1 Chapter: 1 Nursing Process Objective: 4 Nurse Practice Acts & Licensure (p 18; 20) Nurse Practice Acts &

Licensure - Nurse practice acts are laws established in each state in the united states to regulate the practice of nursing - Some are common such as: o Protect the public by defining the legal scope of nursing practice, excluding untrained or unlicensed people from practicing nursing o Create a state board of nursing or regulatory body having the authority to make and enforce rules and regulations concerning the nursing profession o Define important terms and activities in nursing, including legal requirements and titles for RNs and LPNs o Establish criteria for the education and licensure of nurses - The board of nursing for each state has the legal authority to allow grads of approved schools of nursing to take the licensing exam. - Those who successfully meet the requirements for licensure are then given a license to practice nursing in the state. - The license, which must be renewed at specified intervals, is valid during the life of the holder and is registered in the state - Many states have a requirement for a specified # of continuing education units (CEUs) to renew & maintain licensure. - 2 ways in which nurses can practice in other states: o Reprocity allows nurse to apply for & be endorsed as a RN by another state o 23 states are members of the Nurse Licensure Compact allowing a nurse who is licensed & permanently lives in one of the member states to practice in other member states w/o additional licensure (National Council of State Boards of Nursing 2008) - The license and the right to practice nursing can be denied, revoked or suspended for professional misconduct - As nursing roles continue to expand & issues in nursing are resolved, nursing prac acts will reflect those changes. - All nurses should be knowledgeable about the specific nurse prac act for the state in which they prac. 2 Chapter: 5 Nursing Process Objective: 4 Protect of Rights of Human Subj (p 78; 89) Protection of the Rights of Human Subjects - Many nurses work in healthcare institutions in which pts are invited to participate in clinical research. - W/ their focus on the overall well-being of the pt, nurses play an important role in ensuring that patient interests are not sacrificed to research interest - Nursing priorities include determining that research studies have met appropriate scientific and ethical criteria before their implementation, and protecting patient rights - Specific patient rights include informed consent, the patients right to consent knowledgeably to participate in a study without coercion or to refuse to participate without jeopardizing the care he or she is receiving - The right to confidentiality - Right to be protected from harm - Federal regulations require that institutions receiving federal funding or conducting studies of drugs or med devices regulated by the FDA establish IRBs. - Institutional review boards (IRBs) review all studies conducted in the institution to determine the risk status of all studies and to ensure that ethical principles are followed 3 Chapter: 6 Nursing Process Objective: 5 Nursing Standards of Practice (p93, 105) Nursing Standards of Practice

When the American Nurses Association (ANA) revised its Standards of Clinical Nursing Practice in 1991, it developed standards of professional performance as well as standards for care Standard V of professional performance, Ethics, describes the nurses ethical obligations; the nurses decisions and actions on behalf of patients are determined in an ethical manner Standard V: o The nurses practice is guided by the Code of Nurses o The nurse maintains patient confidentiality within legal and regulatory parameters o The nurse acts as a patient advocate and assists patients in developing skills so they can advocate for themselves o The nurse delivers care in a non-judgmental and non-discriminatory manner that is sensitive to patient delivery o The nurse delivers care in a manner that preserves or protects patient autonomy, dignity, and rights o The nurse seeks available resources to help formulate ethical decisions

4 Chapter: 11 Comm & Doc Objective: 3 Documenting the Nursing Process (p197; 215) Documenting the Nursing Process - The ability to communicate clearly is a critical nursing skill Accurate, concise, timely, and relevant documentation provides all the members of the care giving team with a picture of the patient The pt record is chief means of communication among members of the interdisciplinary team. - Legally speaking, a nursing action not documented is a nursing action not performed 5 Chapter: 12 Nursing Process Objective: 1 Assessment and Critical Thinking (p224) Assessment & Critical Thinking Entire nursing process rests on initial & ongoing assessment of the patient o Need to use excellent critical thinking skills when gathering, validating, analyzing, & communicating data. Critical thinking activities linked to assessment are: o Assessing systematically & comprehensively, using a nursing framework to identify nursing concerns & a body systems framework to identify medical concerns o Detecting bias & determining the credibility of info sources o Distinguishing normal from abnormal & identifying risks for abnormal findings o Making judgments about the significance of data, distinguishing relevant from irrelevant o Identifying assumptions & inconsistencies, checking accuracy & reliability, and recognizing missing information Many of these activities are challenging for those new to nursing who most likely lack clinical experience that aids in expert clinical reasoning. Students are urged to ask qs frequently about data & to test their inferences & judgments 6 Chapter: 17 Comm & Doc Objective: 4 Agency Policies (p328, 357) - Everyone who has access to the record (direct caregivers) is expected to maintain its confidentiality - Most agencies grant student nurses access to patient records for education purposes o The student assumes responsibility to hold patient information in confidence - Never use a patients name when preparing written or oral reports for school

Agency policies also indicate which personnel are responsible for recording on each form in the record and such policies might also describe the order in which the forms are to appear in the record - One of the strategies the JCAHO is using to achieve National Patient Safety Goals is a list of do not use abbreviations, acronyms, and symbols - The storage of patient records when a patient is no longer receiving treatment is a function of the health agencys record department - You will also want to be aware of agency policies regarding the patients right to access records o Be sure to check the policy where you work to find out answers to the following FAQs: Can I take my chart home? How long do you retain records? How long will it take to get a copy of my record? How much does it cost? I dont want some parts of my record released to anyone. What do I do? May I look at my fams med record? Who can look at my record? Who do I tell if my name has been changed? 7 Chapter: 17 Comm & Doc Objective: 1 Guidelines for Effect. Doc (p324, 353) Guidelines for Effective Documentation - The patient record is the only permanent legal document that details the nurses interaction with the patient and is the nurses best defense if a patient or patient surrogate alleges nursing negligence - There are often crucial omissions in the nursing doc, along with repetitious or inaccurate entries. - Although errors might go undetected & have no effect on the pt, they might also seriously affect the care the pt receives, undermine nursings credibility as a professional discipline & cause legal probs for the nurse responsible. - In a brief documentation should be consistent with professional and agency standards; complete, accurate, concise, factual, organized, and timely legally prudent and confidential - Box 17.1 p. 326* Content: complete, accurate, concise, current & factual Reflects nursing process, pt findings rather than your interpretation, avoid good normal, avoid generalizations of seems comfortable, note probs in a orderly manner, doc all med visits & consultations, avoid stereotypes Timing: date & military time, never leave unit for break when caring for a seriously ill pt until all sig data are recorded, write a progress note for each such as upon admission, transfer, procedure, any change in pt status Format: proper form, dark ink, use standard term, chart nursing interventions & never skip lines Accountability: sign you 1st initial, last name & title for each entry, be sure pt record is complete before sending it to medical records Confidentiality: info kept private & confident - The ANA introduced a new tool to streamline the nursing documentation process in 2003 o This guide includes policy statements, principles, and recommendations to assist nurses with documentation and to comply with institutional and regulatory requirements 8 Chapter: 21Nursing Process Objective: 3 Using Therapeutic Comm (p444) Using Therapeutic Communication in the Nursing Process

The nurses ability to communicate with patients and with other nurses is essential for effective use of the nursing process Assessing: gather information in both verbal and nonverbal communication forms o Nurses can read their patients records or charts before meeting them o Nurses use one-to-one communication with patients to obtain thorough nursing histories and physical examinations o Effective communication techniques as well as observational skills are used extensively during this phase Diagnosing: written diagnosis becomes a permanent part of the patients record Outcome Identification and Planning: the planning steps requires communication among the patient, nurse and other team members as mutually agreed-upon outcomes are developed and interventions are determined o The formal written plan of care is a form of communication Implementing: implement the plan of care o Verbal and non-verbal communication allows the nurses to enhance basic caregiving measures and to teach, counsel and support patients and their families during the implementation phase Evaluating: nurses often rely on the verbal and nonverbal cues they receive from their patients to verify whether patient objectives or goals have been achieved o Facilitates the revision of parts of the care plan Documenting Communication: this documentation helps promote the continuity of care given by nurses and other healthcare providers

9 Chapter: 24 Comm & Doc Objective: 2/5 Respiratory Depth/Rhythm (p530, 572) Respiratory Depth & Rhythm - The depth of respirations normally varies from shallow to deep - Apnea: periods during which there is no breathing - Dyspnea: difficult or labored breathing o Usually has rapid, shallow respirations and appears anxious o Can breathe more easily in an upright position, condition known as orthopnea While sitting or standing, gravity lowers organs in the abdominal cavity away from the diaphragm. This gives the lungs more room for expansion w/in the chest, allowing the intake of more air with each breath. - Table 24-7: Patterns of Respiration Normal Tachypnea Bradypnea Hyperventilation Hypoventilation Cheyne-Stokes Respirations Biots Respirations Description 12-20 breath/min; regular > 24 breaths/min; shallow <10 breaths/min; regular Increased rate & depth Decreased rate & depth Deep, rapid breathes followed by periods of apnea; regular Varying depth/rate & apnea; irreg Associated Features Normal pattern Fever, anxiety, exercise, resp d/o Depression by meds; brain damage Extreme exercise, fear, o/d aspirin o/d narcotics or anesthetics Drug overdose, heart failure, increased intracranial p, renal failure Meningitis, severe brain damage

