritional screening, 1169–1170, 1169t, 1170–1171f, 1171t Concept Map, 1196f diagnosing, 1174 evaluating, 1194 implementing appetite, stimulating, 1178, 1178t assisting clients with meals, 1178–1179, 1179f, 1179t

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community nutritional services, 1179–1180 enteral nutrition (See Enteral nutrition) parenteral nutrition, 1193–1194 special diets, 1175, 1177–1178, 1177t Nursing Care Plan, 1194–1195t planning, 1174–1175, 1176t oral hygiene assessing, 715–716, 715t, 716t diagnosing, 716–717 evaluating, 723 implementing artificial denture care, 718, 720–721t assisting clients with oral care, 718, 718f brushing and flossing teeth, 718, 718–721t Home Care Considerations, 723t Lifespan Considerations, 723t oral health throughout the life span, 717–718, 717t special oral hygiene needs, 721–723, 722–723t planning, 717 oxygenation assessing, 1274–1275, 1275t, 1276f, 1276t Concept Map, 1309f diagnosing, 1275–1276 evaluating, 1307 implementing artificial airways (See Airways, artificial) chest tubes and drainage systems, 1305–1307, 1306f deep breathing and coughing, 1278, 1279t, 1280t hydration, 1278 incentive spirometry, 1280–1282, 1281f, 1282t medications, 1278–1280, 1280t, 1281t mucus clearance devices, 1283, 1283f overview, 1277–1278 oxygen therapy (See Oxygen therapy) oxygenation, promoting, 1278, 1278t, 1279f percussion, vibration, and postural drainage, 1282–1283 suctioning (See Suctioning) tracheostomy care, providing, 1302–1305t Nursing Care Plan, 1307–1308t planning, 1276–1277, 1277t pain management assessing behavioral and physiological responses, 1126, 1127t nurses’ knowledge of, 1126t overview of, 1121–1122, 1122t pain diaries, 1126–1127 pain history, 1122–1125, 1123f, 1123t, 1124f, 1125t Concept Map, 1149f diagnosing, 1127 evaluating, 1146, 1146t Home Care Considerations, 1146t implementing barriers to, 1130–1131, 1130t, 1131t guidelines for, 1128–1129, 1129t invasive therapies, 1145 key strategies, 1131–1132, 1131t, 1132t nonpharmacologic management, 1141–1145, 1142– 1143t, 1142t, 1144f, 1144t opiates, routes of administration for, 1137–1140, 1138f, 1139t patient-controlled analgesia, 1140–1141, 1140f, 1141t pharmacologic management, 1132–1137, 1132t, 1133t, 1134t, 1135t, 1136t placebos, 1137 Lifespan Considerations, 1146t Nursing Care Plan, 1147–1148t planning, 1127–1128, 1128t postoperative phase assessing, 909–912, 909t, 910–911t, 912t diagnosing, 912 evaluating, 924 implementing

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Index

Nursing Management—Cont. deep-breathing and coughing exercises, 913–914 diet, 914 home care teaching, 923–924 hydration, 914 leg exercises, 914 moving and ambulation, 914 pain management, 912–913 positioning, 913 suction, 914–917, 914f, 915–917t, 918f urinary and gastrointestinal function, 914 wound care (See Wound care, postoperative phase) planning, 912, 913t preoperative phase assessing, 894–895, 894t, 895t diagnosing, 895 evaluating, 904 implementing physical preparation, 899–904, 900f, 901t, 902–904 preoperative teaching, 895–899, 896t, 897–899t planning, 895 safety assessing, 669–670, 670f, 671t, 672t diagnosing, 670 evaluating, 692 implementing adolescents, 673t, 675 bioterrorism attack, 685 carbon monoxide poisoning, 683, 683f electrical hazards, 684, 684f, 685t falls, 676–680, 676t, 677t, 678–680t firearms, 684–685 fires, 682–683, 682f health care settings, 676 middle-aged adults, 674t, 675 newborns and infants, 671, 673t noise, 684 older adults, 674t, 675–676, 675t, 676t poisoning, 683, 683t preschoolers, 673t, 674 problems across the life span, 676 procedure- and equipment-related accidents, 685 radiation, 685 restraining clients, 685–691, 686t, 687t, 688f, 688t, 689–690t, 691f, 691t scalds and burns, 682 school-age children, 673t, 674–675 seizures, 680–681t, 680–682, 682t suffocation or choking, 683–684, 684f toddlers, 671, 673t, 674, 674f, 674t young adults, 673–674t, 675 planning, 670–671 self-concept assessing, 953–954, 953t, 954f, 954t diagnosing, 954–955 evaluating, 955, 957 implementing, 955, 955t, 956–957t, 956f, 957f planning, 955 sensory perception assessing, 933–934, 933t, 934f, 934t Concept Map, 945f diagnosing, 934–935 evaluating, 943, 943–944t implementing confused clients, 941–943, 942t, 943f, 943t healthy sensory function, promoting, 935–937, 936t, 937t, 938–939f, 939t Lifespan Considerations, 939t sensory impairments, managing, 937, 940, 940t, 941t planning, 935, 935t sexuality assessing, 971–972, 972t diagnosing, 972–973

evaluating, 977 implementing altered sexual function, counseling for, 975–976 inappropriate sexual behavior, 977, 977t nurses’ skills and responsibilities, 973, 973t responsible sexual behavior, 974–975, 975f, 975t, 976t self-examination, teaching, 973–974, 974f, 974t sex education, 973 planning, 973 skin hygiene assessing, 696–698, 697t, 698t diagnosing, 698, 698t evaluation, 710 implementing bathing, 700–707, 701f, 702–706t, 707t client teaching, 710, 710t guidelines for, 700, 700t overview, 699 perineal-genital care, 707–708, 708–709t, 708t planning, 698–699, 699f, 699t sleep assessing, 1101–1102, 1102t Concept Map, 1108f diagnosing, 1102–1103 evaluating, 1105 implementing, 1103–1105, 1103t, 1104t, 1105t, 1106t Nursing Care Plan, 1106–1107t planning, 1103 spirituality assessing, 986–987, 986t Concept Map, 994f diagnosing, 987 evaluating, 991, 992–993t, 994f implementing prayer, assisting with, 989–990, 990f, 991t presence, providing, 988 religious practices, supporting, 988–989, 989t, 990t spiritual care experts, referring clients to, 990 spirituality, conversing about, 988, 988t, 989t Nursing Care Plan, 992–993t planning, 987–988 stress and coping assessing, 1005, 1005t Concept Map, 1012f diagnosing, 1005–1006 evaluating, 1009, 1009–1011t, 1012f implementing anger, mediating, 1007, 1007t anxiety, minimizing, 1007, 1007t crisis intervention, 1008, 1008t health promotion strategies, 1006–1007, 1006t relaxation techniques, 1007–1008 stress management for nurses, 1008–1009 Nursing Care Plan, 1010–1011t planning, 1006, 1006t teaching assessing health literacy, 473–474, 473t, 474f, 474t, 475f, 475t, 476t motivation, 472–473 nursing history, 470–471, 471t, 472t physical examination, 472 readiness to learn, 472 diagnosing, 474, 476, 476t documenting, 484 evaluating, 484 implementing, 480–484, 480t, 481f, 481t, 483t planning, 477–480, 477t, 478f, 478t, 479t, 480t urinary elimination assessing components of, 1207 diagnostic tests, 1210 nursing history, 1208, 1208t

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physical assessment, 1208 urine, assessment of, 1208–1210, 1209f, 1209t, 1210f Concept Map, 1232f diagnosing, 1210–1211, 1211t evaluating, 1230 implementing normal urinary elimination, maintaining, 1212, 1214t suprapubic catheter care, 1228, 1228f urinary catheterization (See Urinary catheters/ catheterization) urinary diversions, 1228–1230, 1229f, 1230f urinary incontinence, managing (See Urinary incontinence (UI)) urinary irrigations, 1225, 1226–1227t urinary retention, managing, 1217 urinary tract infection, preventing, 1212 Nursing Care Plan, 1230–1231t planning, 1211, 1212t, 1213t wound healing assessing, 863–867, 863t, 864f, 865–867t, 865f diagnosing, 868 evaluating, 887, 887t implementing heat and cold applications (See Cold applications; Heat applications) pressure ulcers, preventing, 869–872, 871f, 871t pressure ulcers, treating, 872, 872t wound healing, supporting, 868–869, 870t wounds, cleaning (See Wound care, cleaning) wounds, dressing, 872–874, 873t, 874f, 875f wounds, supporting and immobilizing (See Wound care, supporting and immobilizing) planning, 868, 868t, 869t Nursing Minimum Data Set (NMDS) computerized documentation, 254 data standardization and classification, 161 Nursing organizations Academy of Medical Surgical Nursing, 48 American Assembly for Men in Nursing, 34, 34f American Association of Nurse Anesthetists, 48 American Nurses Association (See American Nurses Association (ANA)) International Council of Nurses, 48 Men in Nursing, 34 National Association of Pediatric Nurse Practitioners, 48 National Black Nurses Association, 48 National League for Nursing (See National League for Nursing (NLN)) National Male Nurses Association, 34 National Student Nurses Association, 44, 44t, 48 Sigma Theta Tau, 48 Nursing outcomes, 237f, 238 Nursing Outcomes Classification (NOC) data standardization and classification, 161 defined, 223–224, 223t Nursing Philosophy, 66 Nursing practice. See also Nursing education Chapter Highlights, 48–49t contemporary practice definitions of nursing, 39 nurse practice acts, 41 recipients of nursing, 39 scope of nursing dying, caring for, 40 health, restoring, 40 health and wellness, promoting, 39–40 illness, preventing, 40 settings for, 40–41, 40f standards of practice, 41 critical thinking nursing process, 173–174 problem solving, 173–174 factors influencing collective bargaining, 47

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Index consumer demands, 45 demography, 46 family structure, 45 health care reform, 45 health care system, affecting, 44–45 information, telehealth, and telenursing, 46 legislation, 46 nursing associations, 47 nursing shortage, 46–47, 47t quality and safety in health care, 45 science and technology, 45–46 growth and development concepts, 349–350 legal aspects of abortions, 85 Americans with Disabilities Act, 83, 83t consent, exceptions to, 81 controlled substances, 83 death and related issues, 85–87, 86f delegation, 82–83 euthanasia, 87 impaired nurses, 83–84, 83t, 84t informed consent, 79–81, 80t, 81t inquests, 87 nurse’s role, 81–82, 82f, 82t organ donation, 87 sexual harassment, 84 violence, abuse, and neglect, 83 legal protections competent nursing care, providing, 94, 95t documentation, 94, 94f Good Samaritan acts, 93 incident reports, 94–95 physician’s orders, carrying out, 94 professional liability insurance, 93–94 regulation of credentialing, 75, 77, 77t nurse practice acts, 75 standards of care, 77–78 technology client status and medical record keeping bedside data entry, 159–160, 159f clinical decision support systems, 160 computer-based client records, 160, 160f data standardization and classifications, 161 tracking client status, 161, 161f, 162t computers, applications of case management, 163–164 community and home health, 163, 163f electronic access to client data client monitoring and computerized diagnostics, 162, 162f, 163f telemedicine and telehealth, 162–163 overview, 159 practice management, 163 Nursing presence, described, 429, 429f Nursing process in action, 181, 182–183f characteristics of, 181–182, 185, 185t, 186f communication, 453 critical thinking, 173–174 defined, 181 diagnosing, 201, 202f documentation of, 256, 257t health promotion, 280 phases of, 181, 184t, 185f teaching process, compared to, 464, 465t Nursing research Chapter Highlights, 61t critiquing reports, 58, 59t history of, 53 locating, 58, 58t nursing theory, 65 qualitative, 55, 55t quantitative, 54–55, 55t

recent studies, examples of, 53, 54t research process, 55–57, 57t, 58f role expectations for nurses level of educational preparation, 53, 54t research consumer, 57–58, 58t, 59t research team member, 59–60, 60f, 60t technology data collection and analysis, 165 literature review, 165 problem identification, 164–165 research design, 165 research dissemination, 165–166 research grants, 166 Nursing Research, 53 Nursing Research Consortium on Violence, 382t Nursing rounds, 265 Nursing: Scope and Standards of Practice (ANA), 101 Nursing Student Reflection Checkpoint, caring, 433t Nursing theories and conceptual frameworks Chapter Highlights, 71t Critical Thinking Checkpoint, 71t metaparadigm for nursing, 64, 65f nursing theories Henderson’s definition of nursing, 66–67 King’s goal attainment theory, 67–68, 67f, 68f Leininger’s cultural care diversity and universality theory, 69 Levine’s conservation model of nursing, 70t Neuman’s systems model, 68, 69f Nightingale’s environmental theory, 63, 66 Orem’s general theory of nursing, 67 Parse’s humanbecoming theory, 70 Peplau’s interpersonal relations model, 66 Rogers’ science of unitary human beings, 67 Roy’s adaptation model, 68–69 Watson’s human caring theory, 70 nursing theory, critique of, 70 nursing theory, role of clinical practice, in, 65–66 education, in, 65 overview, 64 research, in, 65 theories, introduction to, 63–64 Nursing’s Agenda for Health Care Reform (ANA), 131 Nursing’s Social Policy Statement, 39 Nutrients, defined, 1153 Nutrition. See also Diet and nutrition adolescents, 375t altered nutrition, 1168–1169 body alignment and activity, 1043 body weight and body mass standards, 1157, 1157t Chapter Highlights, 1197t complementary and alternative therapy, 326 culturally responsive care, 312–313 defined, 1153 energy balance, 1156–1157 essential nutrients Anatomy & Physiology Review, 1155f carbohydrates, 1154 lipids, 1155–1156 macro- and micronutrients, 1153 proteins, 1154–1155 vitamins and minerals, 1156 factors affecting advertising, 1160 alcohol consumption, 1159–1160 development, 1158 economics, 1159 ethnicity and culture, 1158, 1158t food, beliefs about, 1158 gender, 1158 health, 1159 lifestyle, 1159 medications and therapy, 1159, 1160t

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personal preferences, 1158–1159 psychological factors, 1160 religious practices, 1158t, 1159 growth and development, 339 healthy diet, standards for dietary guidelines for Americans, 1165–1166, 1165t, 1166f food guides, purpose of, 1163 recommended dietary intake, 1166–1168, 1167f, 1167t vegetarian diets, 1168, 1168t infection, susceptibility to, 635 middle-aged adults, 387t newborns and infants, 361t Nursing Management assessing anthropometric measurements, 1170, 1172, 1172f, 1172t biochemical (laboratory) data, 1172–1173 clinical data (physical examination), 1173, 1174f, 1175t dietary data, 1173–1174 nursing history, 1170 nutritional assessment, 1169, 1169t nutritional screening, 1169–1170, 1169t, 1170–1171f, 1171t Concept Map, 1196f diagnosing, 1174 evaluating, 1194 implementing appetite, stimulating, 1178, 1178t assisting clients with meals, 1178–1179, 1179f, 1179t community nutritional services, 1179–1180 enteral nutrition (See Enteral nutrition) parenteral nutrition, 1193–1194 special diets, 1175, 1177–1178, 1177t Nursing Care Plan, 1194–1195t planning, 1174–1175, 1176t nutritional variations throughout the life cycle, 1160–1163, 1163t, 1164–1165t, 1164t older adults, 408t prenatal development, 355 preoperative phase, 899–900 preschoolers, 367t pressure ulcer prevention, 870 pressure ulcers, 856 school-age children, 370t self-care for nurses, 430 stress and coping, 1006, 1006t surgical risk, 892–893, 893t toddlers, 364t wound healing, 862, 869 young adults, 384t Nutrition labeling, 1166, 1167f, 1168 Nutrition Screening Initiative, 1170, 1171t Nutritive value, defined, 1153 Nutting, Mary Adelaide, 33

O OASIS (Outcome and Assessment Information Set), 151 Obama, Barack Children’s Health Insurance Program Reauthorization Act, 127 health care reform, 132 Patient Protection and Affordable Care Act (ACA), 126 Obama, Michelle, 1165 Obese, defined, 1168 Obesity adolescents, 374 blood pressure, 526 body mass index, 1157t cardiovascular risk factor, 1320t, 1321 middle-aged adults, 386 school-age children, 370 surgical risk, 893t Objective data, 186–187, 189t

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Index

Obligations, conflicting, 105 Obligatory losses, 1339 Observation interventions, 228 Observing, for data collection, 190, 190t Obstructive sleep apnea noninvasive positive pressure ventilation, 1287 sleep apnea, type of, 1100 surgical risk, 893 Occult blood defined, 755 urine testing, 762, 762t Occupation, and wellness, 289, 290f Occupational exposure defined, 662 steps to follow, 662t Occupational hazards, and home health nursing, 148 Occupational health clinics, 117, 117f Occupational Safety and Health Administration (OSHA) infection prevention for healthcare workers, 662 needlestick injuries, preventing, 810 Occupational therapists, 120, 120f Occupied beds, changing, 739–740, 739–740t Oculomotor nerve (CN III), 616t Odors, 711 Oedipus complex, 366 Office of Dietary Supplements, NIH, 326 Office of Management and Budget, 303 Office of Minority Health, 305 Office of Minority Health and Health Equity (CDC), 305 Official name of medications, 777 Oil retention enemas, 1252t, 1253 Oils, defined, 1155 Ointment, 777t Older adults abdomen, assessment of, 603t abdominal paracentesis, 768t active ROM exercises, 1076t aging, attitudes toward ageism, 391, 392t myths and stereotypes, 392, 392t antiemboli stockings, 904t anus, assessment of, 623t assisting a client to ambulate, 1081t average daily urine output, 1205t bandages and binders, applying, 882t bathing, 706t biologic dimension of health, 293 blood pressure, 532t body alignment and activity, 1043 body temperature, 512t bone marrow biopsy, 769t breast and axilla assessment, 597t capillary blood glucose, 754t care settings for acute care facilities, 393 community, 394, 394f hospice, 393 long-term care facilities, 393 rehabilitation, 393–394 catheterization, 1223t Chapter Highlights, 408–409t characteristics of demographics, 390, 391f ethnicity, 391, 391t health, 391 socioeconomics, 391 circulation, 1320t cognitive abilities and aging cognitive ability, 404 learning, 404 memory, 404 perception, 403–404 communication with, 454t computer use, 165t

Critical Thinking Checkpoint, 408t death, concept of, 1022t death, responses to, 1029t defecation, 1239, 1240t Developmental Assessment Guidelines, 407t diagnosing, 211t diagnostic testing, 773t ear and hearing assessment, 569t enema, administering, 1256t eye and vision assessment, 564–565t factors in potential bowel elimination problems, 1245t falls, preventing, 667t female genitalia and inguinal area assessment, 618t fluid, electrolyte, and acid–base balance, 1343–1344, 1343t functional levels, assessing, 128t gerontological nursing development of, 392–393 nurses’ roles, 393 hair, 724 hair assessment, 555t hair care, 727t Havighurst’s age period and developmental tasks, 343t health assessment and promotion, 407, 408t health assessment general survey, 549t health care decisions, 178t health care delivery, 141t health problems alcoholism, 406 chronic disabling illness, 405 dementia, 406, 406t drug abuse and misuse, 405–406 injuries, 405 mistreatment of older adults, 406–407 health promotion and illness prevention, factors affecting, 282t Health Promotion Guidelines, 408t health promotion topics, 276t hearing impairment and distracters, 940t heart and central vessels, assessment of, 591t home care, 152t IM injections, 829t increasing numbers of, 122 infection, signs of, 909t infections, 636t Internet and health information, 470 intraoperative positioning, 906t learning, 469t liver biopsy, 772t loss and grief responses, 1019 lumbar puncture, 767t male genitalia and inguinal area assessment, 622t massage, uses of, 333t medication administration, 800–801, 800t medication nonadherence, 297t mistreatment of, 406–407 moral reasoning, 404 mouth and oropharynx assessment, 575t musculoskeletal system assessment, 606t nail assessment, 557t neurologic system assessment, 615t normal sleep patterns and requirements, 1096 nose and sinus assessment, 571t nursing care plans, 229t nutrition, 1163, 1164t, 1165t oral health, 718 oral hygiene, 723t oral medications, 805t pain experience, 1119, 1120t, 1121t pain management, 1146t PCA pump, 1141t peripheral vascular system assessment, 593–594t physiological aging biological theories of, 395, 395t cardiovascular system, 396t, 399–400

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death and grieving, 403 economic change, 402 e-health, 402 endocrine system, 397t gastrointestinal system, 397t, 400 genitals, 397t, 400–401 grandparenting, 402 immunologic system, 397t independence and self-esteem, 403 integumentary system, 395, 396t, 397 neuromuscular system, 396t, 397–398, 398f overview of, 395, 407t psychosocial aging, 401, 401t, 407t pulmonary system, 396t, 399 relocation, 402–403 retirement, 401–402, 401f, 402f sensory-perceptual system, 396t, 398–399 sleep, 399t urinary system, 397t, 400 positioning, moving, and turning clients, 1070t postoperative care, 912t preoperative teaching, 899t pressure ulcer and wound care, 879t pulse, 520t pulse and respiration average and normal range, 513t pulse oximetry, 535t respirations, 525t respiratory development, 1272, 1274t safety, 674t, 675–676, 675t, 676t, 691t safety hazards, 667t self-esteem, enhancing, 957f, 957t sensory perception, 939t sequential compression devices, 1330t sexual development, 961t, 962–964 skin assessment, 554t sleep disturbances, 1097t spiritual development, 983t spirituality and aging, 404–405 sputum and throat specimens, 763t stool specimens, 757t stress and coping, 1010t stressors, 999t suctioning, 1297t suctioning a tracheostomy or endotracheal tube, 1301t suicide, 1023t surgical risk, 892 teaching considerations, 472t temperature measurement, 511t thoracentesis, 769t thorax and lungs, assessment of, 586t tracheostomy care, 1305t transferring clients, 1076t tube feeding, administering, 1190t urinary elimination, 1203, 1204t urine specimen collection, 760t wound healing, 863t Olfactory defined, 930 impaired olfactory sense, 937 Olfactory nerve (CN I), 616t Oliguria, 1205–1206, 1206t Omaha System of data standardization and classification, 161 Omnibus Budget Reconciliation Act (1987) long-term care documentation, 258 rural health care, 119 Oncotic pressure (colloid osmotic pressure), 1337 Ondansetron, 901 Online, defined, 156t Online BSN programs, 37 Onset of action of a drug, 781 Opana. See Oxymorphone Open awareness, defined, 1024 Open method of suctioning, 1298 Open system, defined, 271

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Index Open-ended questions interviews, 190, 191t therapeutic communication, 446t Opening stage of an interview, 192–193 Open-tipped suction catheters, 1294, 1294f Operant conditioning, 345 Ophthalmic medications administration, skill for, 839–841t Lifespan Considerations, 841t ophthalmic, defined, 839 Ophthalmoscope, 543t Opinion, statements of, 173, 173t Opioids categories and examples, 1132, 1132t moderate pain, 1132, 1132t, 1134 patient-controlled analgesia, 1140–1141, 1140f, 1141t routes of administration, 1137–1140, 1138f, 1139t severe pain, 1132, 1132t, 1134–1135, 1135t side effects, 1135, 1135t, 1136t types of, 1133–1134 urinary retention, 1205t Opportunistic pathogens, 629 Opposition of thumb and fingers, 1041f, 1041t Optic nerve (CN II), 616t Oral body temperature measurement advantages and disadvantages, 507t described, 507 pacifier thermometers, 512f, 512t thermometer placement, 511t Oral hygiene, 697t Oral route of administration described, 784, 784t, 801 Lifespan Considerations, 805t opioids, 1137 pharmacokinetics, 782f rounding numbers for, 791t skill for, 801–804t Oral stage of psychosexual development described, 341, 341t, 344t newborns and infants, 358–359 Oral-genital sex, 966 Order of Deaconesses, 29 Orem, Dorothea, and general theory of nursing, 67 Orem’s self-care model, 195 Organ and tissue transplantation, 108 Organ donation, 87 Organ Donation and Recovery Improvement Act (2004), 87 Organizing, as a management function, 492 Orgasmic phase of the sexual response cycle, 968, 968t, 969f Orientation, neurologic, 607, 607t, 609t Orientation (introductory) phase of the helping relationship, 449, 450t Origin of Species (Darwin), 64 Oropharyngeal airways, 1291, 1291f Orthopnea, 524t, 1273 Orthopneic position, 1063, 1063f Orthostatic hypotension controlling, 1079t, 1081 described, 527 immobility, 1048 physiological aging, 396t, 399 OSHA (Occupational Safety and Health Administration), 662, 810 Osmolality, defined, 1336–1337 Osmolality, serum described, 747, 748t normal values, 1356t, 1357 OsmoPrep. See Sodium phosphate Osmosis, 1337, 1337f Osmotic pressure, 1337 Osmotic/saline laxatives, 1251t Ossicles of the ear, 565f, 566

Osteoporosis body alignment and activity, 1043 physiological aging, 398 Ostomy bowel diversion anatomic location, 1244, 1244f permanence, 1244, 1244t stoma, surgical construction of, 1244–1245, 1244f, 1245f types of, 1244 defined, 1244 management appliances, described, 1258–1259, 1258f, 1259f changing a bowel diversion appliance, 1259–1261t, 1262t colostomy irrigation, 1262 stoma and skin care, 1258 Otic medications administration, skill for, 841–843t Lifespan Considerations, 843t otic, defined, 841 Otoscope, 543t, 565 Outcome and Assessment Information Set, 151 Outcome evaluation, defined, 240 Output, defined, 271, 271f Overflow urinary incontinence, 1207, 1211t Overhydration, 1346 Overnutrition, 1168 Overt change, defined, 497 Over-the-needle IV catheters (angiocatheters), 1363–1364, 1365f Overweight body mass index, 1157t defined, 1168 school-age children, 370 Ovide. See Malathion Owned Faith stage, in Westerhoff ’s theory of spiritual development, 349, 350t Oxybutynin ER, 1211t Oxycodone Drug Capsule, 1135t pain management, 1132, 1132t, 1133t, 1134, 1135t Oxycodone/acetaminophen, 1135t Oxycodone/aspirin, 1135t OxyContin. See Oxycodone Oxygen concentration, and respiratory regulation, 1272 diffusion of, 1271, 1272 gas exchange, 1351f prenatal development, 355 transport of, 1271 Oxygen concentrators, 1290–1291t Oxygen cylinders, 1290f, 1290t Oxygen hoods, 1290t Oxygen saturation (SaO2), 533 factors affecting, 533, 534t Home Care Considerations, 535t Lifespan Considerations, 535f, 535t measuring, skill for, 534–535t pulse oximeter devices, 533, 533f Oxygen tents, 1290t Oxygen therapy delivery systems cannulas, 1285–1286, 1285f, 1288–1289t face masks, 1286–1287, 1286f, 1288–1289t face tents, 1287, 1287f, 1288–1289t Lifespan Considerations, 1290t noninvasive positive pressure ventilation, 1287–1288, 1287f skill for, 1288–1289t transtracheal catheters, 1287, 1287f flow meters, 1284, 1284f home care equipment, 1290–1291t, 1290f how supplied, 1283 humidifying devices, 1283–1284, 1284f

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indications for, 1283 safety precautions, 1284–1285, 1285t Oxygenation Chapter Highlights, 1310t Nursing Management assessing diagnostic studies, 1275, 1276f, 1276t nursing history, 1274–1275, 1275t physical examination, 1275 Concept Map, 1309f diagnosing, 1275–1276 evaluating, 1307 implementing artificial airways (See Airways, artificial) chest tubes and drainage systems, 1305–1307, 1306f deep breathing and coughing, 1278, 1279t, 1280t hydration, 1278 incentive spirometry, 1280–1282, 1281f, 1282t medications, 1278–1280, 1280t, 1281t mucus clearance devices, 1283, 1283f overview, 1277–1278 oxygen therapy (See Oxygen therapy) oxygenation, promoting, 1278, 1278t, 1279f percussion, vibration, and postural drainage, 1282–1283 suctioning (See Suctioning) tracheostomy care, providing, 1302–1305t Nursing Care Plan, 1307–1308t planning, 1276–1277, 1277t respiration process, components of, 1267 respiratory function, alterations in air movement, 1273 airway, 1273 diffusion of gases, 1273–1274, 1274t transport of gases, 1274 respiratory function, factors affecting age, 1272, 1274t environment, 1272 health status, 1273 lifestyle, 1272 medications, 1273 stress, 1273 respiratory system (See Respiratory system) Oxyhemoglobin, 1271 Oxymorphone, 1132t

P PACE (Program of All-Inclusive Care for the Elderly), 151 Pace of verbal communication, 439 Pacific Islander heritage, people with adolescent families, 413 culture that values family inclusion in client teaching, 483t older adults, 391t Pacifier thermometers, 512f, 512t Pacifiers, and SIDS, 360 Packed red blood cells (PRBCs), 1385t Packing for wounds, 877, 878t Paclitaxel, 324 Pain. See also Pain management acknowledging and accepting, 1131, 1131t associated concepts, 1114–1115, 1115t clients reluctant to report, 1122, 1122t common chronic pain syndromes, 1115t defined, 1112 fecal elimination, 1241 learning, barrier to, 469t misconceptions, reducing, 1131, 1132t misconceptions about, 1130, 1130t pain experience, factors affecting developmental stage, 1119, 1120t, 1121t environment and support people, 1119–1120 ethnic and cultural values, 1118–1119, 1119t

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Index

Pain—Cont. pain, meaning of, 1121 previous experiences, 1120 painful stimuli, 1116, 1116t physiology of gate control theory, 1117–1118, 1117f modulation, 1116–1117 nociception, described, 1115–1116 perception, 1116 responses to, 1118, 1118f transduction, 1116, 1116t transmission, 1116, 1116f, 1117f types of duration, 1114, 1114t etiology, 1114, 1115t intensity, 1114 location, 1113, 1113f unrelieved, 1118 Pain diaries, 1126–1127 Pain history ADLs, effect on, 1125 affective responses, 1125 alleviating factors, 1125 Assessment Interview, 1122t associated symptoms, 1125 coping resources, 1125 intensity or rating scales, 1123–1124, 1123f, 1123t, 1124f location, 1123 overview of, 1122 pain quality, 1124–1125, 1125t pattern, 1125 precipitating factors, 1125 Pain management. See also Pain Chapter Highlights, 1150t Critical Thinking Checkpoint, 1147t defined, 1113 Nursing Management assessing behavioral and physiological responses, 1126, 1127t nurses’ knowledge of, 1126t overview of, 1121–1122, 1122t pain diaries, 1126–1127 pain history, 1122–1125, 1122t, 1123f, 1123t, 1124f, 1125t Concept Map, 1149f diagnosing, 1127 evaluating, 1146, 1146t Home Care Considerations, 1146t implementing barriers to, 1130–1131, 1130t, 1131t guidelines for, 1128–1129, 1129t invasive therapies, 1145 key strategies, 1131–1132, 1131t, 1132t nonpharmacologic management, 1141–1145, 1142– 1143t, 1142t, 1144f, 1144t opiates, routes of administration for, 1137–1140, 1138f, 1139t patient-controlled analgesia, 1140–1141, 1140f, 1141t pharmacologic management, 1132–1137, 1132t, 1133t, 1134t, 1135t, 1136t placebos, 1137 Lifespan Considerations, 1146t Nursing Care Plan, 1147–1148t planning, 1127–1128, 1128t pain, defined, 1112 postoperative care, 912–913 Pain threshold, 1114, 1115t Pain tolerance, 1114, 1115t Palliative care, described, 1027 Palliative surgery, 892t Pallor, 549 Palmar grasp reflex, 358t Palpation technique, described, 543–544, 543f, 544f, 544t Palpatory method of blood pressure measurement, 529 Panic, described, 1002, 1002t

Papanicolaou (Pap) test, 383 Papules, 550f Paradigm, defined, 64 Paradoxical-consolidative stage of Fowler’s theory of spiritual development described, 349, 350t middle-aged adults, 386 Parainfluenza virus, 632t Paralysis, 454 Paramedical technologists, 121 Parasites, 629 Parasomnia, 1101, 1101t Parenteral nutrition described, 1193–1194 IV push medications, 833t Parenteral route of administration described, 784t, 785 injectable medications, preparing, 810–817, 811f, 812f, 813–814t, 814–815t, 816–817t intradermal injections, 817, 817f, 818–819t, 823t intramuscular injections deltoid site, 826, 826f dorsogluteal site, 824–825 Lifespan Considerations, 829t overview, 823, 823f, 823t rectus femoris site, 825, 825f technique for, 826, 827–828t vastus lateralis site, 824, 824f, 825f ventrogluteal site, 823f, 824, 824f intravenous medications intermittent infusion devices, 833–834, 834f intermittent IV infusions, 831–832, 832f, 833f IV push, 833, 833t, 834–837t large-volume infusions, 829, 829–831t volume-control infusions, 833, 833f, 834t, 1366 needles, 809–810, 809f needlestick injuries, preventing, 810, 810f, 810t, 811f rounding numbers for, 791t subcutaneous injections, 817, 819–820, 820f, 820–822t, 823t syringes, 806–809, 806f, 807f, 808f, 809f, 810, 811f Paresis, defined, 1048 Parish nursing, 136–137 Parotid gland, 571, 572f Parotitis, 572, 716t Paroxetine, 1134 Parse’s humanbecoming theory, 70 Parsons, Talcott, 288 Partial baths, 701 Partial pressure, defined, 1271 Partial rebreather oxygen masks, 1286, 1286f Partial thickness wounds, 855t Pasero Opioid-Induced Sedation Scale, 1135, 1135t Passive euthanasia, 108 Passive (acquired) immunity, 634, 634t Passive ROM exercises, 1076–1077, 1077f, 1077t Passive safety syringes, 810, 811f Paste, described, 777t Patch, 550f Pathogenicity, defined, 629 Pathologic fractures, 398 Patience, in caring, 424 Patient, defined, 39 Patient and Family Education standards, 464 Patient Protection and Affordable Care Act (ACA) community nursing, 132 health care spending in the U.S., 122 health disparities, 305 health literacy, 80 key features, 126 nursing practice, influencing, 45 Patient Self-Determination Act (PSDA) advance health care directives, 85 nursing practice, influencing, 46

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Patient-Centered Care abdomen, assessment of, 603t administering medications, 805t antiemboli stockings, 904t bandages and binders, applying, 883t biocultural considerations in CBCs, 747t blood and blood products, 1384t blood pressure, 533t blood samples, drawing, 745t body piercing and dermal implants, 901t body temperature, 512f, 512t capillary blood glucose, 754t catheterization, 1223t changing an ostomy appliance, 1262t clients in pain, 1130t closed-wound drainage system, 922t cultural views of older adults, 392t cultures that value family inclusion in client teaching, 483t ear and hearing assessment, 569t enema, administering, 1256t ethnopharmacology, 783t eye and vision assessment, 565t families, 317t fecal elimination, 1248t fluid, electrolyte, and acid–base balance, 1359t gender and race disparities in clients with cardiovascular disease, 1323t GI suction, 917t grieving, 1021t hair assessment, 555t hand hygiene, 642t health assessment general survey, 549t health care interpreter, working with, 82t hearing aids, 732t home care oxygen equipment, 1290–1291t, 1290f hygiene, 699f, 699t infection, 637t intradermal injection, administering, 819t IV push antibiotics, administering, 837t leadership, management, and delegation, 497t metered-dose inhalers, 848t moral distress, 106t moral principles, 103t mouth and oropharynx assessment, 575t musculoskeletal system assessment, 606t nutrition, 1176t nutritional practices, 1158t oral hygiene, 723t oxygenation, 1277t pain, 1128t pain management, 1146t peripheral vascular system assessment, 594t personal space, 192t positioning, moving, and turning clients, 1070t postoperative instructions, 913t providing culturally and linguistically appropriate services, 81t pulse, 521t pulse oximetry, 535t self-concept. assessing, 953t sensory perception disturbances, 935t sequential compression devices, 1330t skin assessment, 554t sleep, 1102t social support, cultural aspects of, 281t specimen collection, 763t sterile field, 657t stool specimens, 757t subcutaneous injections, 822t suctioning, 1297t suctioning a tracheostomy or endotracheal tube, 1301t surgical clients, 913t sutures or staples, removing, 924t temperature measurement, 512f, 512t

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Index therapeutic movement modalities from Eastern cultures, 1045f, 1045t tracheostomy care, 1305t transferring from bed to a chair, 1076t tube feeding, administering, 1191t urinary elimination, 1212t urine specimen collection, 760t wound care, 879t wound care and prevention of pressure ulcers, 868t Patient-controlled analgesia (PCA) described, 1140–1141, 1140f, 1141t PCA by proxy, 1141 Patient-controlled epidural analgesia (PCEA), 1139 Patient-Generated Subjective Global Assessment, 1170, 1170–1171f A Patient’s Bill of Rights, 464 PCA. See Patient-controlled analgesia (PCA) PCEA (patient-controlled epidural analgesia), 1139 PCM (protein-calorie malnutrition), 1169 PE (pulmonary embolism), 910t, 1324 Peak level of medications, 748 Peak plasma level of a drug, 780, 780f, 781 Pearson’s product-moment correlation coefficient (Pearson’s r ), 57t Peck, Robert, 342, 344t Peck’s theory of adult development, 342, 344t Pectus carinatum (pigeon chest), 580, 581f Pectus excavatum (funnel chest), 580, 581f Pedagogy, 466 Pediculosis hair hygiene, 724–725 lice in excessively matted hair, 726t Pediculus capitis, 724 Pediculus corporis, 724 Pediculus pubis, 724 Peer groups, 372, 372f PEG (percutaneous endoscopic gastrostomy), 1184, 1184f, 1190t PEG 3350. See Polyethylene glycol 3350 PEG-ES, 1251t PEJ (percutaneous endoscopic jejunostomy), 1184, 1184f Pelvic floor anatomy and physiology, 1202, 1203f muscle exercises, 1215, 1215t Penetrating wounds, 855t Penis assessment of, 621t Tanner stages of development, 620t Penlights, 543t Pennsylvania Hospital School of Nursing for Men, 34 Penrose drain, 921 Pentazocine, 1132t Peplau, Hildegard, and interpersonal relations model, 66 Pepsin, 1154 Pepto-Bismol. See Bismuth subsalicylate Perceived loss, 1015 Perception communication process, 442 defined, 930 older adults, 403–404 Percocet. See Oxycodone/acetaminophen Percodan. See Oxycodone/aspirin Percussion (clapping), and oxygenation, 1282, 1282f Percussion (reflex) hammer, 543t Percussion technique, described, 544–545, 544f, 545f, 545t Percutaneous, defined, 837 Percutaneous endoscopic gastrostomy (PEG), 1184, 1184f, 1190t Percutaneous endoscopic jejunostomy (PEJ), 1184, 1184f Perfusion, described, 592 Perfusion scan, 764 Pericardium, 1313, 1314f Peridural anesthesia, 905 Perineal care, with indwelling catheters, 1224 Perineal-genital care overview of, 707–708, 708t providing, skill for, 708–709t

Periodic limb movement disorder, 1101t Periodontal disease, 572, 715, 716t Perioperative nursing Chapter Highlights, 925t Critical Thinking Checkpoint, 925t intraoperative phase (See Intraoperative phase) perioperative period, defined, 891 postoperative phase (See Postoperative phase) preoperative phase (See Preoperative phase) sites for, 891–892 surgery, classifications of purposes for, 892, 892t risk, degree of age, 892 general health, 892, 893t medications, 893 mental status, 893 nutritional status, 892–893, 893t obstructive sleep apnea, 893 urgency, degree of, 892 surgery, phases of, 891 Peripheral neuropathic pain, 1114 Peripheral pulse, 513 Peripheral vascular resistance (PVR) arterial circulation, 1318 blood pressure, 526 Peripheral vascular system, assessment of Home Care Considerations, 594t Lifespan Considerations, 593–594t overview, 592 skill for, 592–593t Peripherally inserted central venous catheter (PICC), 1365 Peripheral-midline IV catheters, 1364–1365 Peripheral-short IV catheters, 1363–1364, 1364t, 1365f Peristalsis, 1237 Permethrin, 725 Permissive (laissez-faire) leader, 490, 490t PERRLA, defined, 562t Perseverance, in critical thinking, 175 Persistence, in the temperament theory of Chess and Thomas, 345t Personal critical thinking indicators, 171, 172t Personal distance, defined, 442–443, 443f Personal health record (PHR), 160 Personal knowing, 427, 428f Personal protective equipment eyewear, 647–649t, 651 face masks, 647–649t, 649, 650t, 651 gloves, 646–647, 647–649t, 651t gowns, 647–649t, 649 Home Care Considerations, 649t Personal space, 442–443, 443f Personal values, defined, 100 Personality, psychosocial development, 340 PES (Problem, Etiology, Signs and Symptoms) format, 208, 209t PET (positron emission tomography), 766, 766t Pew Research Center, 470 PH defined, 1342 urine testing, 762, 1209t Phagocytosis, 861 Phallic stage of Freud’s theory of psychosexual development described, 341, 341t, 344t preschoolers, 365–366 Phantom pain, 1115t Pharmacists, 120f, 121, 777 Pharmacodynamics, 781 Pharmacogenetics, 783 Pharmacokinetics defined, 781 oral medications, 782f processes of, 781 Pharmacology, 777 Pharmacopoeia, 778