10 Chapter: 24 Nursing Process Objective: 2 Physiology of BP (p531; 571) Physiology of Blood Pressure - Arterial walls contain elastic tissue that allows them to stretch & distend (compliance) as blood enters with each ventricular contraction When heart rests btw each beat, the walls of the arteries return to their original position, although pressure In them doesnt drop to 0 Arterioles offer resistance to the pressure of the blood & keep the blood entering the capillaries in a continuous flow rather than in spurts. Therefore, the elasticity of the arterial walls, in addition to the resistance of the arterioles, helps to maintain normal BP. With increased age, the walls of the arterioles become less elastic, which interferes with their ability to stretch & dilate. This can limit right blood flow & contribute to the rising pressure within the vascular system. - Blood pressure refers to the force of the blood against arterial walls - Max blood pressure is exerted on the walls of the arteries when the left ventricle of the heart pushes blood through the aortic valve into the aorta at the beginning of systole - Systolic pressure: highest pressure - Diastolic pressure: lowest pressure present on arterial walls - Pulse pressure: difference between the two - Blood pressure regulation is controlled by a variety of mechanisms to maintain adequate tissue perfusion - The arterial blood pressure has constant minor variations from activities of daily living such as rising from sitting to a standing position, exercise or emotion 11 Chapter: 24 Nursing Process Objective: 4 Assessing Apical-Radial Pulse (p 527, 567) Assessing the Apical-Radial Pulse - When the radial pulse is irregular, counting the pulse at the apex of the heart and at the radial artery simultaneously is used to assess the apical-radial pulse rate - Pulse deficit: the difference between the apical and radial pulse rates o Indicates that all the heartbeats are not reaching the peripheral arteries or are too weak to be palpated 12 Chapter: 24 Nursing Process Objective: 5 Normal Blood Pressure (p 532, 574) Normal Blood Pressure - Systole: <120 - Diastolic < 80 - Rise or fall of 20-30 mm Hg in a persons BP is significant. - AHA recommends BP readings be averaged on 2 or more occasions before determining if the BP is outside acceptable parameters. - Measurements should be taken after the pt rests for at least 5 min & has not consumed caffeine or smoked for 30 min before the measurement. 13 Chapter: 24Nursing Process Objective: 2 Increased Respiratory Rate (529; 571) Increased Respiratory Rate - Tachypnea, an increased respiratory rate, often occurs in response to the increased metabolic rate when a person has a fever - Cells require more oxygen at this time and have more CO2 that must be removed The rate increases as much as 4 breaths/min with every 1F that the temp rises above normal.

Any condition causing an increase in CO2 and a decrease in oxygen in the blood also tends to increase the rate and depth of respiration 14 Chapter: 24Nursing Process Objective: 3 Sites & Methods of Assessing Pulse (527; 568) Sites & Methods of Assessing the Pulse - Although peripheral pulses are most commonly assessed, an apical pulse or an apical-radial pulse should be assessed in certain situation - Radial pulse is used most often in children and adults - Peripheral pulses are assessed by placing the middle 3 fingers over the artery and lightly compressing the artery so pulsation can be felt and counted - Circulation to the legs and feet is assessed at the femoral, popliteal, posterior tibial and dorsalis pedis sites - Carotid pulse is used in ER situation - Brachial pulse site is used for infants who have had a cardiac arrest o Peripheral arterial pulses Temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis Radial most common Carotid emergency people in shock or cardiac arrest Brachial infants o Apical pulse If peripheral is weak, irregular, very rapid Assessed when giving meds that alter heart rate or rhythm 5th and 6th intercoastal space, 3inc left of the median line and slightly below nipple o Apical-radial pulse When radial pulse irregular, count pulse at apex and radial artery together Difference between the rates pulse deficit indicates that all of the heart beats are not reaching the peripheral arteries or are too weak to be palpated 15 Chapter: 25 Comm & Doc Objective: 7 Documentation of Data (607; 649) Documentation of Data - After completing the nursing history and assessment, organize all assessment data to identify actual and potential health problems, make nursing diagnoses, plan appropriate care, and evaluate the patients responses to treatment - Documentation example Box 25-6 (610) 16 Chapter : 26 Nursing Process Objective: 2 Physical Health State (p618, 662) Physical Health State - Anything that affects the patients health state potentially can affect the safety of the environment - When a person is chronically ill or in a weakened state, the focus of healthcare includes preventing accidents as well as promoting wellness and restoring the individual to a healthy state - Prevention of complications and return to the optimal level of functioning require attention to safety and become primary concerns in a stroke rehabilitation program - The nurse strives to maximize the patients potential by considering safety factors in all phases of the illness and recovery experience 17 Chapter: 26 Preventing Falls - Preventing falls in the home Preventing Falls (p633, 677)

o Major causes of falls in the home include slippery surfaces, poor lighting, clutter, and improperly fitting clothing or slippers o Common traffic pathways in the home, the bathroom and access areas to and from the home are hazardous areas for older adults o Measures as simple as installing hand rails in bathrooms and on stairs, ensuring good lighting and discarding or repairing broken equipment around the home help prevent accidents Hendrich II Fall Model evaluates: Risk factor: confusion/disorientation/impulsivity, depression, altered elimination, dizziness/vertigo, gender (male), antiepileptics, benzodiapines Get-up-and-go test rising from chair: rise in single movement, pushes up successful in 1 attempt, multiple attempts but successful, unable to rise w/o assistance The Get up and Go test: identifies if a patient is at risk for falling o A variety of factors such as poor vision, the effects of multiple medication, lower extremity weakness or a gait disorder can reduce the patients mobility o During this test, assess the patients stability, balance, gait and lower body strength any limitations in any of these areas may indicate vulnerability for a fall Misunderstandings about fall risk: Advanced age w/o presence of other risk factors can no longer be viewed as a definite fall risk factor Adverse effects related to meds are more predictive of falling (antiepileptic) Previous fall is a predictor of future fall Preventing falls in the healthcare facility o Box 26-3 (p.633, 678)

18 Chapter: 27 Comm & Doc Objective: 6 Gloves (p669) Gloves - Gloves, not a substitute for good hygiene, are worn only once and discarded appropriately according to agency policy - Gloves should always be changed prior to moving from a contaminated task to a clean one - When care activities do not involve the possibility of soilage of hands with body fluids, gloves are not necessary - While wearing gloves, never do the following: o Leave the patients room (unless transporting a contaminated item or a patient requiring transmission-based precautions) o Write in the patients chart o Use the computer keyboard or telephone in the nurses station - The warmth and moisture inside gloves create an ideal environment for bacteria to multiply, making it even more important to perform good hand hygiene before and after using gloves - Double gloving is recommended if the healthcare worker is going to be exposed to blood or body fluids - Latex sensitivity reactions ranging from local skin reaction to urticaria (hives) to systemic anaphylaxis, an exaggerated allergic reaction that can result in death - The National Institute for Occupational Safety and Health (NIOSH) recommends that nonlatex gloves or powder-free low-allergen latex gloves be available for employees 19 Chapter: 27 Nursing Process Objective: 6 Performing Hand Hygiene (p661; 708) Performing Hand Hygiene - Hand hygiene is the most effective way to help prevent the spread of organisms - According to CDC guidelines, the term hand hygiene applies to either hand washing with plain soap and water, use of antiseptic handrubs including alcohol-based products or surgical hand antisepsis

Skills 27-1 (726)

20 Chapter: 27 Comm & Doc Objective: 1 Infectious Agent (p653, 704) Infectious Agent - Some of the more prevalent agents that cause infection are bacteria, viruses, and fungi - Bacteria, the most significant and most commonly observed infection-causing agents in healthcare institutions o Categorized by shape as spherical (cocci), rod shaped (bacilli), or corkscrew shaped (spirochetes) o Can be gram positive (thick wall that resists decolorization and stain violet) or negative (doesnt stain) o Most bacteria require oxygen to live and grow and are therefore referred to as aerobic o Those that can live without oxygen are anaerobic bacteria - Virus is the smallest of all microorganisms, visible only with an electron microscope o Many infections care caused by viruses, including the common cold and the deadly disease AIDs o Antibiotics have no effect on viruses, however, there are some antiviral medications available that seem to be effective with some viral infection o When given in the prodromal stage of certain viruses, these medications can shorten the full stage of the illness - Fungi, plantlike organisms (molds and yeast) that also can cause infection, are present in the air, soil, and water o Athletes foot, ring worm, and yeast infection o Treated with anti-fungal medication, however, many infections due to fungi are resistant to treatment - An organisms potential to produce disease in a person depends on a variety of factors: o Number of organism o Virulence of the organism, or its ability to cause disease o Competence of the persons immune system o Length and intimacy of the contact between the person and the microorganism 21 Chapter: 27 Teaching/Learning Objective: 1 Means of Transmission (p 656, 704) Means of Transmission) - An organism may be transmitted from its reservoir ( natural habitat of the organism) by various means or routes - Some organisms can be transmitted by more than one route - It can be direct or indirect o Direct contact involves proximity between the susceptible host and an infected person or a carrier such as touching, kissing, or sexual intercourse o Indirect route involves personal contact with an inanimate object such as touching a contaminated instrument - Contaminated blood, food, water or inanimate objects (fomites) are vehicles of transmission - Vectors, such as mosquitoes, ticks, and lice are nonhuman carriers that transmit organisms from one host to another by injecting salivary fluid with a human bite occurs - Microorganisms can also be spread through the airborne route when an infected host coughs, sneezes or talks or when the organism becomes attached to dust particles - Droplet transmission is similar to airborne transmission 22 Chapter: 27 (657, 705) Nursing Process Objective: 3 Full Stage of Illness

Full Stage of Illness - The presence of specific signs and symptoms indicates the full stage of illness - The type of infection determines the length of the illness and the severity of the manifestations - Localized symptoms: occur in only one body area - Systemic symptoms: symptoms manifested throughout the entire body 23 Chapter: 27 Nursing Process Objective: 4 Factors Affecting Risk (658, 705) Factors Affecting Risk for Infection - The susceptibility of the host depends on various factors: o Integrity of skin and mucous membranes, which protect the body against microbial invasion o pH levels of the GI and genitourinary tracts, as well as the skin, which helps to ward off microbial invasion o Integrity and number of the bodys white blood cells which provide resistance to certain pathogens o Age, sex, and race and hereditary factors, which influence susceptibility o Immunization, natural or acquired, which act to resist infection o Level of fatigue, nutritional and general health status, the presence of preexisting illnesses, previous or current treatments and certain medications which play a part in the susceptibility of a potential host o Stress level: stress may adversely affect the bodys normal defense mechanism o Use of invasive or indwelling medical devices, which provide exposure to and entry for more potential in a patient whose defenses are already weakened by disease - Sensible nutrition, adequate rest and exercise, stress-reduction technique and good personal hygiene habits can help maintain optimum bodily function and immune response 24 Chapter: 28 Nursing Process Objective: 4 Botanical (Herbal Products) (p714, 761) Botanical (Herbal Products) & Nutritional Supplements - Description o Some consumers and practitioners are attached to herbs because they are natural plant products, which are perceived as more compatible with the body than manufactured pharmaceutical agents o Herbs can be used for treatment of disease and reduction of symptoms o Echinacea and goldenseal are frequently used for respiratory infections and ginkgo biloba is frequently used to dilate cerebral blood vessels and reduce symptoms of memory loss and mental confusion o Nutritional supplements are chemical compounds that contain ingredients believed to promote health - Nursing considerations o Nurses adds an aspect of safety to their practice o Some herbs and/or supplements may interact with prescribed medications patients are taking o Ginkgo biloba, the most widely sold herb in Europe and used by many to improve memory, affects platelet function and thus should be used with warfarin or aspirin - Teaching to Promote Health at Home 28-1 (761) 25/26 Chapter: 29 (p732, 773) Nursing Process Objective: 3 Serum Drug Levels

Serum Drug Levels - After a drug has been absorbed, its serum level can be monitored by drawing a blood specimen and measuring the level of the drug in the serum - A drugs therapeutic range is the concentration of drug in the blood serum that produces the desired effect without causing toxicity - Peak level: highest plasma concentration of the drug should be measured when absorption is complete - The trough level is the point when the drug is at its lowest concentration, and this specimen is usually drawn in the 30-min interval before the next dose - A drugs half-life is the amount of time it takes for 50% of the blood concentration of a drug to be eliminated from the body 27 Chapter: 29 Dosage Calculations (736; 782) Dosage Calculations - Systems of Measurements o Three systems of measurements are used for administering medication: metric, apothecary and household o Metric: meter (linear), liter (volume), and the gram (weight) Weight: 1 kg=1000g 1g=1000mg 1mg=1000micrograms Volume 1 liter = 1 ml o Apothecary: basic unit of weight is grain. Minim, dram, ounce, pint and quart are used for volume - Dose on hand/ quantity on hand = dose desired/ X (quantity desired) 28 Chapter: 29 Nursing Process Objective; 7 Checking Med Order (735, 781) Checking the Medication Order - Nurses should be familiar with the system used in the agency where they work and should implement it correctly to minimize errors - In many institutions, the order is coped onto the patients medication record (MAR) medication administration record - Increasing numbers of healthcare facilities are computerized medication administration record (CMAR) - Nurse is responsible for checking that the medication order was transcribed correctly by comparing it with the original order - Nurse is also responsible for double-checking the dosage and appropriateness of the medication 29 Chapter: 29 Nursing Process Objective: 1/7 Medication Orders (p732, 778) Medication Orders - No medication may be given to a patient without a medication order from a licensed practitioner - CPOE systems allow the prescriber to enter medication orders in a standard format - The computer sends the order directly to the pharmacy and enter the order into the patients permanent record o Prevents guessing handwriting - Some of the information this system provides includes recommended dosing of medications, drug-specific information, current patient information, laboratory tests that monitor the action of the drug, and potential interaction that may occur with other medications and foods

A computerized entry system can make medication administration safer and reduce adverse drug events Usual hospital policy dictates that when a patient is admitted, unless specific orders to the contrary are written, all drugs that the physician may have ordered while the patient was at home are discontinued When a patient has had surgery or is transferred to another clinical service or another health agency, it is general practice that all orders related to drugs are discontinued and new orders are written in the new setting

30 Chapter: 29 Nursing Process Objective: 7 Types of Orders (p 733, 779) - A standing order is carried out as specified until it is canceled by another order - P.r.n order (as need): patient receives medication when it is requested or required o P.r.n orders are commonly written for treatment of symptoms - Single or one time order: directive is carried out only once, at a time specified by the prescriber o Medication to be administered immediately before surgery - Stat order: single order, but it is carried out immediately o Bronchodilator or an antihistamine 31 Chapter : 30 Teaching/Learning Objective: 1 General Anesthesia (p822) Involves admin of drugs by the inhalation or IV route to produce CNS depression. o It is a combo of both IV & inhalation anesthetics. o Desired actions of general anesthesia are loss of consciousness, analgesia, relaxed skeletal muscles, & depressed reflexes. o Choices of route & type of anesthesia are made primarily by the anesthesia provider after discussion with the patient. o Many factors influence these choices, including the type & length of surgery & the physical & psychological status of the patient. o Inhalation anesthesia is often used b/c it has the advantage of rapid induction, excretion & reversal of effects. 3 phases are induction, maintenance, & emergence. o Induction admin of agent & continues until the pt is ready for the incision. o Maintenance continues from this pt until near the completion of the procedure. o Emergence starts as the pt begins to awaken from the altered state induced by the anesthesia & usually ends when the patient is ready to leave the operating room; the length of time depends on the depth & length of anesthesia. New agents allow pts to emerge from anesthesia & wake up in a fraction of the time required in the past. o As these become more commonly used, pts will bypass the PACU. o This allows more surgical procedures to be safely done in drs offices. o It is advantageous b/c it can be used for pts of any age & for any surgical procedure with the patient unaware of the physical trauma of the surgery & respiratory depression, post-op nausea & vomiting & alterations in thermoregulation. 32 Chapter: 30 Teaching/Learning Objective: 1/3 Assessing/interviewing o Daily/weekly bathing habits Skin o Rashes, lumps, itching, dryness, lesions Assessing (p868)

How long have you had this problem? Does it bother you? How does it bother you? Document patients typical hygiene practices and any complaints (use of creams, soaps) Oral cavity o History of teeth, tongue, salivary glands o Identify variables that cause oral problems deficient self-care, poor nutrition, or excess of sugars, family history Eyes, ears, nose o Glasses, contacts, hearing aids Hair o Texture, amount of hair, treatments, malnutrition Nails & feet o Type of footwear worn, foot problems, history of biting nails o Perineal and vaginal areas o Foley cath, childbirth, surgery, UTI, diabetes Physical assessment Skin o Cleanliness, color, texture, temperature, turgor, moisture, sensation, lesions o Lesion type, color, size, distribution & grouping, location, and consistency o Dry skin, acne, rashes Oral cavity o Odors o Lips: color, moisture, lumps, ulcers, lesions, edema o Buccal mucosa: color, moisture, lesions, nodules, bleeding Color of gums and surface of gums: lesions, bleeding, edema, exudates o Teeth: loose, missing, decayed teeth; dentures or other orthodontic devices o Tongue: color, symmetry, movement, texture, lesions o Hard and soft palates: intactness, color, patches, lesions o Oropharynx: movement of uvula and condition of tonsils if present o Caries: decay of teeth wit the formation of cavities o Plaque: invisible, destructive, bacterial film that builds up and leads to destruction of tooth enamel o Gingivitis: inflammation of gingival, the tissue surrounding the teeth o Periodontitis: inflammation of gums that also involves degeneration of the dental periosteum (tissues) and bone o Halitosis: strong mouth odor Eyes, ears, and nose o Check position, alignment, and appearance of eye Check eyelashes are equally distributed and curl outward Note lesions nodules, redness, swelling, crusting, flaking, tearing or discharge of eyelids Check color of conjunctiva and test blink reflex o Ear: position, alignment and appearance Buildup of wax in canal, dryness, crusting, or presence of any d/c or foreign body o Nose: position and appearance, nostrils, check tenderness, dryness, edema, bleeding, discharge or secretions Hair o Texture, cleanliness, and oiliness o Scaling, lesions, infections on scalp o Dandruff, hair loss, infestations o o

o Pediculosis: infestation with lice Nails and feet o Observe nail base for redness, swelling, bleeding, d/c, tenderness o Cleanliness and intactness