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Pharmacy, defined, 777 Phenelzine, 1160t Phenobarbital, 1273 Phenol, 644t Phenomenology, 55 Phenylketonuria (PKU), 749 Phenytoin, 716 Philosophy, defined, 66 Phlebitis, 1383, 1383t Phlebotomists, 745 Phosphate imbalances, 1350 normal values, 748t, 1356t regulation of, 1341t, 1342 Physical component of wellness, 289, 290f Physical dependence, 1130 Physical development middle-aged adults, 384–385, 384t, 387t newborns and infants head and chest circumference, 356–357, 357f head molding, 357, 357f hearing, 357, 362t length, 356, 356f motor development, 358, 358f, 359t, 362t reflexes, 358, 358t smell and taste, 358 touch, 358 vision, 357, 362t weight, 356 school-age children, 367–368, 370t young adults, 380, 383t Physical examination client teaching, 472 health promotion, 280 Physical fitness assessment, 280, 280t, 281t Physical needs, in Maslow’s hierarchy of needs, 273, 273f Physical restraints, 685 Physical therapists, 120f, 121 Physician assistants, 121 Physician-assisted suicide, 87 Physicians, 120f, 121 Physicians’ offices, 117 Physicians’ orders, 94 Physiological aging biological theories of, 395, 395t cardiovascular system, 396t, 399–400 death and grieving, 403 economic change, 402 e-health, 402 endocrine system, 397t gastrointestinal system, 397t, 400 genitals, 397t, 400–401 grandparenting, 402 immunologic system, 397t independence and self-esteem, 403 integumentary system, 395, 396t, 397 neuromuscular system, 396t, 397–398, 398f overview of, 395, 407t psychosocial aging, 401, 401t, 407t pulmonary system, 396t, 399 relocation, 402–403 retirement, 401–402, 401f, 402f sensory-perceptual system, 396t, 398–399 sleep, 399t urinary system, 397t, 400 Physiological dependence, 780, 1130 Piaget, Jean, 345, 346t, 347t Piaget’s theory of cognitive development adolescents, 373 described, 197 newborns and infants, 359 school-age children, 369 toddlers, 363 young adults, 381

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Index

PICC (peripherally inserted central venous catheter), 1365 PICO format for research studies, 56 PICOC format for research studies, 56 PICOD format for research studies, 56 PICOS format for research studies, 56 PICOT format for research studies, 56 PIE (Problems, Interventions, Evaluation) documentation model, 252 Pigeon chest (pectus carinatum), 580, 581f Piggyback IV setups, 831, 832, 832f Pilates, described, 330 Pilates, Joseph, 330 Pillows, 871t, 1061t Pills, 777t Pilot study, defined, 56 Pinna (auricle), 565, 565f Piroxicam, 1132t Piston syringes for irrigation, 849, 849f Pitch of sound with auscultation, 545 Pitting edema, 1345–1346, 1346f Pityrosporum ovale, 629t Pivot joints, 1039f, 1039t PKU (phenylketonuria), 749 Place for interviews, 191 Placebo, defined, 1137 Placebo effect, 1137 Placenta, 355 Plague, 672t Plain Writing Act (2010), 81 Plaintiff, defined, 75, 76f Planned change, defined, 497 Planned Parenthood, 33 Planning. See also under Nursing Management Chapter Highlights, 232t client records, 248 Critical Thinking, Applying, 230t evaluation checklist, 239, 239t Lifespan Considerations, 229t management function, 492 nursing care plans documents in, 216, 217f example of, 229–230t formats for, 218, 220, 220f, 231t guidelines for writing, 221 multidisciplinary care plans, 220 standardized approaches, 216–218, 218f, 219f nursing interventions classification, 228, 229t nursing process, 215, 216f nursing process in action, 182–183f nursing process purpose and activities, 181, 184t, 185f planning process client goals/desired outcomes, establishing, 223–225, 223f, 223t, 224t, 225t, 226t individualized nursing interventions, writing, 227–228, 229–230t nursing interventions and activities, selecting, 225–227 priority setting, 221–223, 222t therapeutic communication, 447t types of discharge planning, 215–216 initial planning, 215 ongoing planning, 215 Plantar flexion, 1042f, 1042t Plantar (Babinski) reflex, 358t, 610t Plantar warts, 711 Plaque, dental, 572, 716 Plaque, skin, 550f Plasma fresh frozen, for transfusion, 1385t intravascular fluid, described, 1335, 1335f, 1336f plasma protein fraction, for transfusion, 1385t Plateau of concentration of a drug, 781

Platelets platelet count, 747t, 748f transfusion of, 1385t Play preschoolers, 367t school-age children, 370t toddlers, 364t Pleural effusion, 1305 Pleximeter, 544 Plexor, defined, 544 PLISSIT model for altered sexual function, 975–976 PM (hour of sleep) care, 695–696 Pneumococcal vaccine adolescents, 375t infants, 361t older adults, 408t preschoolers, 367t toddlers, 364t Pneumonia, 910t Pneumonic plague, 672t Pneumostat device for chest tubes, 1306, 1306f Pneumothorax, 1305 Podcast, defined, 156t Podiatrists, 121 Point of maximal impulse, defined, 513 Poisoning, 683, 683t Policies, for nursing care plans, 217 Polycythemia, 747 Polydipsia, 1205 Polyethylene glycol 3350, 1251t Polypnea (tachypnea), 523, 524t, 1273 Polysaccharides, 1154 Polysomnography, 1102 Polyunsaturated fatty acids, 1156 Polyurethane foam dressings, 873t Polyuria, 1205, 1206t Pomeroy syringe, 849, 849f POMR. See Problem-oriented medical record (POMR) Popliteal artery, 513f, 514, 514t, 516t Population defined, 134 older adults, U.S. and world, 390 Portal of entry, in the chain of infection, 631f, 632, 639t Portal of exit, in the chain of infection, 631f, 632, 632t, 639t Positioning clients dorsal recumbent position, 1063, 1063f, 1063t fecal elimination, 1249, 1249f, 1250–1251t, 1250f Fowler’s position, 1062–1063, 1062f, 1062t guidelines for, 1061–1062, 1061t Home Care Considerations, 1070t intraoperative phase, 906, 906t, 907f lateral position, 1063–1064, 1064f, 1064t, 1067–1068t Lifespan Considerations, 1070t orthopneic position, 1063, 1063f physical health assessment, 542, 542t postoperative care, 913 prevention of, 869 prone position, 1063, 1063f, 1064t, 1067–1068t Sims’ position, 1064, 1064f, 1065t support devices, 1061, 1061t Positive affirmations, 431, 431t Positive feedback, 271 Positive inotropic drugs, 1327 Positive reinforcement, 466 Positron emission tomography (PET), 766, 766t Post-Anesthetic Recovery Score (Aldrete Score), 908, 908t Postconventional level of Kohlberg’s theory of moral development adolescents, 373 described, 347, 348t, 350t middle-aged adults, 385–386 young adults, 381 Posterior tibial artery, 513f, 514, 514t, 516t

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Postformal thought stage of Piaget’s theory of cognitive development, 381 Post-herpetic neuralgia, 1115t Postmortem care, 1029 Postmortem examination, 85 Postoperative phase defined, 891 immediate postanesthetic phase, 907–909, 908f, 908t Nursing Management assessing assessment protocols, 909, 912 Lifespan Considerations, 912t potential problems, 910–911t diagnosing, 912 evaluating, 924 implementing deep-breathing and coughing exercises, 913–914 diet, 914 home care teaching, 923–924 hydration, 914 leg exercises, 914 moving and ambulation, 914 pain management, 912–913 positioning, 913 suction, 914–917, 914f, 915–917t, 918f urinary and gastrointestinal function, 914 wound care (See Wound care, postoperative phase) planning, 912, 913t ongoing care, preparing for, 909 Postural drainage, 1283 Postural hypotension. See Orthostatic hypotension Posture nonverbal communication, 441 normal movement, 1037, 1037f Postvoid residual (PVR) urine, 1209–1210, 1210f, 1210t Potassium food sources, 1341t imbalances, 1347, 1347t, 1348t normal values, 1356t normal values and functions, 748f, 748t regulation of, 1340, 1341t Potassium chloride, 1160t Potassium supplements oral supplements, 1361–1362 potassium given intravenously, guidelines for, 1347t Potentiating effect, defined, 780 Poverty, and health care delivery, 124, 124t Powder, described, 777t PPO (preferred provider organization), 128 Practice, as teaching strategy, 479 Practice discipline, defined, 63, 64 Practice Guidelines active ROM exercises, 1077t bandaging, 879t bed-making, 735t bedpans, giving and removing, 1250–1251t, 1250f bladder retraining, 1214t bloodborne pathogen exposure, 662t bloodborne pathogen exposure, practice guidelines for, 662t central vascular access device, client with, 1367t colleague accountability in pain management, 1131t communication during an interview, 193t damp gauze versus advanced dressings, 878t documentation, 262t facilitating fluid intake, 1361t fall prevention in health care agencies, 678t helping clients restrict fluid intake, 1361t home health care documentation, 259t individualizing care for clients with pain, 1129t interpreters, using, 310t IV starts, tips for, 1364t legal protection for nurses, 95t long-term care documentation, 259t medication administration, 795t

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Index medication administration by nasogastric or gastrostomy tube, 806t N95 respirator masks, 650t normal voiding habits, maintaining, 1214t nurses self-disclosing personal spiritual beliefs, 989t passive ROM exercises, 1077t praying with clients, 991t pressure sites, assessing, 860f, 860t pressure ulcers, treating, 872t religious practices, supporting, 989t reporting a crime, tort, or unsafe practice, 95t restraints, applying, 688t safe use of stretchers, 1072t skin preparations, applying, 838t surgical wounds, assessing, 918t vein selection, 1363t verbal communication with clients who have limited English proficiency, 310t wheelchair safety, 1072t wound assessment, 863t wounds, cleaning, 875t Prayer assisting clients with, 989–990, 990f, 991t complementary and alternative modality, 330–331 defined, 983–984 Prealbumin level, 1173 Preceptor, defined, 493 Preconceptual phase of Piaget’s theory of cognitive development described, 345, 346t, 347t toddlers, 363 Precontemplation stage of health behavior change, 278, 285f Preconventional level of Kohlberg’s theory of moral development described, 347, 348t, 350t school-age children, 369 toddlers, 363 Precordium, described, 586–587, 587f Prednisone, 1160t Preemptive analgesia, 1132 Preferred provider arrangements, 128 Preferred provider organization (PPO), 128 Prefilled unit-dose systems, 809, 809f Pregabalin coanalgesic, 1136 pain management, 1132t Pregenital stages of psychosexual development, 341, 341t Pregnancy breast and axilla assessment, 597t domestic violence in pregnant military women, 382t periodontal disease, 715 unwanted, teaching prevention of, 975, 975f, 976t Pregnancy test, 895t Prehelping (introductory) phase of the helping relationship, 449, 450t Prehypertension, 526, 527t Preinteraction phase of the helping relationship, 449, 450t Preload cardiac output, 1317, 1317t, 1318f heart failure, 1323t Prenatal development health promotion elimination, 355 nutrition and fluids, 355 oxygen, 355 safety, 355–356, 356t sleep and activity, 355 temperature maintenance, 355 maternal factors of impaired development, 355t stages of, 354–355 Preoperative phase defined, 891 informed consent, 893–894 Nursing Management

assessing physical assessment, 894 preoperative assessment data, 894, 894t screening tests, 895, 895t diagnosing, 895 evaluating, 904 implementing physical preparation, 899–904, 900f, 901t, 902–904t preoperative teaching, 895–899, 896t, 897–899t planning, 895 preoperative checklist, 899, 900f Preparation stage of health behavior change, 278, 285f Prepubertal changes, 368 Presbycusis, 396t, 398 Presbyopia, 396t, 398, 559 Preschoolers cognitive development, 366 communication with, 443t Developmental Assessment Guidelines, 368t health assessment and promotion, 367, 367t, 368t health care decisions, 178t Health Promotion Guidelines, 367t health risks, 367 moral development, 366–367 normal sleep patterns and requirements, 1095 nutrition, 1161–1162 oral health, 717 pain experience, 1120t physical development hearing and taste, 365, 368t height, 364, 368t motor abilities, 365, 365f, 368t vision, 364, 368t weight, 364, 368t psychosocial development, 365–366, 366f, 368t safety, 673t, 674 safety hazards, 667t sexual development, 961t spiritual development, 367 teaching considerations, 472t urinary elimination, 1202 Prescription, defined, 777 Presencing, defined, 988 Pressure Ulcer Scale for Healing (PUSH) tool, 861 Pressure ulcers. See also Wound care; Wound healing assessing, 864, 864f, 865f defined, 855 documentation on EHRs and paper-based records, 162t etiology of, 855–856 Home Care Assessment, 868t Lifespan Considerations, 879t preventing, 869–872, 871f, 871t reduction of as goal, 855, 855t risk assessment tools, 858, 859f, 860f, 860t risk factors, 856, 861t RYB color code, 872 stages of, 856, 857–858f supportive devices, 870–872, 871f, 871t treating, 872, 872t Preterm infants, 70t Prevention interventions, 228 Primary care defined, 133, 133f primary health care, differentiating from, 133, 133t Primary health care defined, 132 primary care, differentiating from, 133, 133t principles of, 132 Primary hypertension, 526 Primary intention healing, 860 Primary nursing framework for care, 126 Primary prevention described, 115, 115t

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health promotion, 274, 275t Neuman’s systems model, 68 Primary sexual characteristics, 371 Primary union, 860 Principled (postconventional) level of Kohlberg’s theory of moral development. See Postconventional level of Kohlberg’s theory of moral development Principled reasoning, 381 Principles-based (deontological) theories of morality, 102 Priority setting clinical reasoning, 175, 176t nursing care plans, 221–223, 222t Prison Rape Elimination Act (2003), 137 Privacy client labels on disposable supplies, 652t clients’ health information, 92, 92t data, 187 defecation, 1247–1248 electronic health records, 160 invasion of, 90–91, 90t, 91f Private law, defined, 74 Privilege, nursing license as, 77 Prn (as-needed) care, 696 Prn order defined, 786 pain management, 1128–1129, 1129t Probability (p value), 57 Pro-Banthine, 1205t Probing questions, as communication barrier, 448t Problem, in nursing diagnosis described, 202 evaluating phase of nursing process, 237f, 238, 238f Problem identification for nursing research, 164–165 Problem list, for POMR, 250–251, 251f Problem solving critical thinking, 173–174 stress, 1003 Problem-focused assessment, 185, 187t Problem-oriented medical record (POMR) advantage of, 250 database, 250 described, 250 plan of care, 251 problem list, 250–251, 251f progress notes, 251–252, 252f Problem-oriented record (POR), 250. See also Problemoriented medical record (POMR) Procedure-related accidents, 685 Procedures, for nursing care plans, 217 Process evaluation, defined, 240 Process recording, 456–457, 456–457t Proctoscopy, 763 Proctosigmoidoscopy, 763–764 Profession criteria for, 42–43 defined, 42 Professional advocacy, 110 Professional liability insurance, 93–94 Professional negligence, 88–89, 88t, 89t, 90t Professional values defined, 100 essential nursing values, 100, 100t Professionalism, defined, 43 Professionalization, defined, 43 Prognosis, as a barrier to learning, 469t Program of All-Inclusive Care for the Elderly (PACE), 151 Progress notes documentation in, 257 POMR, 251–252, 252f Progressive relaxation, 329t Projection, and stress, 1003t Proliferative phase of wound healing, 861 Promotion interventions, 228 Pronation, 1038t, 1040f, 1040t

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Index

Prone position, 542t, 1063, 1063f, 1064t, 1068–1068t Propionibacterium acnes, 629t Propoxyphene, 1133t, 1134 Propranolol circulation, 1327 oxygenation, 1280 urinary retention, 1205t Proprioception, 1038 Proprioceptors, 607 ProQuest, 58t Prosocial, defined, 366–367 Prospective payment system for health care, 127 Prostaglandins, 1116 Prostate cancer, 541t Prostheses, 901 Protein-calorie malnutrition (PCM), 1169 Proteins digestion, 1154 metabolism, 1155 storage, 1155 types of, 1154 vegetarian diets, 1168, 1168t Proteus species body reservoirs, in, 632t resident flora, 629t Prothrombin levels, 750t Protocols nursing care plans, 217 research studies, 56 Proventil. See Albuterol Provider of service, nurse as, 78, 79t Provigil. See Modafinil Proxemics, defined, 192, 442 Proximodistal direction of growth and development, 339f, 339t Pruritus, 1136t PSDA. See Patient Self-Determination Act (PSDA) Pseudoaddiction, 1130 Pseudoephedrine, 1205t Pseudomonas aeruginosa body reservoirs, in, 632t nosocomial infections, 630t Psoriasis, 550f Psoriasis vulgaris, 550f Psychological Abstracts (PsychINFO), 58t, 157t Psychological dependence, defined, 780, 1130 Psychological dimension of health, 293 Psychological factors fecal elimination, 1240 medication action, affecting, 783 nursing health history, 188t Psychological homeostasis, 272 Psychomotor domain, and learning, 466, 469 Psychoneurologic system exercise, benefits of, 1046–1047 immobility, effects of, 1051, 1055t Psychosocial aging, 401, 401t, 407t Psychosocial development adolescents, 371–373, 372f, 375t middle-aged adults, 385, 385t, 387t newborns and infants, 358–359, 359t, 362t preschoolers, 365–366, 366f, 368t school-age children, 368–369, 370t theories Erikson, 341–342, 342f, 344t Freud, 340–341, 341t, 344t Gould, 343–344, 343f, 344t Havighurst, 342, 343t, 344t Peck, 342, 344t toddlers, 362–363, 362t, 365t young adults, 380, 380f, 380t, 383t Psychosocial needs/factors isolation clients, 652 urinary elimination, 1204 Psyllium hydrophilic mucilloid, 1251t Puberty, 370–371

Pubic hair development of, 724 females, 617t, 618f, 618t males, 619, 620t, 621t Public advocacy, 110 Public distance, defined, 442, 443 Public health Internet as an effective public health intervention, 280t Nightingale, Florence, 32 Wald, Lillian, 33, 33f Public health agencies, 116, 116f Public law, defined, 74 PubMed, 58t Pulmonary embolism (PE) postoperative phase, 910t signs of, 1324 Pulmonary function tests, 1275, 1276f, 1276t Pulmonary system. See Respiratory system Pulmonary ventilation, 1269, 1271 Pulmonic area of the chest, 587, 587f Pulse apical pulse assessment, 517–520, 518–520t apical-radial pulse assessment, 520, 521t averages and normal ranges by age, 513t defined, 513 digoxin, affecting, 522t factors affecting, 513, 513t Home Care Considerations, 521t Lifespan Considerations, 520t peripheral pulse assessment, 514–517, 514f, 515–517t sites for, 513–514, 513f, 514f, 514t Pulse deficit, 520 Pulse oximeter, 533, 533f. See also Oxygen saturation (SaO2) Pulse pressure, 525 Pulse rhythm, defined, 515 Pulse volume, defined, 515 Punctures, 855t Pupils assessment of, 561–562t normal appearance, 560 Pureed diet, 1177 Purkinje fibers, 1316, 1316f Purosanguineous exudate, 862 Purulent exudate, 862 Pus, 862 Pustules, 550f PVR. See Peripheral vascular resistance (PVR) Pyorrhea, 572, 716 Pyrethrins, 725 Pyrexia clinical signs, 506, 506t defined, 505, 506f fevers, types of, 505 nursing interventions, 506, 507t

Q QA. See Quality assurance (QA) QI. See Quality improvement (QI) Qi, defined, 323 Qi gong, 330 QSEN. See Quality and Safety Education for Nurses (QSEN) Quad canes, 1081, 1081f Quadrants of the abdomen, 597, 598f, 598t Qualifiers, for problem, in nursing diagnosis, 202 Qualitative research, 55, 55t Quality and Safety Education for Nurses (QSEN) collaboration, competencies for, 138 moral distress, 106t nursing practice, influencing, 45 quality improvement, 241 safety, 667 Quality assurance (QA) described, 240 nursing administration, technology use in, 164