33 Chapter: 30 Nursing Process Objective: 2/3 Developmental Considerations (p825) Developmental Considerations Infants & older adults are at a greater risk from surgery than are children & young or middle aged adults. o Infant has a lower total blood volume, making even a small loss of blood a serious concern b/c of the risk for dehydration & the inability to respond to the need for ed O2 during surgery. Also airway is small, soft, & flexible and infants & small children have more upper respiratory infections such as colds that cause airway obstruction & hypoxia This population can quickly develop bronchospasm, stridor, & respiratory arrest. o If child has signs of even mild respiratory infections on the day of surgery, their procedure will be postponed until it resolves. Infant also has difficulty maintaining stable body temperature during surgery b/c the shivering reflex is not well developed, making hypothermia or hyperthermia more likely. o Their lower glomerular filtration rate & creatinine clearance can lead to a slower metabolism of drugs that require renal biotransformation. B/c the liver is immature until after the 1st year of life, the effects of muscle relaxants & narcotics may be prolonged. Physiologic changes associated w/ aging increase the surgical risk for older patients. o These changes older adults ability to respond to the stress of surgery, alter the effects of preoperative & postoperative meds & anesthesia, & prolong or alter wound healing processes. o With an increasing older adult population, assessing physiologic changes is crucial to providing knowledgeable, safe, holistic nursing care to older surgical patients. o Chronic illnesses, more common in the older population, also surgical risk & may require alterations in usual perioperative procedures. Ex. A patient w/ congestive failure may be more easily fatigued & thus unable to be up and about as rapidly after surgery Age Related Changes Cardiovascular - cardiac output, stroke volume, & cardiac reserve - peripheral circulation - ed vascular rigidity Respiratory - Reduced vital capacity - Diminished cough reflex - ed O2 of blood - ed chest expansion & strength of intercostal muscles & diaphragm Central Nervous System - ed reaction time & coordination Nursing Interventions - Obtain & record baseline vital signs - Assess peripheral pulses - Teach leg exercises, turning & ambulating - Document normal activity levels & tolerance of fatigue - Monitor fluid admin rate - Allow enough time for effects of meds to occur - Obtain & record baseline respiratory depth & rate - Teach coughing & deep breathing exercises - Teach use of incentive spirometer - Assess color of skin - Explain use of pulse oximeter for monitoring postop oxygenation - Orient surroundings - Institute safety measures, such as keeping

- Reduced short-term memory - Sensory deficits - thermoregulation ability Renal - ed renal blood flow - Reduced bladder capacity Gastrointestinal - ed gastric pH - Prolonged gastric-emptying time - ed hepatic blood flow, liver mass, & enzyme fxn Integumentary - ed vascularity - skin moisture & elasticity - ed subcutaneous fat

environment clear of clutter & using a night light Allow additional time for teaching Use appropriate measures to conserve body heat Monitor amt & times of voiding Monitor fluid & electrolyte status Maintain & record intake & output Obtain baseline weight Monitor nutritional status (wt, lab data) Observe for prolonged effects of meds Assess skin status Monitor fluid status Pad & protect boney prominences Monitor skin for pressure areas Use min amts of tape on dressings & intravenous sites Physical Assessment

34 Chapter: 30 (p828)

Communication Objective: 2

& Documentation Physical Assessment Assessing the patients current physical status provides data for interventions to surgical risk & potential postop complications. Depending on the situation, the physical assessment is conducted Presurgical screening tests provide objective data of normal body fxn In cases of abnormalities, such tests provide data for medical interventions to improve the patients physical status & thus the risks for surgical complications Nurses role is to ensure that the tests are explained to the patient, appropriate specimens are collected, the results are documented in the pts record before surgery, & abnormal findings are reported. Usual presurgical screening tests include chest x-ray, electrocardiography, complete blood count, electrolyte levels, & urinalysis. Significant abnormal findings include elevated WBC (infection), ed hemoglobin/hematocrit (bleeding, anemia), hyperkalemia or hypokalemia (ed risk for cardiac probs), elevated blood urea nitrogen or creatinine (possible renal failure), and abnormal urine constituents (infection or fluid imbalances) PREOPERATIVE PHYSICAL ASSESSMENT QS & APPROACHES Note general state of health Note body posture & stature Take & record vital signs Inspect skin for color, characteristics, & location & appearance of lesions Assess skin over bony prominence Palpate skin turgor Observe chest excursion & diameter & shape of thorax Auscultate breath sounds Palpate for any pain or tenderness Inspect for jugular vein distention Auscultate apical rate, rhythm, & character

FACTORS TO ASSESS General survey Skin

Chest & lungs Cardiovascular system

Abdomen Neurologic System

Musculoskeletal System

Auscultate heart sounds Assess for peripheral edema Palpate character of peripheral pulses Ask time of last bowel movement Inspect abdominal contour Auscultate bowel sounds Note orientation, level of consciousness, awareness, & speech Assess reflexes Assess motor & sensory ability Assess visual & hearing ability Inspect & note joint range of motion Palpate muscle strength Assess ability to ambulate

35 Chapter: 30 Nursing Process Objective: Elimination (p834) Elimination Emptying the bowel of feces is no longer a routine procedure before surgery, but the nurse should use preop assessments to determine the need for an order to facilitate bowel elimination o If the patient has not had a bowel movement for several days or has had preop barium diagnostic tests, an enema helps prevent postop constipation If the pt is scheduled for surgery of the GI tract, a prescribed bowel prep & a cleansing enema are usually ordered o Peristalsis does not return for 24-48 hrs after the bowel is handled, so preop cleansing helps to postop constipation o An empty bowel also prevents contamination of the surgical area during surgery o Insertion of an indwelling urinary catheter may be ordered before surgery, especially in pts having pelvic surgery to prevent bladder distention or accidental injury. o If an indwelling cath is not in place, the pt should void immediately before receiving preop meds to ensure an empty bladder during surgery 36 Chapter: 30 Pneumonia Objective: 4/5 Pneumonia (p844) Pneumonia Pneumonia inflammation of the alveoli as the result of an infectious process or the presence of foreign material. o May occur postop as a result of aspiration, infection, depressed cough reflex, increased secretions from anesthesia, dehydration, & immobilization. o Manifestations fever, chills, cough that produces a nasty or purulent sputum, crackles & wheezes, dyspnea, and chest pain o Goals of care: treat underlying infection, maintain respiratory fxn, & prevent spread of microorganisms o Nursing interventions incl those used to prevent or monitor for respiratory, complications & promoting fall aeration of the lungs by positioning the pt in a semiFowlers or Fowlers position, administering O2, administering meds (antibiotics, expectorants, analgesics), providing frequent oral hygiene, & ensuring rest/comfort 37 Chaper: 30 Nursing Process Objective: 4/5 Immediate Postop Assess & Care (p839) Immediate Postoperative Assessment & Care Postop divided into 2 stages immediate care (PACU) in both hospital & outpatient/same day surgery centers & ongoing postop care (lasting from return to the unit thru convalescence). Assessments carried out to maintain function, promote recovery, facilitate coping with alterations in structure or function.

Care in PACU assessing postop patient w/ emphasis on preventing complications from anesthesia or surgery. o Assessments are continuous, using preop & intraop data as bases for comparison. These include respiratory status, CV status, CNS, fluid, wound, & general condition. Made every 10-15 minutes. Children can quickly lose their airway & go into a crisis. o Emergence delirium, where they wake up thrashing & disoriented is common in children. o They must be safeguarded from hurting themselves & often reinduced into general anesthesia to promote a smoother anesthesia emergence. Average PACU is 1 hr but will vary depending on type of surgery, length of anesthesia, & patient response. o Outpatient/same day surgery pts return home after recovery in the PACU. o PACU nurses vigilant monitoring during emergence from anesthesia & 1st hours after surgery, pain management, fluid & electrolyte balance, stabilization of physiologic parameters (heart & RR), & prep for the next level of care. Respiratory status o Rate, rhythm, & depth auscultate breath sounds, noting O2 saturation level, assessing skin color & monitoring CV & mental status. During a surgical procedure with gen. anesthesia, endotracheal tube may be inserted to administer anesthetic gases & maintain patent air passages. Airway is not removed until laryngeal & pharyngeal reflexes return, allowing the patient to control the tongue, cough, & swallow. Airway is assessed for patency, humidified oxygen is administered & pulse oximetry is initiated. Ineffective respiratory function is indicated by restlessness & anxiety; unequal chest expansion with use of accessory muscle; shallow noisy respirations; cyanosis; & tachycardia. o Respiratory obstruction is most common. Occurs as a result of secretion accumulation, obstruction by the tongue, laryngospasm (sudden, violent contraction of the vocal cords), or laryngeal edema. Respiratory obstruction is indicated by assessments of ineffective respiratory function plus observing for wheezing or crowing sounds with respiratory effort. Positioning, administering humidified oxygen, encouraging pt to take deep breaths, & suctioning may be used to maintain a pt airway & tissue oxygenation. Cardiovascular status o Take vital signs, monitory electrocardiogram rate & rhythm, & observing skin color & condition. BP findings are compared with baseline data from preop period. Transient hypertension can occur as a result of anesthetic effects, respiratory insufficiency, surgical procedure, or excitement phase of recovery from anesthesia. o Hypotension result of anesthetic agents, preop meds, position changes, blood loss, respiratory alterations, peripheral blood pooling. O2 admin, deep breathing, leg exercises, verbal stimulation (to help expel anesthetic gases & facilitate increasing level of consciousness), & maintaining accurate IV flow rates can increase low BP.