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Quality improvement (QI) defined, 241 nursing care quality, evaluating, 240–241, 240t Quality of health care, and health disparities, 304 Quality of life, 70 Quality of sound with auscultation, 545 Quantitative research, 54–55, 55t. See also Nursing research Quantity of sleep, defined, 1096 Queer, defined, 965 Questioning (sexuality), 965 Questions answering, as teaching strategy, 479t encouraging clients to write down questions, 479t Quinine, 324

R Race biologic similarities, 303, 303f blood pressure, 526 defined, 303 RACE (Rescue, Alarm, Confine, Extinguish) protocol for fires, 682 Racial and Ethnic Approaches to Community Health Across the United States (REACH US), 305 Racism, defined, 304 Radial artery, 513f, 514, 514t, 516t Radiation safety, 685 sterilization, 644 Radiation of heat, 504 Radiation therapy, 1159 Radiopharmaceutical, 765–766 Rales (crackles), 582t Range, defined, 57t Range of motion (ROM), defined, 1038 Range-of-motion (ROM) exercises active ROM, 1076, 1076t, 1077t active-assistive ROM, 1077t passive ROM, 1076–1077, 1077f, 1077t Ranitidine, 901 Rapport, 190 Rashes, 710t Ratio and proportion method of dosage calculation, 791–792 Rationales developing, for clinical reasoning, 176 nursing care plans, 218, 229–230t Rationalization, 1003t Ray’s theory of bureaucratic caring, 425, 426f RDA (recommended dietary allowance), 1166, 1167t REACH US (Racial and Ethnic Approaches to Community Health Across the United States), 305 Reaction formation, 1003t Reactive hyperemia, 856 Readiness to learn, 467, 472 Reagent, defined, 755 Reality, presenting, 447t Reassurance, unwarranted, 448t Rebound phenomenon for heat or cold, 883–884, 884t Receiver, in the communication process, 438–439, 438f Recent memory, 404 Receptor defined, 781 sensory process, 930 Recommended dietary allowance (RDA), 1166, 1167t Reconstitution of drugs, 812 Record, defined, 247 Recording, defined, 247 Recreation, 430–431, 431t Rectal body temperature measurement advantages and disadvantages, 507t described, 507 thermometer placement, 511t Rectal route of administration described, 776, 784t Lifespan Considerations, 846t

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Index opioids, 1137 overview, 846, 846f Rectum, and fecal elimination, 1237, 1237f, 1238f Rectus femoris site for IM injections, 825, 825f Red blood cell (RBC) count, 746t, 747, 747t, 748f Red blood cell (RBC) indices, 746t, 747 Refeeding syndrome, 1186 Referral summaries, 257–258 Referrals continuity of care, 140t, 141 home health care, 145, 145t postoperative phase, 924 Referred pain, 1113, 1113f Reflection clinical reasoning, 176 clinical reflection activity, 432, 432t defined, 432 nursing students, 432, 433t reflective journaling, 432, 432t therapeutic communication, 447t Reflections newsletter, 48 Reflex (percussion) hammer, 543t Reflexes neurologic system assessment, 607, 610t newborns and infants, 358, 358t pain, reaction to, 1118, 1118f Reflexology, 327, 328f Reflux, ureteral, 1201 Reflux urinary incontinence, 1211t Refusal of treatment, 82 Regeneration, described, 634 Regional anesthesia, 904–905 Regions of the abdomen, 597–598, 598f, 598t Registered nurses (RNs) delegation to, 497 educational programs associate degree, 36 baccalaureate degree, 37, 38t diploma programs, 36 licensing examination, 35 Registry, defined, 146 Regression stress, 1003t toddlers, 363 Regularity, in the temperament theory of Chess and Thomas, 345t Regurgitation, 1161 Rehabilitation older adults, 393–394 rehabilitation centers, 118–119, 119f Reiki, 328 Reimbursement, 248 Rejection, as a communication barrier, 448t Relapsing fever, 505 Relationships communication process, 443–444 Gilligan’s theory of caring and relationships, 348–349, 350t Relationships-based (caring) theories of morality, 102 Relaxation response, 1047 Relaxation techniques pain management, 1144–1145 stress and coping, 1007–1008 Relevance learning, 468 verbal communication, 439 Reliability of research data, 56 Religion. See also Spirituality cognitive dimension of health, 294 death-related practices, 1024, 1024f defined, 303–304, 980 history of nursing, 28–29, 29f hygienic practices, 696t morality, distinguishing from, 101, 101t nutritional practices, 1158t, 1159 sexuality, influencing, 967

Religious coping, 981 Relocation, by older adults, 402–403 REM sleep, 1093, 1094, 1094f, 1094t Remission, defined, 297 Remittent fever, 505 Renal disorders, as surgical risk, 893t Renin-angiotensin-aldosterone system, 1339 Reparative phase of inflammation, 634 Repetition, and learning, 468 Report, defined, 247 Reporting. See also Communication care plan conferences, 265 change-of-shift reports, 263–264, 263t, 264t Chapter Highlights, 266t Critical Thinking Checkpoint, 265t ethical and legal issues, 247–248, 248t nursing rounds, 265 purpose of, 262–263 report, defined, 247 telephone orders, 264–265, 265t telephone reports, 264 Repression preschoolers, 366 stress, 1003t Res ipsa loquitur, 88 Research client records, 248 defined, 53 dissemination of, using technology, 165–166 participants, rights of, 59–60, 60f, 60t professional status, aspect of, 43 roles and responsibilities for nurses, 57–60, 58t, 59t, 60f, 60t Research consumer, nurse as, 42, 57–58, 58t, 59t Research design defined, 56 technology use, 165 Research grants, 166 Research process critical thinking, 174 data, analyzing, 56–57, 57t data, collecting, 56 defined, 55 findings, communicating, 57 findings, using in practice, 57, 58f problem and purpose, formulating, 55–56 study methods, determining, 56 Research team member, nurse as, 59–60, 60f, 60t Reserpine, 324 Reservoir, in the chain of infection, 631–632, 631f, 632t, 639t Resident flora, defined, 628, 629t Residual volume (RV), 1276f, 1276t Resistive (isokinetic) exercises, 1044 Resolution phase of the sexual response cycle, 968, 968t Resonance, 545, 545t Resources health promotion, 284 management of, as skill of nurse managers, 493 self-concept, 953 Respect collaborative health care, 139 communication process, 444 Respiration assessing, 523, 523t, 524–525t average rates and normal ranges by age, 513t breathing, mechanics and regulation of, 522, 522f, 523f breathing, types of, 522 defined, 522 factors affecting, 523, 524t Home Care Considerations, 525t Lifespan Considerations, 525t Respiratory acidosis, 1351, 1351f, 1352t Respiratory alkalosis, 1351, 1351f, 1352t Respiratory character, 523 Respiratory disorders depression, with opioids, 1135, 1136t

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stress, 1000f surgical risk, 893t Respiratory hygiene/cough etiquette, 644 Respiratory membrane, 1269, 1269f Respiratory quality, 523 Respiratory rhythm, 523, 524t Respiratory system alveolar gas exchange, 1271 Anatomy & Physiology Review, 1270f exercise, benefits of, 1046 fluid, electrolyte, and acid–base imbalance, 1354t immobility, effects of, 1049–1050, 1049f, 1055t older adults, 396t, 399 oxygen and carbon dioxide systemic diffusion, 1272 oxygen and carbon dioxide transport, 1271 pulmonary ventilation, 1269, 1271 regulation of, 1272, 1272t structure of, 1268–1269, 1268f, 1269f, 1269t, 1270f Respiratory therapists, 120f, 121 Respiratory tract infections, 364 Respondeat superior defined, 78 negligence, 88 Response, in the communication process, 438f, 439 Responsibility defined, 79 legal responsibilities of nurses, 79t management principle, 492 moral principle, 103 one’s own actions, for, 497t Rest and sleep newborns and infants, 361t preschoolers, 367t toddlers, 364t Restating client’s message, 446t Resting energy expenditure (REE), 1157 Resting tremor, 603 Restoril. See Temazepam Restraints alternatives to, 686, 687t applying, skill for, 689–690t defined, 685 Home Care Considerations, 691t legal implications, 686, 686t, 687t Lifespan Considerations, 691f, 691t physical or chemical, 685–686 safety of older clients, 687t seclusion, 686, 686t selecting, 686–687 side rails, 733–734 types of, 687–688, 688f, 688t Retention enemas, 1253 Retention (indwelling, or Foley) urinary catheters, 761, 761f, 1218, 1219f, 1224–1225 Reticular activating system (RAS), 1092, 1093f Retirement older adults, 401–402, 401f, 402f retirement centers, 118 Retrograde pyelography, 764 Retrospective audit, 241–242 Return-flow enemas, 1253 Reverse Trendelenburg’s position for hospital beds, 734t Review of systems, described, 193, 194–195f Rhesus (Rh) factor, 1384 Rhonchi (gurgles), 582t Ribs, 580, 580f Richards, Linda, 32, 33f Rid. See Pyrethrins Right circumstances for delegation, 494 Right direction and communication for delegation, 494 Right person for delegation, 494 Right supervision and evaluation for delegation, 494 Right task for delegation, 494 Right to full disclosure, 60 Right to not be harmed, 60

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Index

Right to privacy, 60 Right to self-determination, 60 Rights defined, 79 legal rights of nurses, 79t nursing license not included, 77 refusal of treatment, 82 research participants, 59–60, 60f, 60t right-to-die statutes, 87 Right-to-die statutes, 87 Rigor mortis, 1029 Rinne test, 568–569t Risk factors, and cognitive dimension of health, 293 Risk management, 492 Ritalin. See Methylphenidate Rituals, challenging, 174–175 RN Response Network, 669 Roach’s theory of caring, the human mode of being, 425, 425t Robb, Isabel Hampton, 33 Robert Wood Johnson Foundation Quality and Safety Education for Nurses project, 45 Transforming Care at the Bedside, 241 Robinul. See Glycopyrrolate Roe v. Wade, 85 Rogers, Martha, and science of unitary human beings, 67 Role ambiguity, 951 Role conflicts, 951 Role development, 951 Role mastery, 951 Role model, defined, 491 Role performance defined, 951, 952t role performance model of health, 290 self-concept, 953–954, 954t Role strain, 951, 952t Role-playing, as a teaching strategy, 479t Roles communication process, 443–444 defined, 951 ROM. See Range-of-motion (ROM) exercises Roman Catholics, and health-related information, 990t Romberg test, 610t Root cause analysis, 241 Rooting reflex, 358t Rosaries, 983, 984f Rosenbaum eye charts, 563t Rosenstock and Becker’s health belief model action, likelihood of, 295–296 individual perceptions, 295 injury prevention practices, 296t modifying factors, 295 Rotation (movement), 1038t, 1039–1042f, 1039–1042t Rotavirus vaccine, 361t Rounding numbers, 790, 791t Routes of administration. See also individual routes buccal, 784t, 785, 785f inhalation, 784t, 785 medication orders, 787, 787t oral, 784, 784t parenteral, 784t, 785 rectal, 776, 784t sublingual, 784, 784t, 785f topical, 784t, 785 transdermal, 784t vaginal, 784t, 785 Roy, Callista, 68–69 Roy’s adaptation model described, 68–69, 195, 196t health and wellness, 290 RSS feed, defined, 156t Rubber bulb syringes for irrigation, 849, 849f Rubor, defined, 633t Rural health care agencies, 119, 127 Rural Health Clinics Act (1978), 127

Rust v. Sullivan, 85 RYB (Red, Yellow, Black) color code, 872

S S1 heart sound, 587, 587f, 587t, 1315t S2 heart sound, 587, 587f, 587t, 1315t S3 heart sound, 587 S4 heart sound (ventricular gallop), 587 SA (sinoatrial or sinus) node, 1316, 1316f Saddle joints, 1040–1041f, 1040–1041t Safe Patient Handling and Mobility Interprofessional National Standards Across the Care Continuum, 1058–1059 Safety adolescents, 375t Chapter Highlights, 692–693t clinical reasoning and medication administration safety, 178t Critical Thinking Checkpoint, 692t factors affecting age and development, 666, 667t cognitive awareness, 667 communication ability, 667 emotional state, 667 environmental factors bioterrorism, 668 community, 668 disaster planning, 668–669 health care setting, 667–668 home, 668 workplace, 668 lifestyle, 666 mobility and health status, 666 safety awareness, 667 sensory-perceptual alterations, 667 home health nursing clients, 147–148, 148f, 148t nurses, 148 Lifespan Considerations, 691t Maslow’s hierarchy of needs, 273, 273f middle-aged adults, 387t newborns and infants, 361t Nursing Management assessing bioterrorism attacks, 669–670, 672t home hazard appraisal, 669 National Patient Safety Goals, 669, 671t nursing history and physical examination, 669, 670f risk assessment tools, 669 diagnosing, 670 evaluating, 692 implementing adolescents, 673t, 675 bioterrorism attack, 685 carbon monoxide poisoning, 683, 683f electrical hazards, 684, 684f, 685t falls, 676–680, 676t, 677t, 678–680t firearms, 684–685 fires, 682–683, 682f health care settings, 676 middle-aged adults, 674t, 675 newborns and infants, 671, 673t noise, 684 older adults, 674t, 675–676, 675t, 676t poisoning, 683, 683t preschoolers, 673t, 674 problems across the life span, 676 procedure- and equipment-related accidents, 685 radiation, 685 restraining clients (See Restraints) scalds and burns, 682 school-age children, 673t, 674–675 seizures, 680–681t, 680–682, 682t suffocation or choking, 683–684, 684f

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toddlers, 671, 673t, 674, 674f, 674t young adults, 673–674t, 675 planning, 670–671 older adults, 408t oxygen therapy, 1284–1285, 1285t prenatal development, 355–356, 356t preoperative preparation, 902, 902t preschoolers, 367t school-age children, 370t toddlers, 364t young adults, 384t Safety angry clients, 1007t assisting a client to ambulate, 1081t CAUTI incidence, reducing, 1217t central line-associated infections, preventing, 1365t client identification, 797t diagnostic tests, timely reporting of, 745t edges of steps, painting to prevent falls, 675 electronic blood pressure cuffs, removing periodically, 532t fall potential, assessing clients for, 89t Fleet enemas, contraindications for, 1253t health care-associated infections, reducing, 630t home hazard appraisal for adults, 148t hygiene, 706t informed consent, obtaining, 82t insulin as high-alert medication, 817t Joint Commission and medication safety, 145t medication reconciliation, 796t medication safety, 804t mercury-in-glass thermometers, 508t microorganisms causing infection in others, 630t mobility and activity problems, 1057t MRI for clients with tattoos, 765t PCA pump, 1141t pressure ulcers, prevention of, 855t rebound phenomenon for heat or cold, 884t respirations, 525t restraints, applying, 691t safety monitoring devices, 680t sedation and respiratory status, assessing for, with opioids, 1136t seizure precautions, 682t side rail entrapment, 734t standard precautions and personal protective equipment, 649t suicide by older adults, 676t, 1023t transfusion errors, eliminating, 1386t Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery, 902t verbal medication orders, 785t Safety Alert! angry clients, 1007t CAUTI incidence, reducing, 1217t central line-associated infections, preventing, 1365t client identification, 797t diabetes, clients with, 710t diagnostic tests, timely reporting of, 745t edges of steps, painting to prevent falls, 675t electronic blood pressure cuffs, removing periodically, 532t Fleet enemas, contraindications for, 1253t food dye, not adding to tube feedings, 1186t health care-associated infections, reducing, 630t insulin as high-alert medication, 817t Joint Commission and medication safety, 145t medication reconciliation, 796t medication safety, 804t mercury-in-glass thermometers, 508t microorganisms causing infection in others, 630t MRI for clients with tattoos, 765t naloxone for opioid-containing epidural infusion, 1139t pressure ulcers, prevention of, 855t rebound phenomenon for heat or cold, 884t responsibility for one’s own actions, 497t

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Index sedation and respiratory status, assessing for, with opioids, 1136t side rail entrapment, 734t stylets in nasogastric tubes, not reinserting, 1182t suicide by older adults, 676t, 1023t transfusion errors, eliminating, 1386t Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery, 902t verbal medication orders, 785t Safety monitoring devices defined, 678 Home Care Considerations, 680t using, skill for, 678–680t Safety syringes, 810, 811f Safety-net hospitals, 118 Salem sump tube, 1180, 1180f Saliva, 762 Salmonella species, 632t Sample, defined, 56 Sander’s phases of bereavement, 1017, 1018t Sanger, Margaret Higgins, 33, 34f Sanguineous exudate, 862, 862t Saquinavir, 1160t Sarcopenia, 397 SAS (Statistical Analysis System), 165 SASH (Saline, Administer drug, Saline, Heparin) flushing procedure, 834 Saturated fatty acids, 1156 Saunders, Cecily, 1026 Saw palmetto, 325t SBAR (Situation, Background, Assessment, Recommendation) communication tool, 263–264, 264t, 459, 459t Scabies, 725 Scald, defined, 682 Scales, skin, 551t Scars, 551t “Scheduled rounding” and fall prevention, 677–678 Schoenhofer and Boykin’s theory nursing as caring, 426 School nursing, 33 School-age children cognitive development, 369, 369f communication with, 443t defecation, 1238–1239 Developmental Assessment Guidelines, 370t health assessment and promotion, 370, 370t health care decisions, 178t Health Promotion Guidelines, 370t health risks, 369–370, 369f moral development, 369 normal sleep patterns and requirements, 1095, 1095t nutrition, 1162 oral health, 717 pain experience, 1120t physical development hearing and touch, 368, 370t height, 367, 370t motor abilities, 368, 370t prepubertal changes, 368 vision, 368, 370t weight, 367, 370t psychosocial development, 368–369, 370t pulse and respiration average and normal range, 513t safety, 673t, 674–675 sexual development, 960, 961t spiritual development, 369 teaching considerations, 472t urinary elimination, 1202–1203 Science, influencing nursing practice, 45–46 Scientific health belief, 308 Scientific validation, defined, 57 Scoliosis, 580, 581f Scope and Standards of Nursing Practice ( ANA), 181 Scope of nursing practice, 75 Scopolamine, 901

Screening examination, described, 193, 194–195f Scrub person, 906 Searching Faith stage of Westerhoff ’s theory of spiritual development, 349, 350t Seating arrangements for interviews, 191 Sebaceous glands, 371 Sebum, 696 Seclusion, defined, 686, 686t “Second degree” BSN programs, 37 Secondary hypertension, 526 Secondary intention healing, 860 Secondary IV administration sets, 1366 Secondary prevention described, 115–116 health promotion, 274, 275t Neuman’s systems model, 68 Secondary sexual characteristics, 371 Sedation opioids, 1135, 1135t, 1136t preoperative preparation, 901 Sedentary lifestyle, 1320t, 1321–1322 Seizure, defined, 680 Seizure precautions defined, 680 Home Care Considerations, 682t implementing, skill for, 680–681t Lifespan Considerations, 681t Selective serotonin reuptake inhibitors (SSRIs), 1134 Selectively permeable, defined, 1336 Self, loss of an aspect of, 1015–1016 Self, offering, 447t Self-actualization, 273, 273f Self-awareness culturally responsive nursing care, 313 defined, 948 self-awareness groups, 453 Self-Care, Dependent Care & Nursing, 67 Self-care abilities Orem’s general theory of nursing, 67 skin hygiene, 696, 697t Self-Care Alert change, as viewed by nurses, 497t compassion fatigue, nurses susceptible to, 83t exercise, thinking of as physical activity, 281t knowledge of health behaviors and action, 294t mild or moderate anxiety, 1002t nurses as interpreters, 311t nurses must protect own health and private information, 124t nurses’ need to analyze own feelings about death, 1023t nurses’ personal definition of health, 289t nursing school as a stressor, 282t prophylaxis for HIV exposure, considering, 662t self-esteem, need for, 951t self-healing methods for nurses, 323t storytelling in nursing education, 431t T’ai chi and yoga for spirituality and health, 281t Self-care deficits, etiologies of, 698, 698t Self-care for nurses healthy lifestyle activity and exercise, 430, 430f nutrition, 430 recreation, 430–431, 431t unhealthy patterns, avoiding, 431, 431t mind-body therapies guided imagery, 431 meditation, 431 music therapy, 431 storytelling, 431, 431t yoga, 431, 432f Self-concept adolescents, 371–372 Chapter Highlights, 958t components of body image, 950–951, 950f