Pts are at a risk for altered body temp related to surgical procedure, its length, anesthetic agents, a cool surgical environment, age, use of cool irrigating or infusion fluids. Inadvertent hypothermia (temp below 96 F) can lead to complication to poor wound healing, hemodynamic stress, cardiac disturbances, coagulopathy, delayed emergence from anesthesia, & shivering & its associated discomfort. Measure body temp, usually by temporal or tympanic route, initiate interventions if pt complains of being cold or is hypothermic. Warmed blankets placed on patients body & head & forced warm air devices are used for rewarming. o All pulses are assessed for bilateral equality, rhythm, rate, & character. Of special significance are assessments of abnormal fxn, irregular rhythm, absence of pulses, or tachycardia. Tachycardia, an early symptom of shock, must be carefully evaluated. Other related assessments for shock are a decreasing BP, cyanosis, a cool skin temp, & a decrease in urine output. Central Nervous System o Pts response to stimuli & orientation. Consciousness returns in reverse order with 1) unconsciousness 2) response to touch & sounds 3) drowsiness 4) awake but not oriented and 5) awake & oriented. Nurses in PACU verbally reorient pt by gently touching & calling them by his or her name. Fluid status o Fluid imbalance result from factors such as preop fluid restriction, fluid loss during surgery, wound drainage, or surgical stress response (w/ retention of Na & H20). Imbalanced fluid volume (deficit or excess) is risk for all surgical pts but is an especially imp consideration in children & older adults. Assessing fluid status includes skin turgor, vital signs, urine output, wound drainage, & IV fluid intake. IV fluid admin assessments include type of fluid infused, rate location of lines, condition of IV insertion site & security/patency of tubing. Wound status o Assess dressing over incision (wound) for amt, consistency, & color of drainage as well as for any tubes or drains & amt & type of drainage by that route. o Large amts of bright red drainage combined with other abnormal physical status assessments (restlessness, pallor, cold moist skin, decreasing BP, increasing PR & RR) may indicate hemorrhage & hypovolemic shock. Pain management o Assessment of pain using a rating scale. o Scale may be verbal ranging from no pain to worse possible pain (0 10 being worst), or a faces rating scale ranging from a smiley face to a face that frowns & tears. o Early admin of analgesia, using nonsteroidal anti-inflammatory drugs & opiates, occurs in the PACU. o Opiates may be delivered by PCA, allowing pt to control analgesic admin. o Nonpharmacologic methods to decrease pain & improve comfort include positioning, verbal reassurance, & touch. o Preop assessments of methods that are personally effective for the pt assist in effective implementation in the PACU. o These should supplement not substitute for pharmacologic pain relief. o

General condition o Ensure physical & emotional comfort & safety. o Constant reorientation & reassurance that the surgery is completed provide psychological comfort. o Careful assessments, proper positioning, & use of side rails maintain physical status & level of consciousness are considered stable. o Family is notified that the pt is being transferred back to the room, & the PACU nurse gives a verbal report to the unit nurse about the assessments & interventions during the intraoperative & immediate postoperative phases. Teaching/Learning Objective: Prov. Outpt/Same-Day

38 Chapter: 30 Surgery Postop

Care (p846) Providing Outpatient/Same-Day Surgery/Postoperative Care Evaluating pts postop status after outpt/same-day surgery focuses on ensuring that the pt can be safely cared for at home. o After surgery & recovery from the anesthetic, the pt is asked to sit up & drink liquids o Pt who is no longer drowsy or dizzy, has stable vital signs, & has voided is allowed to go home accompanied by a responsible adult o Pt is not allowed to drive a car or go home alone on public transportation o Usual length of time from completion of surgery to discharge is 1-3 hrs, provided that establish criteria have been met o Written & verbal instructions for home care are given to the pt & family 39 Chapter: 31 Nursing Process Objective: Skin (p870) Skin Assisting pts with basic hygiene measures provides a good opportunity for examining the pts skin. o Many people dont know that they have skin lesions such as precancerous moles, that if untreated can be fatal. o Early detection & treatment of skin probs are impt nursing fxns. When examining the skin, pay attn to cleanliness, color, texture, temp, turgor, moisture, sensation, vascularity & any lesions. o If a lesion is detected, document the type, color, size, distribution, & grouping, location, and consistency. To assess skin: o Proceed systematically in a head-to-toe fashion. o Use a good source of light, preferably daylight. o Compare bilateral parts for symmetry. o Use standard terms to report & record findings. o Allow data obtained in nursing hx to direct the skin assessment o ID any variables known to cause skin probs such as deficient self-care abilities, immobility, malnutrition, decreased hydration, decreased sensation, sun exposure, vascular probs (altered tissue perfusion or venous return), or the presence of irritants (body secretions or excretions on the skin, other chems, mechanical devices) Since lifestyle factors, changes in health state, illness & certain diagnostic measures may adversely affect the skin, be alert for pts who may be at a high risk for skin probs, & perform the appropriate skin assessment. o Assessment may reveal dry skin, acne, or skin rashes.

When documenting a physical assessment of the skin, describe exactly what is observed or palpated, incl appearance, texture, size, location or distribution, & characteristics of any findings. DEFINITION - Skin loses moisture & may crack & peel, or become irritated & inflamed. - Symptoms may include scaling, flaking, itching, & cracks in the skin. TREATMENT

SKIN PROB Dry Skin

- Keep baths or showers short, and/or bathe less frequently - Use warm, not hot water to bathe - Use as little soap as possible. Try mild cleansers or soaps - Dry skin thoroughly & gently - Use moisturizers at least daily - Drink plenty of water throughout the day - Use a humidifier if the air is dry Acne - A skin condition that is - Avoid squeezing or picking infected areas b/c this can characterized by spread the infection & cause scarring. plugged pores - Gently wash the face 2x/day with a mild cleanser & (blackheads & warm (not hot) water whiteheads) and - Oil-free, water based moisturizers & make up should inflamed pimples be used. Look for products that are (pustules). noncomedogenic or nonacnegenic. Use cosmetics - Hormones stimulate sparingly to avoid further blockages of the sebaceous sebaceous glands of the ducts. skin to enlarge, produce - Keep hair off the face & wash hair daily. oil, & plug the pores - Some acne treatments (both over the counter & prescription) can increase the skins sensitivity to sunlight & UV light. Avoid sun/tanning booth exposure; use sunscreen. Skin - Eruptions or - Wash area thoroughly with mild cleansing agent & rinse Rashes inflammations of the skin well. that may be found - Use a moisturizing lotion on a dry rash to prevent anywhere on the body. May itching & promote healing. be precipitated by skin - Use a drying agent on a wet rash. contact with an allergen, - Try tepid baths to help relieve inflammation & itching. overexposure to the sun, - Use antiseptic sprays or lotions to help lessen itching, and/or systemic causes, promote healing, & prevent skin breakdown. like a reaction to a - Avoid exposure to causative agent, if known. medication. - See a physician if symptoms do not respond to treatment or become worse. 40 Chapter: 31 Nursing Process Objective: 6 Hygiene Practices (p865) Hygiene Practices Hygiene practices include caring for the skin, hair, nails, mouth, teeth, & perineal area o Strong links btw good hygiene practices & health of a person. o Inadequate hygiene practices can contribute to alterations in the health of a person. Skin or integument is the largest organ in the body & has many fxns o Integumentary skin made up of skin, the subcutaneous layer directly under the skin, and the appendages of the skin, including the hair & nails. o Personal hygiene practices play an integral role in caring for the integumentary system. Hair accessory structure of the skin o Good general health is essential for attractive hair & skin, & cleanliness is a positive influence.

Illness affects the hair, esp when endocrine abnormalities, increased body temp, poor nutrition, or anxiety & worry are present. o Changes in color or condition of the hair shaft are related to changes in hormonal activity or to changes in the blood supply to hair follicles. Nails are accessory structure of the skin composed of epithelial tissue. o Healthy nailbeds are pink, convex & evenly curved. o With certain pathologic conditions, and to some extend with aging, nails become ridged & areas become concave. Hygienic care includes keeping the nails trimmed & clean. o Persons general health influences the health of his or her mouth and teeth & proper care of the mouth & teeth leads to overall health. Ex. An established relationship btw healthy teeth & a diet sufficient in Ca & Ph, along with Vit D, which is necessary for the body to make use of these minerals. Maintaining good oral hygiene & dental care has several benefits. o Esthetic value in having a clean & healthy mouth. o Having ones teeth contributes to image. o The beginning of the digestive process & gustatory pleasure are enhanced when the mouth & teeth are in good condition. Perineal area is dark, warm, & often moist, providing conditions that favor bacterial growth. o Patient who cant clean perineal area needs the nurses assistance for this impt part of personal hygiene. o Neglecting perineal cleaning for the pt who cant provide self-care often results in physical & psychological discomfort of the pt, skin breakdown, & offensive odors. o

41 Chapter: 31 Nursing Process Objective: 6 Helping w/ Bathing & Skin Care (p877) Helping with Bathing & Skin Care Bathing purposes: o Cleansing the skin o Acting as a skin conditioner o Helping to relax a restless person o Promoting circulation by stimulating the skins peripheral nerve endings & underlying tissues o Serving as a musculoskeletal exercise thru activity involved with bathing, thereby improving joint mobility & muscle tonus o Stimulating the rate & depth of respirations o Promoting comfort thru muscle relaxation & skin stimulation o Providing sensory input o Helping to improve self-image o Providing an excellent opportunity to strength the nurse-pt relationship, to thoroughly assess the pts integumentary system, to observe the pts physiologic & emotional status closely, to teach the pt as indicated, and to demonstrate care & interest in the pts general welfare Simple act of bathing a pt is a vital & caring intervention o Examples of Nursing Interventions & Nursing Outcomes Classifications (NIC/NOC) lists standardized nursing interventions & corresponding outcomes related to helping the pt promote cleaning of the body for relaxation, cleanliness, & healing. o In recent yrs, this basic personal care measures has often been assigned to an unlicensed staff member rather than the professional nurse. o It has become a task to be accomplished rather than an opportunity for therapeutic individualized intervention.

Altho unlicensed assistive personnel are increasingly performing hygiene measures, the nurse is responsible for ensuring that hygiene measures were performed satisfactorily. o Nurses whose primary focus is the pt, however, can use the time spent assisting with bathing to establish a rapport w/ the pt & to further assess the pts integumentary system. Examples of NIC/NOC - Bathing Nursing Interventions Nursing Outcomes - Monitor functional ability while bathing - Self-care: Bathing - Offer handwashing after toileting & before meals - Pt Satisfaction: Functional assistance - Use fun bathing techniques with children wash - Oral Hygiene dolls/toys - Motivation - Bathe in water of a comfortable temp - Energy Conservation - Monitor skin condition while bathing - Apply lubricating ointment & cream to dry skin areas o Shower & Bath Tubs o Shower preferred bathing for hospitalized pts who are ambulatory & able to tolerate the activity Baths may be an option, particularly in long-term care, depending on the facility policy. o For the most part, even though many pts can bathe on their own, the following responsibilities apply: Check to see that the bathroom is available, clean & safe. Showers should have mats or nonskid strips to prevent pts from slipping & falling Ensure that necessary articles, such as soap, a washcloth, a towel & gown are available for the pt Provide a place for a weak or physically disabled pt to sit in a shower. Most health agencies have a stool or chair that can be used in the shower & handheld showerheasd may facilitiate the process. Some nurses have reported that a commode chair w/ the pan removed serves effectively as a shower chair & offers the pt more support than a stool or chair. Assist the pt to the shower or bathroom, as indicated. Pts who are beginning ambulation often need assistance to help preventing falling or fainting. Check that the water temp is safe & comfortable 110F 115F (43C 46C). The lower temp is recommended for children & elderly pts Ensure privacy for those who can shower & bathe independently. Call device is handy & make sure pt knows what button is for, so that the pt can obtain help if needed. Help pt get in and out of the bathtub. Have pt grasp handrails at the side of the tub or place a chair at the side of the tub. The pt sits on the chair & eases to the edge of the tub. After putting both feet into the tub, it is then relatively easy for the pt to reach the opposite side & ease down into the tub. Pt may kneel 1st in the tub & then sit in it; this process can be reversed when leaving the tub. Use a hydraulic lift when available to lower & lift the pts who are unable to maneuver safely or completely bear their wt. Keep bathroom door unlocked. Health personnel should be able to enter with ease if the pt needs help. Sign hung on the door ensures privacy. Never leave kids or confused pts alone in the bathroom. Help to wash & dry areas of the body that the pt cant reach back. Make any necessary adaptations. For ex. If pt is confused & becomes agitated as a result of overstimulation when bathing, reduce stimuli. Turn

down lights & play soft music and/or warm the room before taking the pt into it. Bed Baths o Some pts must remain in bed as part of their therapeutic regimen but can still bathe themselves. Other patients not on bed rest but require total or partial assistance w/ bathing in bed due to physical limitations, such as fatigue or limited range of motion. Implement the following measures to help pts take a bath in bed: Provide pt with articles for bathing & a basin of water that is comfortable & safe temp. Place these items for the pt on a bedside stand or overbed table. Provide privacy for th pt. Make sure the call device is within reach. Remove the top linen from the pts bed & replace them with a bath blanket. Place cosmetics in a convenient place for the pt. Provide a mirror, good light, & hot water for pts who wish to shave with a razor. o Assist pts who cannot bathe themselves completely. For ex. Some pts can wash only the upper parts of the body. Nursing personnel then complete the remainder of the bath. The Bag Bath or Disposable Bath o Bag bath as an alt to the traditional bed bath 8-10 washcloths are contained in a plastic bag & cleanser & warm water are added to prepare the bath. Another system has 8-10 premoistened, disposable washcloths. Unopened package is warmed in the microwave or stored in a warmer until use. Each part of the pts body is cleansed with a fresh cloth. No rinsing is required. Skin is allowed to air dry (for abt 30 sec) so that the emollient ingredient of the cleaner remains on the skin. Feedback has been positive Nursing staff value the time savings when compared with a traditional bed bath & find if effective & easy to perform. Most pts have commented favorably. Pts with mild-moderate skin impairments demonstrated an improved skin condition w/ consistent use of the bag bath. Promoting Skin Health o To promote the barrier function of the skin & keep skin healthy use soap substitutes daily, topical emollients, & barrier products. Soap cleans the skin, but at the same time it removes dirt from the surface, it affects the lipids that are present on the skin & the skin pH. This contributes to drier skin, damaging the barrier fxn of the skin. The substitution of a nonsoap emollient cleaning agent is an easy way to prevent drying & damage to the skin. Rinseless precuts mentioned in the description of a bag bath are ex. Of nonsoap emollient cleaning agents. o Topical emollient agents aka moisturizers can be applied to the skin as a lotion, cream, gel, or ointment. They act to seal water into the skin & replace lipids in the skin, effectivetly hydrating the skin & recreating the after bathing. Ideally, they should be applied twice a day but may need more frequent application, depending on the skin condition & product used. o Skin barrier products include creams, ointments, & films & are used to protect vulnerable skin.

They are used to protect skin at risk for damage caused by excessive exposure to water & irritants, such as urine & feces. They are also used to prevent skin breakdown around stomas & wounds w/ excessive exudates. Applications of 1 of these products forms a thin layer on the surface of the skin to repel potential irritants. Massaging the Back o Acts as a general body conditioner & can relieve muscle tension & promote relaxation. Some nurses forgo giving backrubs to patients due to time constraints. However, giving a backrub allows the nurse to observe the skin for signs of breakdown. Backrub improves circulation; can decrease pain, distress, & anxiety; can improve sleep quality; & provides a means of communication w/ the pt thru the use of touch. o Effective backrub 4-6 min & if lotion used warm it before use. o Be aware of medical diagnosis when giving backrub Backrub contraindicated for ex if pt has had back surgery or has fractured ribs Position the pt on the abdomen or on the side

42 Chapter: 31 Nursing Process Objective: 6 Skill 31-5: Making an Occupied Bed (p909) Skill 31-5: Making an Occupied Bed Check chart for limitations on patients physical activity Assemble equipment and arrange on bedside chair Perform hand hygiene (put on ppe as indicated) Identity the patient Close the curtains Adjust the bed to a comfortable working height o Lower side rails nearest you, leaving the opposite side rail up. o Place the bed in a flat position unless contraindicated Put on gloves. o Check bed linens for patients personal items. o Disconnect the call bell or tubes/drains from the bed linens Place a bath blanket over the patient. o Fold linen that is to be reused over the back of the chair. o Discard soiled linen in laundry bag or hamper. o Do not place on floor or furniture. o Do not hold soiled linens against your uniform. Assist the patient to turn toward opposite side of the bed, and reposition pillow under patients head. o Loosen all bottom linens from head, foot, and side bed. o Fan-fold soiled linens as close to patient as possible. o Use clean linen and make the near side of the bed. Place the bottom sheet with the center fold in the center of the bed. o Open the sheet and fan-fold to the center, positioning it under the old linens. o Pull the bottom sheet over the corners at the head and foot of the mattress. If using, place the draw sheet with its center fold in the center of the bed positioned so that it will be located under the patients midsection. o Open the draw sheet and fan-fold to the center of the mattress. o Tuck the draw sheet securely under the mattress.

Raise the side rail. o Assist patient to roll over the folded linen in the middle of the bed toward you. o Reposition pillow and bath blanket or top sheet. Loosen and remove all bottom lines. o Discard soiled linen in laundry bag or hamper. o Do not place on floor or furniture. Do not hold soiled linens against your uniform. Ease clean linen from under the patient. o Pull the bottom sheet taut and secure at the corners of the head and foot of the mattress. o Pull drawsheet tight and smooth. o Tuck the drawsheet securely under the mattress. Assist patient to turn back to the center of bed. o Remove pillow and change pillowcase. Apply top linen, sheet, and blanket if desired, so that it is centered. o Fold the top linens over the patients shoulders to make a cuff. o Have the patient hold to the top linen and remove the bath blanket fro underneath. Secure top linens under foot of mattress and miter corners. o Loosen top linens over patients feet by grasping them in the area of the feet and pulling gently toward foot of the bed. o Return patient to a position of comfort. o Remove your gloves. o Raise side rail and lower bed. o Reattach call bell.

43 Chapter: 32 Nursing Process Objective: 1 Intentional & Unintentional Wounds (p922) Intentional & Unintentional Wounds Intentional wound = result of planned invasive therapy or tx. o These wounds are purposely created for therapeutic purposes. Ex. Are from surgery, IV therapy, & lumbar puncture. o These wound edges are clean & bleeding is usually controlled. o B/c wound was made under sterile conditions with sterile supplies & skin prep, the risk for infection is decreased & healing is facilitated. Unintentional wound = accidental o From unexpected trauma such as accidents, forcible injury (such as stabbing or gunshot), & burns. o B/c the wounds occur in an unsterile environment, contamination is likely. o Wound edges are usually jiggered, multiple traumas are common & bleeding is uncontrolled. These factors create a high risk for infection & a longer healing time. 44 Chapter: 32 Nursing Process Objective: 1 Inflammatory Phase (p924) Inflammatory Phase Follows hemostasis Lasts 4-6 days WBC, leukocytes, and macrophages move to the wound o Leukocytes arrive 1st to ingest bacteria and cellular debris o 24 hrs after injury, macrophages enter wound area and remain They release growth factors that are necessary for the growth of epithelial cells & new blood vessels

These growth factors also attract fibroblasts that help to fill in the wound which is necessary for the next stage of healing. Acute inflammation = pain, heat, redness, swelling at the site of the injury During this phase, pt has a generalized body response, including a mild elevated temp, leukocytosis (inc. # of WBC in the blood), & generalized malaise