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personal identity, 950 role performance, 951, 952t self-esteem, 951, 951t Critical Thinking Checkpoint, 958t defined, 948 dimensions of, 948 factors affecting developmental stage, 952 family and culture, 952, 952f history of success and failure, 953 illness, 953 resources, 953 stressors, 942, 942t formation of, 949–950, 949t Nursing Management assessing body image, 953, 954f, 954t culture, 953, 953t personal identity, 953, 953t role performance, 953–954, 954t self-esteem, 954 stressors, 953, 953t diagnosing, 954–955 evaluating, 955, 957 implementing self-esteem, enhancing, 955, 956f, 956–957t strength, areas of, 955, 955t planning, 955 preschoolers, 365, 366f psychological dimension of health, 293 school-age children, 368 toddlers, 362–363 Self-control, 1004 Self-esteem enhancing, 955, 956–957t, 956f, 957f Maslow’s hierarchy of needs, 273, 273f physiological and psychosocial aging, 403 self-concept, 951, 951t, 954 Self-help bed baths, 701 Self-help groups group communication, 452–453, 453t health care agencies, 119 Self-regulation, 271 Self-talk, defined, 437, 438f Semicircular canals, 565f, 566 Semicomatose, described, 931t Semi-Fowler’s position, 734t, 1062, 1062f, 1062t Semilunar valves, 1313, 1314f Sender, in the communication process, 438, 438f Senna, 1251t Senokot. See Senna Sensitivity, in the temperament theory of Chess and Thomas, 345t Sensitization, defined, 1115t Sensorimotor phase of Piaget’s theory of cognitive development described, 345, 346t, 347t newborns and infants, 359 toddlers, 363 Sensorineural hearing loss, 566 Sensoristasis, defined, 930 Sensory deficits communication, impairment to, 453 described, 932–933 Sensory deprivation clients at risk for, 933, 934t clinical manifestations, 932t described, 932 preventing, 940, 941t Sensory function neurologic system assessment, 607–608, 613–614t newborns and infants, 357–358, 362t toddlers, 362, 365t Sensory memory, 404

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Index

Sensory overload clients at risk for, 933, 934f, 934t clinical manifestations, 932t described, 932 noise level, 934t preventing, 940 Sensory perception Chapter Highlights, 946t Critical Thinking Checkpoint, 944t defined, 930 diminished sensation, and pressure ulcers, 856 middle-aged adults, 384t Nursing Management assessing client environment, 933–934, 934t clients at risk for sensory deprivation or overload, 933, 934f, 934t mental status, 933 nursing history, 933, 933t physical examination, 933 social support network, 934 Concept Map, 945f diagnosing, 934–935 evaluating, 943, 943–944t implementing confused clients, 941–943, 942t, 943f, 943t healthy sensory function, promoting, 935–937, 936t, 937t, 938–939f, 939t Lifespan Considerations, 939t sensory impairments, managing, 937, 940, 940t, 941t planning, 935, 935t older adults, 396t, 398–399 safety, 667 sensory alterations sensory deficits, 932–933 sensory deprivation (See Sensory deprivation) sensory overload (See Sensory overload) sensory experience, components of arousal mechanism, 930–931, 931t sensory process, aspects of, 930, 931f sensory function, factors affecting culture, 931 developmental stage, 931 lifestyle and personality, 932 medications and illness, 931–932 stress, 931 Sensory reception, defined, 930 Sensory stimulation, for newborns and infants, 361t Sentinel event, defined, 241 Separation anxiety, 363 Sepsis defined, 629 transfusion reaction, 1385t Septicemia, 629 Septum, cardiac, 1313 Sequence of events, for therapeutic communication, 447t Sequential compression devices circulation, 1328, 1328–1329t, 1328f, 1330t preoperative preparation, 904 Serosanguineous exudate, 861, 862 Serous exudate, 862 Sertraline HCl, 1009t Serum glutamic-oxaloacetic transaminase (SGOT). See Aspartate aminotransferase (AST) Serum osmolality, 747, 748t, 1356t, 1357 Serum pyretic transaminase (SGPT). See Alanine aminotransferase (ALT) Service, orientation to, 43 Sesame Street, and cognitive development, 359 Setting (isometric or static) exercises, 1044, 1044f Seventh-Day Adventists, and health-related information, 990t Severe anxiety, 1001, 1002t Severe pain, 1114 Sex education, 963

Sexual abuse and harassment, 83, 84, 975 Sexual aversion disorder, 969 Sexual behavior inappropriate, dealing with, 977, 977t responsible, 974–975, 975f, 975t, 976t Sexual characteristics of adolescents, 371, 375t Sexual identity, 372 Sexual orientation, types of, 965 Sexual response cycle, phases of, 967–968, 968t, 969f Sexual rights, 964, 964t Sexual self-concept, defined, 964 Sexuality altered sexual function orgasmic disorders, 970 overview, 968–969 past and current factors, 969, 970t satisfaction, problems with, 971 sexual arousal disorders, 969–970, 971t sexual desire disorders, 969 sexual pain disorders, 970–971 Chapter Highlights, 978t Critical Thinking Checkpoint, 977t development of adolescence, 960, 961t, 962, 962t, 963t birth to 12 years, 960, 961t older adulthood, 961t, 962–964 young and middle adulthood, 961t, 962 factors influencing culture, 967 family, 966–967, 966f personal expectations and ethics, 967, 967t religion, 967 middle-aged adults, 384t misconceptions, 962, 962t Nursing Management assessing, 971–972, 972t diagnosing, 972–973 evaluating, 977 implementing altered sexual function, counseling for, 975–976 inappropriate sexual behavior, 977, 977t nurses’ skills and responsibilities, 973, 973t responsible sexual behavior, 974–975, 975f, 975t, 976t self-examination, teaching, 973–974, 974f, 974t sex education, 973 planning, 973 sexual health components of, 964–965, 964f sexual rights, 964, 964t sexual response cycle, 967–968, 968t, 969f varieties of erotic preferences, 966 gender identity, 965–966, 965f sexual orientation, 965 Sexuality Information and Education Council of the United States, 973 Sexually transmitted infections (STIs) adolescents, 962 clinical manifestations, 963t prevention, teaching, 975, 975f, 975t young adults, 382 Shaft of the needle, 809, 809f Shaken baby syndrome, 360 Shampooing hair, 727, 727f Shared governance, defined, 491 Shared leadership, 491 Sharp debridement, 872 Sharps disposal for clients in isolation, 652 Shaving beards and mustaches, 728, 728t Shearing force, 856 Shigella species, 629t Shingles vaccine, 408t Shock phase of GAS, 999, 1001f Short Form McGill Pain Questionnaire, 1123

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Shortness of breath, defined, 1273 Short-term coping strategies, 1004 Short-term memory, 404 Shoulder joint movements, 1039f, 1039t Shower chairs, 701, 701f Showers, giving to clients, 701, 701f Shroud, defined, 1029 Side effect, defined, 779 Side rails, 733–734, 734t SIDS (sudden infant death syndrome), 360, 360t Sigma Theta Tau, 48 Sigmoidoscopy, 1244, 1244f Signatures documentation, 261 prescriber, on medication orders, 787, 787t Signs, defined, 186 Sildenafil citrate, 971t Silence, for therapeutic communication, 446t Silicone catheter balloons, 1218 Simethicone/loperamide, 1252 Simple oxygen face masks, 1286, 1286f Simplicity, in verbal communication, 439 Sims’ position, 542t, 1064, 1064f, 1065t Single adults living alone, 414 Single order, defined, 786 Single stoma, described, 1244 Single-dose vials, 812 Single-parent families, 413 Sinoatrial (SA or sinus) node, 1316, 1316f Sinuses. See Nose and sinuses Sitting position, for physical health assessment, 542t Sit-to-stand power lift, 1059f Situational leaders, 490 Situational stressors, 998 Sitz bath, 886, 887f Six C’s (Compassion, Competence, Confidence, Conscience, Commitment, Comportment) of caring in nursing, 425, 425t Skills activity and exercise assisting a client to ambulate, 1079–1080t assisting a client to sit on the side of the bed (dangling), 1069–1070t logrolling a client, 1068–1069t moving a client up in bed, 1066–1067t transferring between bed and chair, 1072–1074t transferring between bed and stretcher, 1074–1075t turning a client to the lateral or prone position in bed, 1067–1068t asepsis hand hygiene, performing, 640–642t personal protective equipment, applying and removing, 647–649t sterile field, establishing and maintaining, 654–657t sterile gloves, applying and removing (open method), 658–659t sterile gown and gloves, applying (closed method), 659–661t circulation, sequential compression devices, 1328–1329t diagnostic testing collecting a urine specimen for culture and sensitivity by clean catch, 758–760t obtaining a capillary blood specimen to measure blood glucose, 752–754t fecal elimination changing a bowel diversion ostomy appliance, 1259–1261t enema, administering, 1253–1255t fluid, electrolyte, and acid–base balance changing an IV catheter to an intermittent infusion lock, 1382–1383t changing an IV container and tubing, 1379t initiating, maintaining, and terminating a blood transfusion using a Y-set, 1387–1389t IV infusion, discontinuing, 1380–1381t

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Index IV infusion, monitoring, 1376–1378t IV infusion, starting, 1370–1374t health assessment abdomen, 599–602t anus, 622–623t appearance and mental status, 546–547t breasts and axillae, 594–597t ears and hearing, 566–569t eyes and visual acuity, 560–564t female genitals and inguinal area, 617–618t hair, 555t heart and central vessels, 588–591t male genitals and inguinal area, 620–621t mouth and oropharynx, 572–574t musculoskeletal system, 604–605t nails, 556–557t neck, 576–578t neurologic system, 608–614t, 616t nose and sinuses, 570–571t peripheral vascular system, 592–593t skin, 551–553t skull and face, 558t thorax and lungs, 582–585t hygiene adult clients, bathing, 702–706t foot care, providing, 713–714t hair care, 726–727t hearing aids, removing, cleaning, and inserting, 731–732t occupied bed, changing, 739–740t oral care for the unconscious client, 712–713t perineal-genital care, 708–709t teeth, brushing and flossing, 718–721t unoccupied bed, changing, 736–738t medications adding medications to intravenous fluid containers, 829–831t administering intradermal injection for skin tests, 818–819t administering intramuscular injection, 827–828t administering intravenous medications using IV push, 834–837t administering ophthalmic instillations, 839–841t administering otic instillations, 841–843t administering subcutaneous injection, 820–822t administering vaginal instillations, 844–846t mixing medications using one syringe, 816–817t oral medications, administering, 801–804t preparing medications from ampules, 813–814t preparing medications from vials, 814–815t nutrition gastrostomy or jejunostomy feeding, administering, 1189–1190t nasogastric tube, inserting, 1180–1183t nasogastric tube, removing, 1192–1193t tube feeding, administering, 1186–1189t oxygenation oropharyngeal, nasopharyngeal, and nasotracheal suctioning, 1295–1297t oxygen administration by cannula, face mask, or face tent, 1288–1289t suctioning a tracheostomy or endotracheal tube, 1299–1301t tracheostomy care, providing, 1302–1305t pain management, back massage, 1142–1143t perioperative nursing antiemboli stockings, applying, 902–904t cleaning a sutured wound and changing a dressing on a wound with a drain, 918–920t gastrointestinal suction, managing, 915–917t teaching moving, leg exercises, deep breathing, and coughing, 897–899t safety bed or chair exit safety monitoring devices, using, 678–680t

restraints, applying, 689–690t seizure precautions, implementing, 680–681t skin integrity and wound care wound, irrigating, 875–877t wound drainage specimen for culture, obtaining, 865–867t urinary elimination bladder irrigation, performing, 1226–1227t external urinary device, applying, 1215–1217t urinary catheterization, performing, 1220–1223t vital signs apical pulse, 518–520t apical-radial pulse, 521t blood pressure, 530–532t body temperature, 510–511t oxygen saturation, 534–535t peripheral pulse, 515–517t respirations, 524–525t Skin assessment record, 257 clients confined to wheelchairs, 1072t common problems and nursing interventions, 696, 697t, 698 fluid, electrolyte, and acid–base imbalance, 1354t functions of, 696 incontinence, 1215 lesions describing, 553t photographing, 553t primary, 549, 550f secondary, 549, 551f nonspecific defense against infection, 633 physical assessment Home Care Considerations, 554t Lifespan Considerations, 554t overview of, 548–549 skill for, 551–553t postoperative assessment, 909 preoperative preparation, 901 stress, 1000f surgical preparation, 906 trauma, avoiding, 870 Skin hygiene Nursing Management assessing nursing history, 696–698, 697t, 698t physical assessment, 698 diagnosing, 698, 698t evaluation, 710 implementing bathing, 700–707, 701f, 702–706t, 707t client teaching, 710, 710t guidelines for, 700, 700t overview, 699 perineal-genital care, 707–708, 708–709t, 708t planning, 698–699, 699f, 699t pressure ulcer prevention, 870 Skin integrity Chapter Highlights, 888–889t Client Teaching, 868t Critical Thinking Checkpoint, 888t factors affecting, 854 Skin preparations, applying, 838–839, 838t Skin temperature, 544 Skinfold measurement, 1170, 1172, 1172f, 1172t Skin-level gastrostomy tube, 1184, 1185f Skinner, B. F., 345, 347t Skinner’s behaviorist theory, 345, 347t Sklice. See Ivermectin Skull and face, assessment of bones of the head, 557, 557f Lifespan Considerations, 558t overview of, 557–558, 557f skill for, 558t

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1505

Slander, 91–92, 91f Slater’s theory of developmental tasks, 385t Sleep. See also Rest and sleep Chapter Highlights, 1109t common disorders hypersomnia, 1099 insomnia, 1098–1099, 1099t insufficient sleep, 1094t, 1099t, 1100–1101 narcolepsy, 1099–1100, 1100t parasomnias, 1101, 1101t sleep apnea, 1100, 1100t defined, 1092 factors affecting, 1096–1098, 1097t, 1098t functions of, 1094, 1095t mortality of elderly Hispanics, 399t normal patterns and requirements, by age, 1094–1105, 1095t, 1096f, 1096t Nursing Management assessing diagnostic studies, 1102 health history, 1101 physical examination, 1102 sleep diary, 1102 sleep history, 1101, 1102t Concept Map, 1108f diagnosing, 1102–1103 evaluating, 1105 implementing bedtime rituals, supporting, 1104 client teaching, 1103–1104, 1103t comfort and relaxation, 1104 medications, 1105, 1105t, 1106t restful environment, creating, 1104, 1104t Nursing Care Plan, 1106–1107t planning, 1103 physiological aging, 399t physiology of circadian rhythms, 1092–1093 NREM sleep, 1093–1094, 1094f, 1094t REM sleep, 1093, 1094, 1094f, 1094t reticular activating system, 1092, 1093f sleep cycles, 1094, 1094f prenatal development, 355 preoperative preparation, 901 stress and coping, 1006–1007 Sleep apnea described, 1100, 1100t obstructive sleep apnea, 893, 1100, 1287 Sleep architecture, defined, 1093 Sleep deprivation adolescents, 1096, 1097t common disorder, 1100–1101 decision regret among critical care nurses, 1099t hospitalized clients, 1094t Sleep diary, 1102 Sleep hygiene, 1103 Sleep quality, 1096 Sleeptalking, 1101t Sleepwalking, 1101t Sliding boards, 1071 Slipp® Patient Mover, 1060f Slipper (fracture) bedpans, 1249, 1250f Slow-Fe. See Ferrous sulfate Small calorie (c, cal), 1156 Small intestines, 1246f Small-bore feeding tubes, 1180, 1180f Smallpox, 672t Smart phones, 156t Smell, sense of data collection, 190t newborns and infants, 358 Smoking cardiovascular risk factor, 1320t, 1321 prenatal development, 355–356

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Index

Smoking—Cont. sleep, 1098 young adults, 382 Snellen eye charts, 560f, 563–564t Snoring, 1100t SOAP (Subjective data, Objective data, Assessment, Planning) format for progress notes, 251–252, 252f SOAPIE (Subjective data, Objective data, Assessment, Planning, Interventions, Evaluation) format for progress notes, 251–252 SOAPIER (Subjective data, Objective data, Assessment, Planning, Interventions, Evaluation, Revision) format for progress notes, 251–252 Soapsuds enemas, 1252t Social component of wellness, 289, 290f Social constructivism theory of Vygotsky, 346, 347t Social data, for nursing health history, 188t Social distance, defined, 442, 443 Social interactions adolescents, 375t middle-aged adults, 387t older adults, 408t school-age children, 370t young adults, 384t Social justice, 100, 100t Social learning theories of growth and development Bandura, 346, 347t Vygotsky, 346, 347t The Social Life of Health Information, 470 Social media defined, 156t potential liability in nursing, 92 Social needs, in Maslow’s hierarchy of needs, 273, 273f Social network, defined, 156t Social Services Abstracts, 58t Social support networks/systems health promotion, 281, 281t, 284 health status, beliefs, and practices, 294 sensory perceptual functioning, 934 Social workers, 121 Socialization to nursing, 43–44, 44t Society attitudes about nurses and nursing, 30–32, 31f ethical problems in nursing, 105 Socioeconomic status. See also Economic factors family health, 418 health status, beliefs, and practices, 294 loss and grief responses, 1020 nutrition, 1159 older adults, 391 Socrates, 172 Socratic questioning, 172, 172t Sodium imbalances, 1346–1347, 1346f, 1348t normal values, 748f, 748t, 1356t regulation of, 1340, 1341t Sodium oxybate, 1100, 1100t Sodium phosphate, 1251t Sodium sulfate, 1251t Soft contact lenses, 729 Soft diet, 1177, 1177t SOLER (Squarely face, Open posture, Lean toward, Eye contact, Relaxation) portrayal of empathy, 446t Solutes, defined, 1336 Solvent, defined, 1336 Somatic pain, 1114 Somnolent, described, 931t Sonata. See Zaleplon Sordes, 572, 716t Source-oriented record components of, 249t described, 249 narrative charting, 249, 250f, 250t

Space orientation culturally responsive care, 312 distance between interviewee and interviewer, 191–192, 192t Spastic, defined, 1048 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), 127 Specific defenses against infection, 633 Specific gravity defined, 1357 urine testing, 761–762 Specific self-esteem, 951 Spelling, correct, in documentation, 261, 261t Sphenoid sinuses, 570f, 843, 844f Sphygmomanometers, 527, 527f, 528f Spider concept maps, 177f, 177t Spinal anesthesia, 905 Spine, and locomotion, 1054f Spinosad, 725 “Spirit of Nursing” monument, Arlington National Cemetery, 30, 30f Spiritual beliefs cognitive dimension of health, 294 loss and grief responses, 1019–1020 Spiritual care, defined, 981 Spiritual component of wellness, 289, 290f Spiritual coping, 981 Spiritual development adolescents, 373 middle-aged adults, 386 preschoolers, 366 school-age children, 369 toddlers, 363 young adults, 381 Spiritual development theories Fowler, 349, 350t Westerhoff, 349, 350t Spiritual distress Concept Map, 994f defined, 981 Nursing Care Plan, 992–993t Spiritual health assessment of, 281, 281t defined, 981 exercise, benefits of, 1047, 1047f Spiritual interventions, 1145 Spiritual needs, 981, 982t Spiritual nursing care, 981 Spiritual self-awareness for nurses, 991–992 Spiritual support dying and death, 1027–1028 health care providers, 121 Spiritual wellness (well-being), defined, 981 Spirituality Chapter Highlights, 995t complementary and alternative healing modalities, 322 Critical Thinking Checkpoint, 992t defined, 980 Nursing Management assessing, 986–987, 986t Concept Map, 994f diagnosing, 987 evaluating, 991, 992–993t, 994f implementing prayer, assisting with, 989–990, 990f, 991t presence, providing, 988 religious practices, supporting, 988–989, 989t, 990t spiritual care experts, referring clients to, 990 spirituality, conversing about, 988, 988t, 989t Nursing Care Plan, 992–993t planning, 987–988 older adults, 404–405 related concepts, 980–981