45 Chapter: 32 Nursing Process Objective: 2 State of Health (p921) State of Health State of a persons health & therapeutic tx have a direct effect on the condition of the skin Proper nutrition, adequate circulation, & good overall health are imp for healthy skin Very thin & obese ppl tend to be more likely to have skin irritations & injury Fluid loss thru fever, vomiting, or diarrhea reduces the fluid volume of the body aka dehydration & it makes skin appear loose & flabby Excessive perspiration, often associated with being ill, predisposes the skin to breakdown, esp in skin folds. Jaundice due to excessive bile pigments in the skin results in a yellowish skin color. Skin is often itchy & dry, & pts with jaundice are more likely to scratch their skin & cause an open lesion w/ the potential for infection. Diseases of the skin such as eczema & psoriasis may have a genetic predispotition & often casuse lesions that require special care 46/47 Chapter: 32 Nursing Process Objective: 2 Factors Affecting Skin Integrity (p921) Factors Affecting Skin Integrity Unbroken & healthy skin & mucous membranes serve as the 1st line of defense against harmful agents. Resistance to injury of the skin & mucous membranes varies among people. Factors influencing resistance incl persons age, amt of underlying tissues, & illness conditions Adequately nourished & hydrated body cells are resistant to injury. o Better nourished cell is, the better able it is to resist injury & disease. Adeqauate circulation is necessary to maintain cell life. o When circulation is impaired for any reason, cells receive inadequate nourishment & cant remove wastes efficienty. Developmental Considerations: o <2 years: skin thinner & weaker than adults o Infants skin & mucous membranes are injured easily & are subject to infection. Careful handling of infants is required to prevent injury to & infection of the skin & mucous membranes. o Childs skin becomes increasingly resistant to injury & infection. o Structure of skin changes as a person ages. Maturation of epidermal cells is prolonged, leading to thin, easily damaged skin. Circulation & collagen formation are impaired, leading to decreased elasticity & increased risk for tissue damage from pressure. Tissue becomes thin, skin more likely to be injured, wrinkle, & pressure/pain is reduced Sweat gland decreases; skin becomes dryer & pruritus (itching) may occur Cell renewal is shorter; healing time is delayed Melanocytes (color) decrease; leading to gray-white & uneven pigment Collagen fiber is less organized; skin loses elasticity

See State of Health

48 Chapter: 32 Nursing Process Objective: 3/6 Preventing Pressure Ulcers Preventing Pressure Ulcers Assess patients skin on a daily basis with special attention to bony prominences Cleanse skin routinely and whenever soiling occurs, using mild cleansing agent, minimal friction, and not hot water. Maintain humid environment and use skin moisturizers Avoid massage over bony prominences Protect skin from moisture associated with incontinence or wound drainage Minimize shearing and friction by using proper positioning, turning, and transferring. Use lubricants, dressings, protective films, and padding. Investigate any inadequate dietary intake of protein or calories, administer nutritional supplements Try to improve or at least maintain level of activity, mobility, and ROM Document measures used and results 49 Chapter: 32 Nursing Process Objective: 4 Pressure Ulcer Staging (p932) Pressure Ulcer Staging Blanching (pale/white) of skin under pressure ulcer Ischemia makes skin look paler Hyperemia reddening of skin when pressure removed o Body floods area w/ blood to nourish & remove wastes from cells o Area appears red & feels warm but blanches when slight pressure applied o Circulation impaired & pressure ulcer develops o Deep-tissue injury purple/maroon localized area or blood-filled blister Stage I pressure ulcer = intact skin w/ nonblanchable redness of a localized area usually over a bony prominence Defined area of persistent redness in lightly pigmented skin and a persistent red, blue, or purple hue in darker skin. Treated by frequent turning, pressurerelieving devices, and positioning. Stage II partial thickness loss of dermis Superficial; may be present as a blister or abrasion. Maintain moist healing environment w/ saline or occlusive dressing Stage III ulcer with full thickness tissue loss o Subcutaneous fat may be visible o Undermining and tunneling Require debridgement by: wet to dry dressing, surgical intervention, or proteolytic enzyme Stage IV full thickness tissue loss w/ exposed bone, tendon, muscle o Slough or eschar may be present & undermining/tunneling o Unstageable o Base of ulcer covered by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown, black) in wound bed o Eschar thick leathery scab or dry crust that is necrotis Stable (dry, intact) eschar on heel serves as bodys natural biological cover & cant be removed 50 Chapter: 32 (p946) Cleaning the Wound Nursing Process Objective: 7 Cleaning the Wound

Perform wound cleaning to remove microorganism debris w/ as little chemical & mechanical forces as possible & protect healthy granulation tissue. o Normal saline soln (0.9% NaCl) is used to clean pressure ulcer wounds. Wounds are cleaned 1st and before applying any new dressing. o Wound irrigation is a directed flow of soln over tissues. o Sterile equipment & solns are required for irrigating an open wound, even in the presence of an existing infection. o Sterile 0.9% NaCl or sterile water, an antiseptic, or an antibiotic soln may be used, depending on the condition of the wound & primary practioners order. o Sterile large-volume syringe is used to direct flow of the soln. o After irrigation, open wounds may be packed w/ approp dressing materials to absorb additional drainage & allow healing by secondary iintention to take place. o Nonsterile solns used to clean the skin surface if the wound edges are approximated. Wounds with approx edges: clean top to bottom; work outward from the incision in lines parallel to it Wounds with unapprox edge: clean in full or half circles; work in the center to outward

51 Chapter: 32 Nursing Process Objective: 8 Changing the Dressing (p944) Changing the Dressing Explain procedure to pt If wound care uncomfortable, administer a prescribed analgesic 30-45 min before changing the dressing Plan to change the dressing midway btw meals so that the pts appetite & mealtimes are not disturbed Provide privacy by properly screening the pt o Close room door & curtain o Help pt into a position that is comfortable & also convenient for changing the dressing o Expose only the area necessary to perform the wound care while maintaining proper draping Use approp aseptic techniques when changing the dressing is crucial o Perform hand hygiene before & after dressing changes o Surgical wounds = sterile technique o Pressure ulcers = nonsterile 52 Chapter: 32Nursing Process Objective: 9 Effects of Applying Cold (p956) Effects of Applying Cold Cold = constricts peripheral blood vessels, reduces muscle spasms, & promotes comfort o Reduces blood flow to tissues & decreases local release of pain-producing substances such as histamine, serotonin, & bradykinin This in turn reduces formation of edema & inflammation o Decreased metabolic needs & capillary permeability, combined w/ increased coag of blood at the wound site, facilitate control of bleeding & reduce edema formation Cold reduces muscle spasm, alters tissue sensitivity (producing numbness), & promotes comfort by slowing transmission of pain stimuli. o Cold is used for direct trauma, dental pain, muscle spasms, after sprains, & to treat some chronic pain syndromes Exposure to prolonged or extensive environmental cold produces systemic effects of increased BP, shivering, & goose bumps. o Although shivering is a normal body response to cold, prolonged cold may cause tissue injury.

53 Chapter: 33 Nursing Process Objective: 2/5 Developmental Considerations (p1006) Developmental Considerations Persons age & degrees of neuromuscular development markedly influence body proportions, posture, body mass, movements & reflex. To promote neuromuscular development in pts of all ages & to facilitate each pts use of the body to perform self-care actions, nurses need to be familiar w/ developmental variations in body proportions & neuromuscular development. Infant: periods of inactivity & alertness alternate w/ quiet periods & sleep o 3 mths may raise chest & head when prone o 4 mths head control usually achieved Toddler: gross & fine motor development continue rapidly o 15 mths most can walk unassisted o 18 mths most can run o 2 yrs can jump o 3 yrs most can stack blocks, string large beads, work simple puzzles, dress themselves Child: muscles, bone, & nervous system develop, allowing greater gross & fine motor control o 4 yrs negotiate stairs, walk backwards, & hop on 1 foot o 5 yrs skip, jump rope, & jump off hts o Able to manipulate writing materials o Has acquired all basic mechanisms for physical locomotion Adolescent: size increases, growth spurt, physically fit or inactive Adults: stands & sits erect & capable of balance/coordination; purposeful movement o Activity levels vary 54 Chapter: 33 Nursing Process Objective: 7 Body Mechanics (p1005) Body Mechanics Body mechanics application of mechanical laws to the human body, specifically in regard to structure, fxn, & position of the body. o It includes proper body movement in daily activities, prevention & correction of probs associated / posture, & the enhancement of coordination & endurance o It is imp to use the principles of body mechanics during activity & during rest periods, to prevent injury & to prevent sore muscles & joints o Principles of body mechanics are used to assess & maintain alignment of pts o Correct use of body mechanics is part of illness prevention & health promotion o Many activities in which the nurse engages, from as simple an activity as moving a chair, repositioning the med cart, or reaching to silence a monitor alarm, require understanding & using these principles o Nurses who consciously develop good habits can demonstrate to others proper ways of using the musculoskeletal system 55 Chapter: 33 Teaching/Learning Objective: 2 Problem w/ Bone Formation (p1008) Problem with Bone Formation Congenital probs such as achondroplasia in which premature bone ossification leads to dwarfism, or osteogeneis imperfecta, which is characterized by excessively brittle bones & multiple fractures both at birth & later in life Nutrition related probs, such as vit D deficiency, which results in deformities of the growing skeleton (rickets) Disease-related probs such as Pagets disease, in which excessive bone destruction & abnormal regeneration result in skeletal pain, deformities, & pathologic fractures

Age-related probs such as osteoporosis in which bone destruction exceeds bone formation & in which the resultant thin, porous bones fracture easily