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religious practices and beliefs beliefs, sharing, 985t birth, 985 death, 985 diet, 984 dress and modesty, 984–985, 985f ethical guidelines for nurses, 982, 982t holy days, 982 illness and healing, 984 prayer and meditation, 983–984 sacred symbols, 983, 984f sacred texts, 982–983 spiritual development, 981–982, 983t spiritual health and the nursing process, 985–986 spiritual self-awareness for the nurse, 991–992 Spiritually sensitive nursing care, 981 Spoon-shaped nails (koilonychia), 554, 556, 556f Spores, 644t Spreadsheet, defined, 156t SPSS (Statistical Package for the Social Sciences), 165 Sputum defined, 762, 1274 specimen collection, 762–763, 763f, 763t “Sputum trap,” 762 SSRIs (selective serotonin reuptake inhibitors), 1134 St. John’s wort, 325t Stadol. See Butorphanol Stage of exhaustion of GAS, 1000, 1001f Stage of resistance of GAS, 999–1000, 1001f Standard, comparing data with, 204–205, 205t Standard deviation, 57t Standard precautions, described, 644, 645t Standardized care plan approaches to, 216–218, 218f defined, 216 documentation, 256 example of, 219f Standards of care defined, 77–78 nursing care plans, 216, 218f Standards of Practice (Infusion Nurses Society), 1363 Standards of Practice, defined, 41 Standards of Professional Performance (ANA), 41 Standing orders defined, 786 nursing care plans, 217 Stapes, 565f, 566 Staphylococci species, 1238 Staphylococcus aureus body reservoirs, in, 632t nosocomial infections, 630, 630t resident flora, 629t “toxic shock,” 962 Staphylococcus epidermidis, 629t Staphylococcus epidermidis coagulase, 633 Staples, surgical, removing, 922, 923, 923f, 924t Starches, dietary, 1154 Stare decisis, 74 Stat order, defined, 786 Static (isometric or setting) exercises, 1044, 1044f Static low-air-loss beds, 871f, 871t Statin drugs, 1160t Statistical Analysis System (SAS), 165 Statistical Package for the Social Sciences (SPSS), 165 Statuary law (legislation), 46, 74, 74f, 74t, 75t Status quo, challenging, 174–175 Steatorrhea, 757 Stem cell research, 108 Step (blended) families, 414 Stepping (walking or dancing) reflex, 358t Stereognosis, 368, 930 Stereotyping ageism, 392, 392t

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Index communication barrier, 448t defined, 304 Sterile field defined, 652 establishing and maintaining, skill for, 654–657t Home Care Considerations, 657t Sterile technique defined, 629 principles and practices of surgical asepsis, 652, 653t sterile fields, 652, 654–657t sterile gloves, 658, 658–659t, 659–661t sterile gowns, 659, 659–661t Sterilization defined, 643 methods for, 643–644 Sternum, 580, 580f Steroids fecal occult blood testing, 756 sleep, 1098t surgical risk, 893 Stertor, 524t Stimulant laxatives, 1251t Stimulants, and sleep, 1098, 1098t Stimulation needs, in Kalish’s hierarchy of needs, 273 Stimulus, in the sensory process, 930 Stimulus-based stress models, 999 STIs. See Sexually transmitted infections (STIs) Stoma defined, 1244 surgical construction of, 1244–1245, 1244f, 1245f Stomatitis defined, 572 described and nursing implications, 716t Stool, 1236. See also Feces Stool softener laxatives, 1242t, 1251t Stool specimens collecting, 755 colorectal cancer screening, 757t fecal occult blood testing, 755–756, 756f, 756t Home Care Considerations, 757t Lifespan Considerations, 757t testing, reasons for, 755 STOP (Snoring, Tiredness, Observed apnea, high blood Pressure) tool for obstructive sleep apnea, 893 Storytelling, 431, 431t Strabismus, 364 Straight urinary catheters, 1218, 1219t Strengths nursing diagnoses, formulating, 206–207t, 207 self-concept, 955, 955t Streptococcus beta-hemolytic A or B, 632t Streptococcus mutans dental caries in toddlers, 364 resident flora, 629t Streptococcus pneumoniae, 629t Streptococcus species, 629t Stress blood pressure, 526 body temperature, 505 Chapter Highlights, 1013t defined, 998 effects of, 998, 1000f health promotion, 272t, 282 indicators of cognitive indicators, 1003–1004 physiological indicators, 1001, 1002t psychological indicators, 1001–1003, 1002t, 1003t types of, 1000 Lifespan Considerations, 1010t medication, 1009t models of purposes, 998–999 response-based models, 999–1000, 1001f

stimulus-based models, 999 transaction-based models, 1000 Nursing Management assessing, 1005, 1005t Concept Map, 1012f diagnosing, 1005–1006 evaluating, 1009, 1009–1011t, 1012f implementing anger, mediating, 1007, 1007t anxiety, minimizing, 1007, 1007t crisis intervention, 1008, 1008t health promotion strategies, 1006–1007, 1006t relaxation techniques, 1007–1008 stress management for nurses, 1008–1009 Nursing Care Plan, 1010–1011t planning, 1006, 1006t pulse, 513 respiratory function, 1273 sensory function, 931 sources of, 998, 999t Stress electrocardiography, 764 Stress syndrome (general adaptation syndrome), 999–1000, 1001f Stress urinary incontinence, 1207, 1211t Stressors Bible reading and management of stressful life events, 991t defined, 998 infection, susceptibility to, 635 self-concept, 952, 952t, 953, 953t Stretchers described, 1071, 1072t transferring between bed and stretcher, 1074–1075t Stridor, 524t, 1273 Strike, defined, 79 Stroke (cerebrovascular accident), 1323t Stroke volume (SV), 1316, 1317t Structural-functional theory of families, 414–415 Structure evaluation, defined, 240 Structuring a situation, 1004 Student nurses legal responsibilities, 96, 96t student care plans, 218, 220 Sty (hordeolum), 559 Subacute care facilities, 118 Subarachnoid block, 905 Subclinical infection, 628 Subculture, defined, 303 Subcutaneous injections administering, skill for, 820–822t Home Care Considerations, 822t overview, 817, 819–820, 823t sites for, 817, 819, 820f Subcutaneous route of administration described, 784t, 785 opioids, 1137–1138 Subjective data, defined, 186, 189t Sublimaze. See Fentanyl Sublingual route of administration, 784, 784t, 785f Sublingual salivary gland, 571, 572f Submandibular gland, 571, 572f Submissive nonassertive communication, 460 Substance abuse drug abuse, defined, 780 impaired nurses, 84t young adults, 382 Substernal retractions, 524t Sucking reflex, 358t Suction, gastrointestinal Home Care Considerations, 917t managing, skill for, 915–917t postoperative phase, 914–917, 914f, 915–917t, 918f Suctioning collection chamber and control gauge, 1294, 1294f complications, prevention of, 1297–1298, 1298f

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defined, 1293 Home Care Considerations, 1297t, 1301t indications for, 1295 Lifespan Considerations, 1297t, 1301t oropharyngeal, nasopharyngeal, and nasotracheal suctioning, 1295–1297t sterile technique, 1294 suction catheters, 1294, 1294f tracheostomy or endotracheal tube suctioning, 1299–1301t Sudafed. See Pseudoephedrine Sudden infant death syndrome (SIDS), 360, 360t Sudoriferous (sweat) glands, 696 Sugars, dietary, 1154 Suicide adolescents, 374 older adults, 675–676, 676t, 1023t young adults, 382 Summarizing, in therapeutic communication, 447t Sunrise Model, 69 Superego, 341 Supination (movement), 1038t, 1040f, 1040t Supine position, 542t, 1063 Supplemental Nutrition Assistance Program, 1180 Supplemental Security Income (SSI) benefits, 127 Support, providing, for communication, 455 Support people/system client’s pain, 1131 data sources, 188–189 learning needs, 471, 471t loss and grief responses, 1020 pain experience, 1119–1120 Suppositories described, 777t laxatives, 1251 Suppression, conscious, 1003t, 1004 Suppressor T cells, 634 Suppuration, 862 Suprapubic catheters, 1228, 1228f Suprasternal retractions, 524t SUPREP. See Sodium sulfate Surface (topical) anesthesia, 905 Surface temperature, 504 Surfactant, 1271 Surfak. See Docusate calcium Surgery. See also Perioperative nursing fecal elimination, 1241 urinary elimination, 1205 Surgical asepsis defined, 629 principles and practices, 652, 653t sterile technique, 652, 653t Susceptibility, defined, 642 Susceptible host, in the chain of infection, 631f, 632–633, 639t, 642–643 Suspension boots, 1061t Sutures described, 922, 922f removing, 922–923, 922f, 923f, 924t Sutures (skull), in newborns and infants, 357, 357f Swanson’s theory of caring, 427, 427t Sweat (sudoriferous) glands, 696 “Swedish nose” heat moisture exchange devices, 1293, 1294f Sympathetically maintained pain, 1114 Symptoms, defined, 186 Synera. See Lidocaine/tetracaine Synergistic effect, 780 Synthetic-conventional stage of Fowler’s theory of spiritual development adolescents, 373 described, 349, 350t Syphilis clinical manifestations, 963t young adults, 382, 383 Syringe pumps, 832, 833f

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1508

Index

Syringes, 806–809, 806f, 807f, 808f, 809f, 810, 811f Syrup (medication), 777t System, defined, 271 Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT), 161 Systemic infection, 629 Systems concept maps, 177f, 177t Systole cardiac cycle, 1314, 1315t heart sounds, 587, 587f, 587t Systolic pressure, defined, 525

T T cells, 634 Tablet computers, 156t Tablets administering, 802–803t described, 777t Tachycardia, 515 Tachypnea (polypnea), 523, 524t, 1273 Tactile defined, 930 impaired tactile sense, 937 Tadalafil, 971t Tagamet. See Cimetidine T’ai chi, 281t, 330, 1045f, 1045t Tail of Spence, 594, 594f Talwin. See Pentazocine Tandem IV setups, 831–832, 832f Tanner stages females, 618f, 618t males, 619, 620t Target heart rate, 1044 Target population, defined, 56 Tartar, 572, 716 Task groups, 452 Taste, sense of newborns and infants, 358 preschoolers, 365 Tattoos, and MRIs, 765t Taxol. See Paclitaxel Taxonomy II, 211, 212f Td vaccine. See Tetanus-diphtheria (Td) vaccine Tdap (tetanus, diphtheria, acellular pertussis) vaccine, 370t Tea tree, 326t “Teach back” technique, 474, 474t Teacher, nurse as, 41 Teaching. See also Client Teaching Chapter Highlights, 485t clients and families, 464–465 community, in, 465 Critical Thinking Checkpoint, 485t defined, 464 evaluating, 484 health personnel, 465 health teaching, areas of, 464, 465t Internet and health information, 469–470 nurse as educator, 470 Nursing Management assessing health literacy, 473–474, 473t, 474f, 474t, 475f, 475t, 476t motivation, 472–473 nursing history, 470–471, 471t, 472t physical examination, 472 readiness to learn, 472 diagnosing deficient knowledge as the etiology, 476 learning need as the diagnostic label, 474, 476, 476t documenting, 484 evaluating learning, evaluating, 484 teaching, evaluating, 484

implementing special teaching strategies, 481–482 teaching, guidelines for, 480–481, 481f, 481t transcultural teaching, 482–484, 483t planning content, choosing, 478 learning experiences, organizing, 478–480, 479t, 480t learning outcomes, setting, 477–478, 478t sample teaching plan, 477, 477t teaching priorities, determining, 477 teaching strategies, selecting, 478, 478f, 479t nursing process, compared to, 464, 465t Teaching groups, 452 Teaching materials, 479t Team nursing, 125–126 Teams, building and managing, 493 Technical skills, 235 Technology. See also Electronic health records and information technology ethical problems in nursing, 105 health care delivery, factors affecting, 122 nursing practice, influencing, 45–46 Technology Informatics Guiding Education Reform (TIGER) Initiative, 155 Teeth. See also Mouth hygiene brushing and flossing, 718, 718–721t parts of, 715, 715f Telehealth community-based setting, 137 defined, 162–163 Internet and health information, 469 nursing practice, influencing, 46 Telemedicine defined, 162–163 nursing practice, influencing, 46 Telenursing, 46 Teleological (consequence-based) theories of morality, 102 Telepathology, 46 Telepharmacy, 46 Telephone orders, 264–265, 265t Telephone reports, 264 Teleradiology, 46 Temazepam, 1105t Temperament, in growth and development, 338 Temperament theory of Chess and Thomas, 344–345, 345t Temperature, environmental body alignment and activity, 1043 fluid, electrolyte, and acid–base balance, 1344 hygienic environment, 733 preoperative preparation, 902 Temperature-sensitive tape, 508–509, 509f Temporal artery body temperature measurement advantages and disadvantages, 507t described, 508 infants and children, use in, 512t temporal artery thermometers, 509, 509f thermometer placement, 511t Temporal artery pulse measurement, 513, 513f, 514t Ten Rights of Medication Administration, 798–799, 799t TENS (transcutaneous electrical nerve stimulation), 1144, 1144t Teratogens, 355–356, 356t Terfenadine, 1160t Terminal (end) colostomy, 1244, 1244f Termination phase of the helping relationship, 450t, 451 Termination stage of health behavior change, 279, 285f Territoriality, in the communication process, 443 Tertiary intention healing, 861 Tertiary prevention described, 116 health promotion, 274, 275t Neuman’s systems model, 68 Testes/scrotum assessment of, 619, 621t

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Tanner stages of development, 620t testicular cancer, 383 testicular self-examination, 973, 974, 974f, 974t Testing questions, as a communication barrier, 448t Tetanus, diphtheria, acellular pertussis (Tdap) vaccine, 370t Tetanus toxoid vaccine, 387t Tetanus-diphtheria (Td) vaccine adolescents, 375t young adults, 384t Tetracycline, 1159, 1160t Theory, defined, 63 Theory of bureaucratic caring (Ray), 425, 426f Theory of caring (Swanson), 427, 427t Theory of human care (Watson), 426–427, 426t Theory of nursing as caring (Boykin and Schoenhofer), 426 Therapeutic baths, 701 Therapeutic communication attentive listening, 445, 445f barriers to, 445 described, 444–445 techniques for, 445, 446–447t visibly tuning in, 445, 446t Therapeutic effect of drugs, 778–779, 779t Therapeutic relationship, 445. See also Helping relationships Therapeutic touch, 327–328 Therapy groups, 453 Thermometers clients in isolation, 652 correct placement, 511t types of, 508–509, 508f, 508t, 509f Thiazide diuretics, 1160t Third space syndrome, 1344 Third-party reimbursement, 127 “30-minute rule” for medication administration, 798 Thomas, Alexander, and temperament theory, 344–345, 345t Thoracentesis client positioning, 768, 768f defined, 768 Lifespan Considerations, 769t procedure, 768–769, 771t site for, 768, 768f Thoracic (costal) breathing, 522 Thorax and lungs, assessment of. See also Chest breath sounds, 581, 581t, 582t chest landmarks, 576, 579–580, 579f, 580f chest shape and size, 580, 580f, 581f Lifespan Considerations, 586f, 586t skill for, 582–585t Thorazine. See Chlorpromazine Three checks for medication administration, 798, 798t Three-way Foley catheters, 1218, 1219f, 1225, 1226–1227t Thrill, defined, 588 Throat cultures, 763, 763f, 763t Thrombophlebitis immobility, 1049 postoperative phase, 910t, 914 Thrombus immobility, 1049, 1049t postoperative phase, 910t, 914 Throughput, defined, 271, 271f Thumb joint movements, 1040–1041f, 1040–1041t Thyroid gland, 575f, 578t TIBC (total iron-binding capacity), 1173 Ticks, 724 Tidal volume (V1) defined, 523, 1271 oxygenation, 1276f, 1276t Time and timing documentation, time of, 259 interviews, time for, 191 learning, 468, 469t management, with stress and coping, 1007

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Index medication action, affecting, 783–784 medication administration, 798, 799t medication orders, time written, 787, 787t time management, as skill of nurse managers, 493 time orientation and culturally responsive care, 312 verbal communication, 439 “Time out” before surgery, 902 “Timed Up and Go” test, 676–677 Timed urine specimen, 760, 761t Time-lapsed assessment, 185, 187t Tincture, 777t Tinea pedis, 711–712 Tissue perfusion, 909 To Err is Human: Building a Safer Health System (IOM), 45, 240, 667, 669 Toddlers biologic dimension of health, 293 body alignment and activity, 1038 cognitive development, 363 communication with, 443t defecation, 1238 Developmental Assessment Guidelines, 365t health assessment and promotion, 364, 364t, 365t health care decisions, 178t Health Promotion Guidelines, 364t health risks, 363–364, 363f moral development, 363 normal sleep patterns and requirements, 1095 nutrition, 1161 oral health, 717 pain experience, 1120t physical development head circumference, 361, 365t height, 361, 365t motor abilities, 362, 362f, 365t sensory abilities, 362, 365t weight, 361, 365t psychosocial development, 362–363, 362t, 365t safety, 671, 673t, 674, 674f, 674t safety hazards, 667t sexual development, 960, 961t spiritual development, 363 surgical risk, 892 Toe joint movements, 1042f, 1042t Toileting assisting with, 1212 functional levels of self-care, 697t Tolerable upper intake level (UL), 1166, 1167t Tolerance, defined, 1130 Tongue blades, 543t Tonic neck (fencing) reflex, 358t Tonicity, defined, 1336 Topical (surface) anesthesia, 905 Topical route of administration described, 784t, 785 opioids, 1137 Top-level (upper-level) managers, 491–492, 492t Toradol. See Ketorolac Torr, defined, 1271 Tort law, defined, 74, 75t Torts defined, 88 intentional torts, 89–92, 90t, 91f reporting, 95, 95t unintentional torts, 88–89, 88t, 89t, 90t, 91f Total care framework for care, 125 Total iron-binding capacity (TIBC), 1173 Total lung capacity (TLC), 1276f, 1276t Total parenteral nutrition (TPN), 1193–1194 Total protein level, 895t Touch communication, 438, 438f therapeutic communication, 446t

Touch, sense of data collection, 190t newborns and infants, 358 school-age children, 368 Towel baths, 701 “Toxic shock,” 962 TPN (total parenteral nutrition), 1193–1194 Trachea, assessment of, 575f, 578t Tracheostomy care, providing, 1302–1305t described, 1292–1293, 1292f, 1293f, 1293t mist collars for, 1293, 1294f suctioning, 1299–1301t Trade names, 777 Traditional, defined, 306 Traditional care plan documentation, 256 Traditional Chinese medicine (TCM), 323–324 Traditional families, 413, 413f Tragus, defined, 565, 565f Tramadol, 1132, 1132t, 1134 Tranquilizers preoperative preparation, 901 surgical risk, 893 Transactional leaders, 490 Transactional stress theory, 1000 Transcellular fluid, 1335, 1335f Transcultural Concepts in Nursing Care (Andrews and Boyle), 313t Transcultural Health Care: A Culturally Competent Approach (Purnell), 313t Transcultural nursing culture care diversity and universality theory, 425 defined, 306 Transcultural Nursing: Assessment & Intervention (Giger and Davidhizar), 313t Transcultural Nursing Theory and Models: Application in Nursing Education, Practice, and Administration (Sagar), 313t Transcutaneous electrical nerve stimulation (TENS), 1144, 1144t Transdermal patch administration of, 837–838, 838f, 838t defined, 837 described, 777t glove use for application, 837t Transdermal route of administration described, 784t opioids, 1137 Trans-fats, dietary, 1168 Transfer chairs, 1060f, 1060t Transferrin level, 1173 Transferring clients equipment for, 1070–1071, 1071f guidelines for, 1071, 1072t Home Care Considerations, 1076t Lifespan Considerations, 1076t transferring between bed and chair, skill for, 1072–1074t transferring between bed and stretcher, skill for, 1074–1075t Transformational leaders, 490–491 Transforming Care at the Bedside, 241 Transgender, defined, 965 Translators. See Interpreters Transmission method, in the chain of infection, 631f, 632, 639t Transmission-based precautions, 644–646, 645t Transmucosal route of administration, 1137 Transnasal route of administration, 1137 Transparent dressings, 873t, 874 Transparent film dressings, 873t Transplant surgery, 892t Transporting clients with infections, 652 Transtracheal oxygen catheters, 1287, 1287f Transverse colostomy, 1244, 1244f Tranylcypromine, 1160t Travatan. See Travoprost Travoprost, 937t Trazodone hydrochloride, 783–784

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Treatments as interventions, 228 Tremor, defined, 603 Trendelenburg’s position for hospital beds, 734t Treponema pallidum, 632t Trial and error, in critical thinking, 173 Trials, legal, 75, 76f Triangular fossa, defined, 565 Triazolam, 1105t Triceps skinfold, 1172, 1172f, 1172t Trichomonas vaginalis, 383 Trichomoniasis, 963t Triclosan, 644t Tri-Council for Nursing education for entry into professional nursing practice, 38t image of nursing, 31–32 Tricuspid area of the chest, 587, 587f Tricyclic antidepressants pain management, 1132t pain modulation, 1116–1117 urinary retention, 1205t Trigeminal nerve (CN V), 616t Trigeminal neuralgia, 1115t Triglycerides defined, 1156 normal levels and clinical implications, 749, 751t Trigone, 1201–1202, 1201f, 1203f Trihexyphenidyl, 1205t Trilisate. See Choline magnesium trisalicylate Trimesters, defined, 354 Tripod position, 1278, 1279f Tripod (triangle) position for crutches, 1084, 1084f Trocar, for abdominal paracentesis, 767, 767f Trochanter rolls, 1062f, 1062t Troche, described, 777t Trochlear nerve (CN IV), 616t Troponin, 1326 Troponin I, 749, 751t Troponin II, 749, 751t Trough level of medications, 748 Trousseau’s sign, 1347, 1349t, 1350f Trunk, movements of, 1042f, 1042t Trust caring, 424 collaborative health care, 139 Trust versus mistrust Erikson’s theory of developmental stages, 341, 342f, 344t self-concept, 949t Truth, Sojourner, 29, 29f Tub baths, 701 Tuberculin syringe, 807f, 808 Tuberculosis, 644t Tuberculosis (TB) skin test, 817 Tubex system, 809 Tubman, Harriet, 29, 29f Tubular (bronchial) breath sounds, 581t Tularemia, 672t Tumors defined, 633t skin, 550f Tuning forks, 543t Tuskegee study, 59 24-hour clock, 259, 259f, 787 24-hour food recall, 1173 Twitter, 156t Two-career families, 413 Tylenol. See Acetaminophen Tylenol No. 3. See Codeine and acetaminophen Tympanic membrane, defined, 565, 565f Tympanic membrane body temperature measurement advantages and disadvantages, 507t described, 508 infants and children, use in, 512f, 512t thermometer placement, 511t

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Tympanites, 911t Tympany, 545, 545t Tyramine and medications, 1160t

U UAPs. See Unlicensed assistive personnel (UAPs) UI. See Urinary incontinence (UI) Ulcer, skin, 551t Ulesfia. See Benzyl alcohol Ultracet. See Tramadol Ultram. See Tramadol Ultrasonography bladder urine volume, 1210, 1210f, 1210t described, 764 Doppler ultrasound stethoscopes, 514, 514f, 517t, 527 Unconscious clients eye care, 729, 729t informed consent, 81 oral hygiene, 721–723, 722–723t Unconscious mind, defined, 340 Undernutrition, defined, 1168–1169 Underserved Populations Best Practice Intervention Package (HHQI), 151 Undertakers, 1029 Undifferentiated stage of Fowler’s theory of spiritual development, 363 Undoing, described, 1003t Unhelpful thinking, repatterning, 1145 Uniform Anatomical Gift Act, 87, 108 Unintentional torts, 88–89, 88t, 89t, 90t, 91f Unit-dose packaging, 796, 796f United States Pharmacopeia (USP), 777, 778 Universal fall precautions, 677, 677t Universal precautions, defined, 644 Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery, 902, 902t Universalizing phase in Fowler’s theory of spiritual development, 349, 350t University of Minnesota baccalaureate degree in nursing, 37 Unlicensed assistive personnel (UAPs) delegation to, 493, 494, 494t, 495–496f, 497t health care providers, 121 Unoccupied beds, changing, 734–738, 735f, 736–738t Unplanned change, defined, 497 Unprofessional conduct by nurses, 92–93 Unresolved grief, 1016–1017 Unsafe practices, reporting, 95, 95t Unsaturated fatty acids, dietary, 1156 Upper-level (top-level) managers, 491–492, 492t Urea, 1173 Ureterostomy, 1228 Ureters, 1201, 1201f Urethra, 1201f, 1202, 1202f, 1203f Urge urinary incontinence, 1207, 1211t Urgency, described, 1206, 1206t Urinary catheters/catheterization catheter, selecting, 1218, 1218t, 1219f CAUTI, preventing, 1217, 1217t, 1218t changing the catheter and tubing, 1224 clean intermittent self-catheterization, 1225, 1225t drainage systems, 1218–1219 Home Care Considerations, 1223t Lifespan Considerations, 1223t measuring urine from, 1208, 1209f nursing interventions, 1224–1225 performing, skill for, 1220–1223t removing catheters, 1224–1225 suprapubic catheters, 1228, 1228f urethral trauma, 1217 urinary irrigations, 1225, 1226–1227t urinary retention, 1217 Urinary diversions continent diversions, 1229, 1229f, 1230f

incontinent diversions, 1228, 1229f nursing care, 1229–1230 Urinary elimination altered production and patterns oliguria and anuria, 1205–1206, 1206t polyuria, 1205, 1206t anatomy and physiology bladder, 1201–1202, 1201f, 1202f, 1203f kidneys, 1200–1201, 1201f pelvic floor, 1202, 1203f ureters, 1201, 1201f urethra, 1201f, 1202, 1202f, 1203f urination, 1202 average daily output by age, 1205t, 1209t Chapter Highlights, 1233t factors affecting age and development, 1202–1203, 1204t fluid and food intake, 1204–1205 medications, 1205, 1205t muscle tone, 1205 pathologic conditions, 1205 psychosocial factors, 1204 surgical and diagnostic procedures, 1205 frequency and nocturia, 1206, 1206t dysuria, 1206t, 1207 enuresis, 1206t, 1207 urgency, 1206, 1206t urinary incontinence, 1206t, 1207 urinary retention, 1207 Nursing Management assessing components of, 1207 diagnostic tests, 1210 nursing history, 1208, 1208t physical assessment, 1208 urine, assessment of, 1208–1210, 1209f, 1209t, 1210f Concept Map, 1232f diagnosing, 1210–1211, 1211t evaluating, 1230 implementing normal urinary elimination, maintaining, 1212, 1214t suprapubic catheter care, 1228, 1228f urinary catheterization (See Urinary catheters/ catheterization) urinary diversions, 1228–1230, 1229f, 1230f urinary incontinence, managing (See Urinary incontinence (UI)) urinary irrigations, 1225, 1226–1227t urinary retention, managing, 1217 urinary tract infection, preventing, 1212 Nursing Care Plan, 1230–1231t planning, 1211, 1212t, 1213t Urinary frequency, 1206, 1206t Urinary incontinence (UI) bladder retraining, 1214, 1214t described, 1206t, 1207 external urinary draining devices, 1215, 1215–1217t immobility, 1050–1051 managing, overview of, 1213–1214, 1214t NANDA diagnoses, 1211t pelvic floor muscle exercises, 1215, 1215t pressure ulcers, 856 skin integrity, maintaining, 1215 Urinary reflux, 1051 Urinary retention defined, 1207 immobility, 1050–1051 managing, 1217 medication causing, 1205, 1205t opioids, 1136t postoperative phase, 911t

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Urinary stasis, 1050, 1050f Urinary system anatomy and physiology bladder, 1201–1202, 1201f, 1202f, 1203f kidneys, 1200–1201, 1201f pelvic floor, 1202, 1203f ureters, 1201, 1201f urethra, 1201f, 1202, 1202f, 1203f urination, 1202 exercise, benefits of, 1046 immobility, effects of, 1050–1051, 1050f, 1055t middle-aged adults, 384t older adults, 397t, 400 visualization procedures, 764 Urinary tract infection (UTI) immobility, 1051 postoperative phase, 911t preventing, 1212 ultrasound bladder scanner, 1210t Urination anatomy and physiology, 1202 normal habits, maintaining, 1212, 1214t postoperative care, 914 Urine average daily output, by age, 1205t, 1209t characteristics of normal and abnormal, 1208, 1209t fluid output, 1338t, 1339 output, measuring, 1208, 1209f residual, measuring, 1209–1210, 1210f, 1210t Urine tests blood in, 1209t color, clarity, 1209t creatinine, 1173 dipstick testing, 761, 761f glucose, 762, 1209t ketone bodies (acetone), 1209t ketones, 762 microorganisms, presence of, 1209t occult blood, 762, 762t odor, 1209t osmolality, 762 pH, 762, 1209t, 1357 protein, 762 specific gravity, 761–762, 1209t, 1357 specimen collection clean voided urine specimen, 757–758, 758t clean-catch or midstream urine specimen, 757, 758–760, 758f, 758–760t Home Care Considerations, 760t indwelling catheter specimen, 761, 761f Lifespan Considerations, 760t timed urine specimen, 760, 761t urinalysis, preoperative, 895t Urticaria, 550f U.S. Census Bureau race and ethnicity, 305 racial categories, 303 U.S. Department of Agriculture, 1163, 1165–1166, 1166f U.S. Department of Health, Education, and Welfare, 127 U.S. Department of Health and Human Services health literacy, 80–81 Public Health Service, 116 U.S. Food and Drug Administration (FDA) Cologuard test, 756 homeopathy, 326 HPV vaccine, 372 pediculosis products, 725 U.S. News and World Report, 390 U.S. Preventive Services Task Force cancer screening guidelines, 541 Guide to Clinical Preventive Services, 295 User’s Guide to Finding and Evaluating Health Information on the Web, 156

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Index USP (United States Pharmacopeia), 777, 778 Uterine cancer, 541t UTI. See Urinary tract infection (UTI) Utilitarianism, 102 Utility, defined, 102 Utilization reviews, 164

V Vaccines, 817. See also Immunizations; specific vaccines Vacuum-assisted closure for wounds, 877, 878f Vaginal medications administering, skill for, 844–846t overview, 843–844 vaginal route, described, 784t, 785 Vaginal speculum examination, 619, 619f Vaginismus, 970–971 Vagus nerve (CN X), 616t Valerian, 325t Validation of data, 197, 198t Validity of research data, 56 Valium. See Diazepam Valsalva maneuver, 1048 Valuables, personal, 901, 901t Value system, defined, 99 Values Chapter Highlights, 110t client advocacy, 109t communication process, 442 defined, 99 transmission of, 99–100, 100t Values clarification client values, clarifying, 100–101, 101t client values, determining, 103t defined, 100, 100t nurse’s values, clarifying, 100 Vancomycin-resistant Enterococcus (VRE) chlorhexidine gluconate, 702t nosocomial infections, 630t Vardenafil, 971t Variable data, 187 Variance in case management documentation, 254, 256t Varicella vaccine infants, 361t preschoolers, 367t toddlers, 364t Variola virus, 672t Vascular response to inflammation, 633 Vasoconstriction, 882 Vasodilation, 856 Vasodilators, 1327 Vastus lateralis site for IM injections, 824, 824f, 825f VC. See Vital capacity (VC) Vector-borne transmission, 632 Vegetarian diets, 1168, 1168t Vehicle-borne transmission, 632 Veins immobility, 1048–1049, 1049f venous return, 1318, 1319f Venipuncture defined, 745 peripheral sites, 1363, 1363f, 1363t, 1364t Venous stasis, preventing, 1327–1330, 1328–1329t, 1328f, 1330t Venous thromboembolism (VTE), 1328 Ventilation, environmental, 733 Ventilation, respiratory, 522 Ventilation scan, 764 Ventolin. See Albuterol Ventricles, cardiac, 1313 Ventricular gallop (S4 heart sound), 587 Ventrogluteal site for IM injections, 823f, 824, 824f Venturi oxygen masks, 1286f, 1287 Veracity, as a moral principle, 103, 103t

Verapamil, 1160t Verbal communication adaptability, 439 clarity and brevity, 439 credibility, 440 culturally responsive nursing care, 310, 310t, 311t defined, 439 humor, 440 Nursing Management, 454 pace and intonation, 439 simplicity, 439 timing and relevance, 439 Verbal orders, 265, 265t, 785, 785t Verdict, defined, 75, 76f Vernix caseosa, 355 Versed. See Midazolam Vesicant, described, 1378t, 1383 Vesicles, 550f Vesicostomy, 1228 Vesicular breath sounds, 581t Vestibule of the ear, 565f, 566 Vestibulitis, 971 Veterans Affairs (VA), 116 Viagra. See Sildenafil citrate Vials, 811–813, 811f, 814–815t Vibration, and oxygenation, 1282–1283, 1282f Vicodin. See Hydrocodone Vietnam War, 30, 31f Vietnam Women’s Memorial, 30, 31f Vietnamese heritage, and views of older adults, 392t Violence adolescents, 374 family health, 417 legal aspects of, 83 young adults, 381–382, 382t Viral hemorrhagic fevers, 672t Virulence, defined, 629 Viruses disinfectants and antiseptics, 644t infection, cause of, 629 Visceral, defined, 930 Visceral pain, 1113 Visicol. See Sodium phosphate Vision. See also Eyes and vision data collection, 190t impairment, and assisting clients with meals, 1179f, 1179t newborns and infants, 357, 362t preschoolers, 364, 368t school-age children, 368, 370t sensory perception disturbances, 936, 937t, 938–939f, 939t, 941t toddlers, 364 Vision for effective leadership, 491 Visiting Nurse Service, 33, 33f Visiting Nurse Service of New York, 151 Visiting nursing, defined, 144 Visual, defined, 930 Visual acuity, 559 Visual fields, 559 Vital capacity (VC) immobility, 1049 oxygenation, 1276f, 1276t Vital signs blood pressure (See Blood pressure) body temperature (See Body temperature) Chapter Highlights, 536t Critical Thinking Checkpoint, 536t defined, 503 fluid, electrolyte, and acid–base balance, 1354–1355 oxygen saturation (See Oxygen saturation) physical health assessment, 548 postoperative assessment, 909 preoperative preparation, 902

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pulse (See Pulse) registered nurse, responsibility for, 503–504 respiration (See Respiration(s)) times for assessment, 503, 504t Vitamin A nutrition, 1156 wound healing, 893t Vitamin B complex nutrition, 1156 wound healing, 893t Vitamin C nutrition, 1156 supplements, 756 wound healing, 893t Vitamin D, 1156 Vitamin E, 1156 Vitamin K medication action, affecting, 783 nutrition, 1156 warfarin, 1160t wound healing, 893t Vitamins, 756, 783, 893t, 1156, 1160t Vitiligo, 549 Voiding defined, 1202 normal habits, maintaining, 1212, 1214t postoperative care, 914 Voltaren. See Diclofenac Volume expanders, defined, 1362 Volume-control IV infusion sets, 833, 833f, 834t, 1366 Volume-oriented spirometer, 1281f, 1282t Vomiting opioids, 1136t postoperative phase, 911t VRE. See Vancomycin-resistant Enterococcus (VRE) Vulvodynia, 971 Vygotsky, Lev, 346, 347t Vygotsky’s social constructivism theory, 346, 347t

W Wakefield, Mary, 132 Wald, Lillian, 33, 33f Walkers, using, 1082, 1083f, 1083t Walking, mechanical aids for canes, 1081, 1081f, 1082f, 1082t crutches, 1082–1086, 1083f, 1084f, 1084t, 1085f, 1086f walkers, 1082, 1083f, 1083t Walking (stepping or dancing) reflex, 358t Wanderer’s Alert Program, 675 War, and history of nursing, 29–30, 29f, 30f, 31f Warfarin diet, 783 nutrition, 1160t shaving beards and mustaches, 728 Warmth (attitude), in the communication process, 444 Water beds, 871t Water in blood, function of, 748f Water-soluble vitamins, 1156 Watson, Jean, 70 Watson’s theory of human care, 70, 426–427, 426t Wear-and-tear theory of aging, 395t Weber’s test, 568t Webster v. Reproductive Health Services, 85 Weed, Lawrence, 250 Weight dosage calculation, 793 fluid, electrolyte, and acid–base balance, 1344, 1354 newborns and infants, 356 physical health assessment, 548, 548f preschoolers, 364, 368t school-age children, 367, 370t standards for, 1157, 1157t toddlers, 361, 365t

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Index

Weight loss, calculating percentage of, 1173, 1174t Well-being, feelings of defined, 289 women’s attraction to other women, 963t Wellness. See also Health Chapter Highlights, 300t components of, 289, 290f Critical Thinking Checkpoint, 299t defined, 289 models of Dunn’s high-level wellness grid, 291–292, 291f illness-wellness continuum, 292, 292f nurses promoting, 39–40 nurses’ understanding of, 289–290 postoperative phase, 924 Wellness models for data organization, 196–197 Westberg, Granger, 136 Westerhoff ’s theory of spiritual development, 349, 350t Western medicine, defined, 321 Wheals, 550f Wheelchairs described, 1071, 1072t transferring between bed and chair, 1072–1074t Wheeze, 524t, 582t Whisper test, 568t Whistle-tipped suction catheters, 1294, 1294f White blood cell (WBC) count. See also Leukocytes described and normal levels, 746t, 747, 748f nutrition, 1173 Whitman, Walt, 30 WHO. See World Health Organization (WHO) WHO Multicentre Growth Reference Study, 356 Whole blood, 1385t WIC (Special Supplemental Nutrition Program for Women, Infants, and Children), 127 Widget, defined, 156t Wiki, defined, 156t Windup phenomenon, 1115t, 1118 “Wink” reflex, 623t Withdrawal, in the temperament theory of Chess and Thomas, 345t Withdrawing or withholding food and fluids at the end-of-life, 109 Women attraction to other women and feelings of well-being, 963t health care delivery, factors affecting, 122–123 women’s roles, in history of nursing, 28 Women, Infants, and Children (WIC) Program, 127 Wong-Baker FACES Rating Scale, 1123, 1124f Working phase of the helping relationship, 449–451, 450t Work-related social support groups, 453 World Health Organization (WHO) Child Growth Standards, 356 folate/folic acid supplements, 1162 health, defined, 288 infectious diseases, 629 International Classification of Diseases (ICD), 161

palliative care, 1027 Primary Health Care, 132 safe patient handling and mobility standards, 1058 three-step analgesic ladder, 1132–1133, 1132t World Medical Assembly, 1023 World Organization of National Colleges, 161 World War I, 30, 30f World War II, 30, 31f Wound care. See also Wound healing; Wounds Chapter Highlights, 888–889t cleaning irrigating and packing, 875–877, 875–877t, 878t Practice Guidelines, 875t, 878t vacuum-assisted closure, 877, 878f Critical Thinking Checkpoint, 888t infection prevention, 638t Lifespan Considerations, 879t organizations, 887t postoperative phase assessment, 917–918, 918t cleaning and dressing, 918, 918–920t, 921t sutures and staples, 922–923, 922f, 923f, 924t wound drains and suction, 921, 921f, 922f, 922t supporting and immobilizing bandages, 879–881, 879t, 880t, 882t, 883t binders, 880t, 881–882, 882f, 882t, 883t purposes of, 877 Wound healing. See also Wound care; Wounds complications, 862 factors affecting, 862–863, 863t Nursing Management assessing skin integrity assessment, 863 wound assessment, 863–867, 863t, 864f, 865–867t, 865f diagnosing, 868 evaluating, 887, 887t implementing heat and cold applications (See Cold applications; Heat applications) pressure ulcers, preventing, 869–872, 871f, 871t pressure ulcers, treating, 872, 872t wound healing, supporting, 868–869, 870t wounds, cleaning (See Wound care, cleaning) wounds, dressing, 872–874, 873t, 874f, 875f wounds, supporting and immobilizing (See Wound care, supporting and immobilizing) planning, 868, 868t, 869t overview, 858 phases of, 861 postoperative phase, 924 types of, 860–861 wound exudate, 862, 862t Wound Ostomy Continence Nurses, 887t Wounds depth, 855, 855t types of, 855, 855t Wrist joint movements, 1040f, 1040t

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X Xenophobia, 304 Xerostomia, 721 Xylocaine. See Lidocaine Xyrem. See Sodium oxybate

Y Yankauer suction tubes, 1294, 1294f Yellow fever, 672t Yersinia pestis, 672t Yoga described, 328–329 Eastern culture, 1045f, 1045t self-care for nurses, 431, 432f spirituality and health, 281t Young adults boomerang kids, 379–380 Chapter Highlights, 388t cognitive development, 381 Critical Thinking Checkpoint, 387t Developmental Assessment Guidelines, 383t health assessment and promotion, 383, 384t Health Promotion Guidelines, 384t health risks eating disorders, 382–383 hypertension, 382 injury and violence, 381–382, 382t malignancies, 383 sexually transmitted infections, 382 substance abuse, 382 suicide, 382 moral development, 381 nutrition, 1162–1163, 1163t physical development, 380, 383t psychosocial development, 380, 380f, 380t, 383t safety, 673–674t, 675 sexual development, 961t, 962 spiritual development, 381 stressors, 999t Youth Risk Behavior Surveillance survey (2011), 372, 373, 374

Z Zaleplon, 1105t Zantac. See Ranitidine Zinc, and wound healing, 893t Zithromax. See Azithromycin Zofran. See Ondansetron Zoloft. See Sertraline HCl Zolpidem, 1105t, 1106t Zostrix. See Capsaicin

C/M/Y/K Short / Normal

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ANATOMY & PHYSIOLOGY REVIEW  Client Positioning  907 Digestive System  1155 Fecal Elimination  1146 Gas Exchange  1351 Glaucoma 938 Pharmacokinetics of an Oral Medication  782 Preload and Afterload  1318 Respiratory System  1270 Reticular Activating System (RAS)  1093 Upper and Lower Body Integration  1054 Urinary Bladder  1203

ASSESSMENT INTERVIEW  Activity and Exercise  1052 Body Image  954 Circulation 1325 Complementary and Alternative Therapies  323 Dying Client’s Family  1025 Eyes 728 Fecal Elimination  1247 Fluid, Electrolyte, and Acid–Base Balance  1353 Foot Hygiene  711 Hair Care  724 Heritage Assessment Tool  316 Learning Needs and Characteristics  471 Loss and Grieving  1020 Medication Nonadherence  296 Nail Hygiene  714 Oral Hygiene  715 Oxygenation 1275 Pain History  1122 Personal Identity  953 Risk for Infections  636 Role Performance  954 Sample Questions  986 Sensory-Perceptual Functioning  933 Sexual Health History  972 Skin Hygiene  698 Sleep Disturbances  1102 Stress and Coping Patterns  1005 Urinary Elimination  1208

CLIENT TEACHING  Active ROM Exercises  1076 Activity and Exercise  1057 Back Injuries  1060 Breast Self-Examination  974 Breathing 1278 Canes 1082 Clients with Low Literacy Levels  476 Cough Medications  1281 Crutches 1084 Diagnostic Testing  745 Diarrhea 1249 Fecal Elimination  1248 Fluid and Electrolyte Balance  1360 Fluid, Electrolyte, and Acid–Base Balance Home Care  1360 Foot Care  712 Forced Expiratory Technique  1279 Healthy Defecation  1248 Healthy Heart  1327 Healthy Nutrition  1176 Home Care and Circulation  1327 Incentive Spirometer  1282 Infection Prevention  638

Learning Attributes  466 Metered-Dose Inhaler  848 Monitoring Pain  1128 Nutrition for Older Adults  1164 Occult Blood  756 Oxygenation 1277 Pelvic Muscle Exercises (Kegels)  1215 Physical Activity  1045 Poisoning 683 Postural Hypotension  1079 Reducing Dietary Fat  1165 Reducing Electrical Hazards  685 Safety Measures Throughout the Life Span  673 Self-Catheterization 1225 Self-Management of Pain  1141 Sensory Perception Disturbances  936 Skin Integrity  868 Skin Problems  710 Sleep 1103 STI and HIV Transmission  975 Teaching Tools for Children  481 Testicular Self-Examination  974 Tooth Decay  717 Tube Feedings  1192 Urinary Elimination  1213 Walkers 1083 Wound Care  477 Written Teaching Aids  475

CLINICAL MANIFESTATIONS  Colorectal Cancer  1240 Common Chronic Pain Syndromes  1115 Fever 506 Hypothermia 507 Hypoxia 1274 Impending Clinical Death  1025 Insomnia 1099 Malnutrition 1175 Sensory Deprivation  932 Sensory Overload  932 Sexually Transmitted Infections  963 Sleep Deprivation in Teens  1096 Spiritual Needs  982 Stress 1002

Admission Assessment  624 Amputation and Self-Concept  958 Anxiety Diagnosis  211 Assessing Surgical Client  198 Bathing Self-Care Deficit  741 Behavior Change  299 Bereavement 1030 Blood Pressure  925 Cancer Client  333 Caring and Knowing  434 Child with Ear Infection  375 Child’s Development Stage  351 Circulatory Pain  1331 Client Decision  299 Client Safety at Home  692 Consent Form  96 Critical Thinking  285 Delivering Home Care  129 Documentation for Client in Pain  773 Family Health Crisis  419 Health Agencies  285 Illness and Lifestyle  285 Illness and Sexual Activity  977 Influencing Health Care  299 Leadership Styles  498 Lifestyle Change  485 Mattress Overlays  60 Medications Following Appendectomy  850 Mixed Cultural Background Client  318 Nonverbal Communication  460 Osteoporosis 408 Pain After Surgery  1147 Physical Examination  387 Pressure Ulcer Development  888 Respiratory Infection  663 Sensory Deprivation or Overload  944 Specimen Collection  773 Spiritual Distress  992 Surgical Client  925 Treating a Client with AIDS  71 Using Computers to Communicate  166

CULTURALLY RESPONSIVE CARE 

CONCEPT MAP  Acute Pain  1149 Altered Bowel Elimination  1264 Deficient Fluid Volume  1391 Grieving Client  1030 Growth and Development Moral and Spiritual Theories 350 Growth and Development Psychosocial Theories 344 Growth and Development Theories  347 Ineffective Airway Clearance  1309 Ineffective Airway Clearance (Gas Exchange)  231 Ineffective Coping  1012 Nutrition 1196 Risk for Disuse Syndrome  1088 Sensory Perception Disturbance  945 Sleep 1108 Spiritual Distress  994 Urinary Elimination  1232

CRITICAL PATHWAY  Wound Management  869

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CRITICAL THINKING CHECKPOINT 

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Assessing Self-Concept  953 Biocultural Considerations  747 Blood and Blood Products  1384 Body Piercing  901 Clients in Pain  1130 Cultural Aspects of Social Support  281 Cultural Views of Elders  392 Culturally and Linguistically Appropriate Services 82 Disparities with Cardiovascular Disease  1323 Drawing Blood Samples  745 Ethnopharmacology 783 Families 317 Health Care Interpreter  82 Leadership, Management, and Delegation  497 Moral Principles  103 Movement Modalities  1045 Personal Space  192 Responses to Pain  1119 Valuing Family Inclusion  483 Variations in Nutritional Practices  1158

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DRUG CAPSULE  Anesthetic, midazolam hydrochloride (Versed)  905 Anticholinergic Agents, oxybutynin ER (Ditropan XL)  1211 Cardiac Glycosides or Digitalis Glycoside, digoxin (Lanoxin)  522 Diuretic Agent, furosemide (Lasix)  1347 Emollient or Surfactant docusate calcium (Surfak); docusate sodium (Colace)  1242 Glucocorticosteroids Inhaled: fluticasone (Flovent)  1281 Low Molecular Weight Heparins, enoxaparin (Lovenox) 1330 Macrolide Antibiotic, azithromycin (Zithromax)  643 Mineral, ferrous sulfate (Slow-Fe, Feosol)  1163 Narcotic Analgesic (Opioids), oxycodone (OxyContin); oxycodone/acetaminophen (Percocet); oxycodone/aspirin (Percodan)  1135 Non-Benzodiazepine Sedative-Hypnotics, zolpidem (Ambien)  1106 Parasympathomimetic or Cholinesterase Inhibitor, donepezil (Aricept)  406 Phosphodiesterase Type 31 (PDES) Inhibitor, sildenafil (Viagra); tadalafil (Cialis); vardenafil (Levitra) 971 Selective Serotonin Reuptake Inhibitor (SSRI), sertraline HCL (Zoloft)  1009 Sympathomimetics, albuterol (Proventil, Ventolin)  1281 Travoprost (Travatan)  937

EVIDENCE-BASED PRACTICE  Attitudes on Aging  392 Black Pepper Essential Oil  1364 Bladder Scanner  1210 Cardiovascular Disease  139 Caregivers Need Essential Knowledge  418 Chronic Conditions and Disabilities  125 Clean Gloves  651 Clinical Reasoning in Safe Medication Administration 178 Colorectal Cancer Screening  757 Community Health Nurses  139 Coping Strategies  1005 Cultural Competence  314 Death with Dignity  1026 Decision Regret  1099 Developing Ethical Caring  433 Domestic Violence  382 Early Mobilization  1078 Ethical Caring  433 Exercises for COPD  1280 Fetal Alcohol Spectrum Disorders  356 Healing Touch  328 Health Belief Model  296 Health Care–Associated Infections  702 Health Care Decision Making  103 Health Literacy  473 Hearing Loss Impact  940 Home Care Nurses  152 Internet as Intervention  280 Levine-Based Theory  70 Malpractice Claims  90 Nasogastric and Percutaneous Endoscopic Gastrostomy Tube  1190 Nursing Care Outcomes  264 Nursing Diagnoses  202 Nurse Leader  491 Nurse–Physician Relationships  458 Nurse Residency Program  47 Ostomy Care  1243 Pain Assessment and Management  1126 Poor Sleep Challenge  1095 Predicting Feelings of Well-Being  963 Preoperative Teaching  896 Pressure Ulcer Documentation  162

Pressure Ulcers  162 Pulse Oximeter  534 Reading the Bible  991 Role Strain  952 Safe Medication Administration  801 Safety of Older Clients  687 Shift-to-Shift Nursing Reports  264 Sleep Characteristics of Older Adults and Mortality 399 Socioeconomic Status and Health Outcomes  348 Vision Loss Impact  939

HOME CARE ASSESSMENT  Fecal Elimination  1248 Fluid, Electrolyte, and Acid–Base Balance  1359 Grieving 1021 Home Hazard Appraisal  148 Hygiene 699 Infection 637 Mobility and Activity Problems  1057 Nutrition 1176 Oxygenation 1277 Pain 1128 Sensory Perception Disturbances  935 Stress and Coping  1006 Surgical Clients  913 Urinary Elimination  1212 Wound Care  868

HOME CARE CONSIDERATIONS  Administering an Enema  1256 Administering Medications  805 Antiemboli Stockings  904 Assessing the Abdomen  603 Assessing Ears and Hearing  569 Assessing Eyes and Vision  565 Assessing the Hair  555 Assessing Mouth and Oropharynx  575 Assessing the Musculoskeletal System  606 Assessing the Nails  557 Assessing the Peripheral Vascular System  594 Assessing the Skin  554 Assisting Client to Ambulate  1081 Bandages and Binders  883 Blood Pressure  533 Capillary Blood Glucose  754 Catheterization 1223 Changing an Ostomy Appliance  1262 Cleaning a Sutured Wound  921 Closed Wound Drainage System  922 Communicating and Clinical Reasoning  176 Exit Safety Monitoring Device  680 General Survey  549 GI Suction  917 Hand Hygiene  642 Hearing Aids  732 Home Care Oxygen Equipment  1290 Hygiene 706 Intradermal Injection  819 IV Push Antibiotics  837 Metered-Dose Inhalers  848 Oral Hygiene  723 Pain Management  1146 PCA Pump  1141 Positioning Clients  1070 Postoperative Instructions  913 Pressure Ulcers  868 Pulse 521 Pulse Oximetry  535 Removing Sutures or Staples  921 Respirations 525

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Restraints 691 Seizure Precautions  682 Sequential Compression Devices  1330 Sleep 1102 Specimen Collection  763 Standard Precautions and Personal Protective Equipment 649 Sterile Field  657 Stool Specimen  757 Subcutaneous Injection  822 Suctioning 1297 Suctioning a Tracheostomy or Endotracheal Tube 1301 Surgical Clients  913 Temperature 512 Tracheostomy Care  1305 Transferring from Bed to Chair  1076 Tube Feeding  1191 Urine Specimen  760 Wound Care  879

LIFESPAN CONSIDERATIONS  Abdominal Paracentesis  768 Administering an Enema  1256 Antiemboli Stockings  904 Bandages and Binders  882 Assessing the Abdomen  603 Assessing the Anus  623 Assessing Breasts and Axillae  597 Assessing Ears and Hearing  569 Assessing Eyes and Vision  564 Assessing Female Genitals and Inguinal Areas  618 Assessing the Hair  555 Assessing Heart and Central Vessels  591 Assessing Male Genitals and Inguinal Areas  622 Assessing Mouth and Oropharynx  574 Assessing the Musculoskeletal System  606 Assessing the Nails  557 Assessing the Neck  578 Assessing the Neurologic System  615 Assessing the Nose and Sinuses  571 Assessing Peripheral Vascular System  593 Assessing the Skin  554 Assessing the Skull and Face  558 Assessing the Thorax and Lungs  586 Assessment 193 Assisting Client to Ambulate  1081 Bathing 706 Blood Pressure  532 Bone Marrow Biopsy  769 Bowel Elimination Problems  1245 Capillary Blood Glucose  754 Catheterization 1223 Circulation 1320 Communication with Children  443 Communication with Older Adults  454 Computer Use  165 Diagnosing 211 Functional Levels  128 Enhancing Self-Esteem  956 Evaluating 242 Factors Affecting Voiding  1204 Fluid and Electrolyte Imbalance  1343 General Considerations  773 General Survey  549 Hair Care  727 Health Care Decisions  178 Health Care Delivery  141 Health Promotion Topics  276 Health Promotion and Illness Prevention  282 Home Care  152 Infections 636

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Inserting a Nasogastric Tube  1183 International Adoption  306 Intradermal Injection  819 Intramuscular Injections  829 Liver Biopsy  772 Long-Term Care  258 Lumbar Puncture  767 Massage 333 Medication Nonadherence  297 Metered-Dose Inhalers and Nebulizers  847 Nursing Care Plan  229 Nutrition 1164 Ophthalmic Medications  841 Oral Hygiene  723 Oral Medications  805 Otic Medications  843 Oxygen Delivery Equipment  1290 Pain 1121 Pain Management  1146 PCA Pump  1141 Positioning Clients  1070 Postoperative Care  912 Preoperative Teaching  899 Pressure Ulcer and Wound Care  879 Preventing Falls  667 Pulse 520 Pulse Oximetry  535 Rectal Medications  846 Respirations 525 Respiratory Development  1274 Responses to Death  1029 Restraints 691 Safety 691 Seizure Precautions  681 Sensory Perception  939 Sequential Compression Devices  1330 Sleep Disturbances  1097 Spiritual Development  983 Sputum and Throat Specimens  763 Stool Specimen  757 Stress and Coping  1010 Suctioning 1297 Suctioning a Tracheostomy or Endotracheal Tube  1301 Teaching Considerations  472 Temperature 512 Thoracentesis 769 Tracheostomy Care  1305 Transferring Clients  1076 Tube Feeding  1190 Urine Specimen  760

NURSING CARE PLAN  Acute Pain  1147 Altered Bowel Elimination  1262 Deficient Fluid Volume  1389 Ineffective Airway Clearance  1307 Ineffective Airway Clearance Modified  1307 Ineffective Airway Clearance Pneumonia  1307 Ineffective Coping  1010 Nutrition 1194 Risk for Disuse Syndrome  1087 Sensory-Perception Disturbance  943 Sleep 1106 Spiritual Distress  992 Urinary Elimination  1230

PRACTICE GUIDELINES  Administering Medications  795 Applying Restraints  688 Bandages or Binders  880

Bandaging 879 Bed-Making 735 Bed Pan  1250 Bladder Retraining  1214 Bloodborne Pathogen Exposure  662 Cleaning Wounds  875 Common Pressure Sites  860 Communication During Interview  193 Damp Gauze Versus Advanced Dressings  878 Documentation 262 Facilitating Fluid Intake  1361 Herbal Preparations  325 Home Health Care Documentation  259 Individualizing Care  1129 IV Starts  1364 Legal Protection for Nurses  95 Long-Term Care Documentation  259 Nasogastric or Gastrostomy Tube Medication Administration 806 Pain Report Response  1131 Passive ROM Exercises  1077 Praying with Clients  991 Preventing Falls  678 Religious Practices  989 Reporting a Crime, Tort, or Unsafe Practice  95 Respirator Mask  650 Restricting Fluid Intake  1361 Skin Care Preparations  838 Spiritual Beliefs  989 Stretchers 1072 Surgical Wounds  918 Treating Pressure Ulcers  872 Using an Interpreter  310 Vein Selection  1363 Vascular Access Device  1367 Verbal Communication  310 Voiding Habits  1214 Wheelchair Safety  1072 Wounds 863

SKILLS  Adding Medications to Intravenous Fluid Containers 829 Administering an Enema  1253 Administering an Intradermal Injection  818 Administering an Intramuscular Injection  827 Administering Medications Using IV Push  829 Administering Ophthalmic Instillations  839 Administering Oral Medications  801 Administering Otic Instillations  841 Administering Oxygen by Cannula, Face Mask, or Face Tent  1288 Administering a Subcutaneous Injection  820 Administering a Tube Feeding  1189 Administering a Vaginal Instillation  844 Applying Antiemboli Stockings  902 Applying an External Urinary Device  1215 Applying Restraints  689 Applying a Sterile Gown and Gloves (Closed Method) 659 Applying and Removing Personal Protective Equipment (Gloves, Gown, Mask, Eyewear)  647 Applying and Removing Sterile Gloves (Open Method) 658 Assessing the Abdomen  599 Assessing the Anus  622 Assessing an Apical Pulse  518 Assessing an Apical-Radial Pulse  521 Assessing Appearance and Mental Status  546 Assessing Blood Pressure  530 Assessing the Body Temperature  510 Assessing the Breasts and Axillae  594

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Assessing the Ears and Hearing  566 Assessing the Eye Structures and Visual Acuity  560 Assessing the Female Genitals  617 Assessing the Hair  555 Assessing the Heart and Central Vessels  588 Assessing the Male Genitals  620 Assessing the Mouth and Oropharynx  572 Assessing the Musculoskeletal System  604 Assessing the Nails  556 Assessing the Neck  576 Assessing the Neurologic System  608 Assessing the Nose and Sinuses  570 Assessing a Peripheral Pulse  515 Assessing the Peripheral Vascular System  592 Assessing Respirations  524 Assessing the Skin  551 Assessing the Skull and Face  558 Assessing the Thorax and Lungs  582 Assisting Client to Ambulate  1079 Bathing an Adult Client  702 Blood Transfusion Using Y-Set  1387 Brushing and Flossing Teeth  718 Capillary Blood Specimen to Measure Glucose  752 Changing an Occupied Bed  739 Changing an Unoccupied Bed  736 Changing Bowel Diversion Ostomy  1259 Changing Intravenous Container, Tubing, and Dressing  1383 Cleaning Sutured Wound and Applying Sterile Dressing 918 Collecting Clean-Catch Urine Sample  758 Discontinuing an Intravenous Infusion  1380 Establishing and Maintaining a Sterile Field  654 Exit Safety Monitoring Device  678 Gastrostomy or Jejunostomy Tube Feeding  1189 Performing Hand Hygiene  640 Hearing Aid  731 Inserting a Nasogastric Tube  1180 Intravenous Catheter to Intermittent Lock  1382 Irrigating a Wound  875 Lateral or Prone Position  1067 Logrolling a Client  1068 Managing Gastrointestinal Suction  915 Measuring Oxygen Saturation  534 Mixing Medications Using Syringe  816 Monitoring an Intravenous Infusion  1376 Moving a Client Up in Bed  1066 Oropharyngeal/Nasopharyngeal/Nasotracheal Suctioning 1295 Performing Bladder Irrigation  1226 Performing Urinary Catheterization  1220 Preparing Medications from Ampules  813 Preparing Medications from Vials  814 Providing Back Massage  1142 Providing Foot Care  713 Providing Hair Care  726 Providing Perineal-Genital Care  708 Providing Special Oral Care  722 Providing Tracheostomy Care  1302 Removing a Nasogastric Tube  1192 Seizure Precautions  680 Sequential Compression Devices  1328 Shampooing the Hair  726 Sit on Side of Bed (Dangling)  1069 Starting an Intravenous Infusion  1370 Suctioning Tracheostomy or Endotracheal Tube 1299 Teaching Moving, Leg Exercises, Deep Breathing, and Coughing  897 Transferring Between Bed and Chair  1072 Transferring Between Bed and Stretcher  1074 Wound Drainage Specimen for Culture  865

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Kozier & Erb’s Fundamentals of Nursing

Concepts, Process, and Practice

For these Global Editions, the editorial team at Pearson has collaborated with educators across the world to address a wide range of subjects and requirements, equipping students with the best possible learning tools. This Global Edition preserves the cutting-edge approach and pedagogy of the original, but also features alterations, customization, and adaptation from the North American version.

Global edition

Global edition

Global edition

Kozier & Erb’s Fundamentals of Nursing

Tenth edition

Concepts, Process, and Practice Tenth edition

Berman Snyder Frandsen

This is a special edition of an established title widely used by colleges and universities throughout the world. Pearson published this exclusive edition for the benefit of students outside the United States and Canada. If you purchased this book within the United States or Canada, you should be aware that it has been imported without the approval of the Publisher or Author.

Audrey Berman • Shirlee J. Snyder • Geralyn Frandsen

Pearson Global Edition

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