56 Chapter: 33Nursing Process Objective: 4/5 Cardiovascular System (p1013 +1014) Cardiovascular System To meet the demand for O2 created by the rhythmic contraction & relaxation of skeletal muscle groups, the supply of oxygenated blood to skeletal muscle needs to be increased. CVS meets this challenge by increasing the HR, increasing the contractile strength of the myocardium, & increasing stroke volume (volume of blood ejected), thus increasing cardiac output. Arterial (systolic) BP is increased, blood is shunted from nonexercising tissue to the heart & muscles. Exercise also improves venous return b/c the contracting muscles compress superficial veins & push blood back to the heart against gravity. Other time, with cardiovascular conditioning regular exercise produces the following benefits: o ed efficiency of the heart o ed HR & BP o blood flow to all body parts o ed circulating fibrinolysis (substance that breaks up small clots) Primary & serious effects of immobility on the CVS include ed cardiac workload orthostatic hypotension, & venous stasis, with resulting venous thrombosis. o Immobility results in an increased workload for the heart. o With immobility, the skeletal muscles that normally compress valves in the leg veins & help to pump the blood back to the right side of the heart do not adequately contract o There is less resistance offered by the blood vessels & blood pools in the veins, thus increasing the venous BP & changing the distribution of blood in the immobile person. o As a result, the HR, cardiac output, and stroke volume increase Person who is immobile is more susceptible to developing orthostatic hypotension. o Normal neurovascular adjustments that occur to maintain systemic BP with position changes are not used during periods of inactivity & become inoperative. o A drop in BP may occur as result of a lack of vasoconstriction when changing from a supine to an upright position. o Person tends to feel weak & faint when this condition occurs. 57 Chapter: 33 Nursing Process Objective: 4 Respiratory System (p1013 & 1015) Respiratory System Respiratory & CVS work together to make increased oxygen available to the muscles. o During exercise, the depth of respiration, RR, gas exchange at the alveolar level, & rate of CO2 excretion are increased. o Over time, regular exercise leads to improved pulmonary functioning. Effects of immobility on the respiratory system are related to decreased ventilatory effort & increased respiratory secretions. o Immobility causes a decrease in the depth & rate of respirations, in part b/c of a reduced need for O2 by body cells.

When areas of lung tissues are not used over time, atelectasis (incomplete expansion or collapse of lung tissue) may occur. o Immobility results in a poor exchange of CO2 & O2, upsets their balance in the body, & eventually causes an acid-base imbalance. Person who is immobile, the movement of secretions in the respiratory tract is decreased, causing secretions to pool & leading to respiratory congestion. o These conditions predispose the person to respiratory tract infections. o Hypostatic pneumonia is a type of pneumonia that results from inactivity & immobility. o Situation worsens when the person is dehydrated or using pharmacologic agents that increase the tenacity of secretions, depress the coughing mechanism, and/or depress respirations. Decreased movement in the thoracic cage during respirations also occur with immobility. o This decrease may be due to loss of tonus in muscles involved with respirations, pressure on the chest wall b/c of the pts position in bed, or depression of the respiratory system by various pharmaceutical agents. o

58 Chapter: 33 Nursing Process Objective: 8 Additional Equipment (p1029) Additional Equipment Greatest danger to the feet occurs when they are unsupported in the dorsiflexion position. o The toes drop downward, & the feet are in plantar flexion. o B/c of the pull of gravity, this position of the feet occurs naturally when the body is at rest. o If maintained for extended periods, plantar flexion can cause an alteration in the length of muscles, and the pt may develop a complication foot drop. o In this position, the foot is unable to maintain itself in the perpendicular position, heel-toe gait is impossible, & the pt experiences extreme difficulty in walking. o The use of a foot support, such as a foot boot or high-top sneakers, helps avoid this complication. If top bedding must be kept off the pts lower extremities, a device called a cradle is used. o A cradle is usually a metal frame that supports the bed linens away from the pt while providing privacy & warmth. o There are a # of sizes & shapes of cradles o If used, the cradle should be fastened securely to the bed so that it does not slide or fall on the pt. Sandbags, available in various sizes, can be used to immobilize an extremity & support body alignment. o When properly filled, they should be pliable enuff to be shpaped to body contours to provide support. o Avoid hard or firmly packed sandbags. o Position a sandbag to avoid creating pressure on a bony prominence. Trochanter rolls are used to support the hips & legs to that the femurs to no rotate outward. o Properly placed pillows can be used to help prevent the thighs from turning outward, but they tend to slip out of place & require frequent adjustment to be effective. o If a pt is paralyzed or unconscious, hand-wrist splints or hand rolls may be necessary to provide a means for keeping the thumb in the correct position, slightly adducted & in apposition to the fingers. o A hand roll can be created by folding a washcloth, rolling it, & securing it in place with tape. o Once placed against the palm of the hand, it can effectively keep the hand in a functional position.

A commercial plastic or aluminum splint also may be used to hold the thumb in place regardless of the hand position. o Encourage pts who are moving their fingers to do finger exercises, w/ special attn to having the thumb touch the tip of each finger. Side rails can assist the pt in rolling from 1 side to other or to sitting up without calling for assistance. Using the side rails can help the pt retain or gain muscle efficiency. o When using side rails, be sure to explain their use to pts & their families & follow the protocol of the healthcare agency. o If a pt requests that side rails be raised for additional security, the pt must have the ability to raise & lower the side rails independently. o

59 Chapter: 34 Nursing Process Objective: 1 Circadian Rhythms (p1082) Circadian Rhythms Rhythmic biologic clocks exist in plants, animals, & humans o Influenced by both internal & external factors, they regulate certain biologic & behavioral functions in humans. o Some cycles are monthly such as womans menstrual cycle. Circadian rhythms complete a full cycle every 24 hours (1 day) o Circa = approximately o Diem = day Fluctuations in a persons heart rate, blood pressure, body temperature, hormone secretions, metabolism, performance & mood depend in part on circadian rhythms. Circadian synchronization is present when an individuals sleep-wake patterns follow the inner biologic clock. o When physiologic & psychological rhythms are high or most active = person awake; when rhythms are low = person asleep o Even though light & dark are powerful regulators in sleep-wake circadian rhythms, they dont exert primary control o Regulating mechanism is the persons individual biologic clock, which is influenced by many things such as occupational demands & social pressures. Ex. Nurse works at night may sleep 2pm-8pm and peak physiologic activity may be between 10pm-6am during work Problems of desynchronization occur when sleep-wake patterns are frequently altered & person attempts to sleep during high-activity rhythms or to work when the body is physiologically prepared to rest. 60 Chapter: 34 Nursing Process Objective: 1 NREM Sleep (p1082) NREM Sleep NREM = 75% of total sleep o Parasympathetic nervous system dominate in pulse, respiratory rate, blood pressure, metabolic rate, & body temperature are observed 4 stages: Stage I Stage II Stage III Stage IV Person is in a Person falls Depth of sleep Person reaches greatest depth of sleep transitional stage into a stage of increases, & = delta sleep (slow-wave sleep) between wakefulness & sleep. arousal Arousal threshold (intensity of stimulus sleep. Can be becomes required to awaken) is the greatest & Person is in a relaxed aroused with increasingly most difficult. state but still relative ease. difficult. Physiologic changes in body include: somewhat aware of the 50%-55% of 10% of sleep Sloe brain waves recorded on EEG. surroundings. sleep Pulse & respiratory rate Involuntary muscle Blood pressure

jerking may occur & waken the person. Stage lasts only minutes. Person can be aroused easily. 5% of total sleep

Muscles are relaxed. Metabolism slows & body temp is low. 10% of sleep

61 Chapter: 34 Teaching/Learning Objective: 2 Physical Activity and Exercise (p1086) Physical Activity & Exercise Activity & exercise fatigue & can promote relaxation followed by sleep. o Physical activity in REM & NREM sleep o Moderate exercise is a healthy way to promote sleep but exercise that occurs within a 2-hour interval before normal bedtime can hinder sleep o Fatigue that results from normal work activities or exercise is believed to contribute to a restful sleep, whereas excessive exercise or exhaustion can quality of sleep. 62 Chapter: 35 Nursing Process Objective: 1 The Pain Experience (p1112) 63/67 Chapter: 35 Nursing Process Objective: 2 Duration of Pain (p1112) The Pain Experience Bodys defense mechanism o Definition (Margo McCaffery) pain is whatever the experiencing person says it is, existing whenever he/she says it does only one who can be real authority on whether/how individual is experiencing pain is that individual o Health practitioners must rely on pts description of pain b/c its a subjective symptom Types of Pain Duration of Pain o Acute pain generally rapid in onset, varies in intensity from mild to severe; protective in nature (warns individual of tissue damage/organ disease); disappears after underlying cause resolved & should end once healing occurs Causes: pricked finger, sore throat, surgery, etc. o Chronic pain may be limited, intermittent, or persistent but lasts beyond the normal healing period o Most recent definition no longer mentions previous guideline of 3-6 months duration o Commonly ppl experience periods of remission (when disease present but person doesnt experience symptoms) & exacerbation (symptoms reappear) o Pain associated w/cancer or other progressive disorders termed chronic malignant pain & pain in ppl whose tissue injury is nonprogressive/healed is termed chronic nonmalignant pain Pts have difficulty describing b/c may be poorly localized o Healthcare personnel have difficulty assessing b/c of unique responses of individual pts to persistent pain often perceived as meaningless & may lead to withdrawal, depression, anger, frustration, & dependency (unlike acute); misconceptions & personal biases of caregivers can adversely affect management of pts w/chronic pain o Individuals may be viewed by healthcare personnel as hysterical personalities, malingerers, or hypochondriacs nurses need awareness of personal feelings toward pain & factors that affect pain Source of Pain (location) o Cutaneous pain superficial; usu involves skin or subcutaneous tissue Ex. Paper cut that produces sharp pain w/burning sensation o Deep somatic pain diffuse/scattered & originates in tendons, ligaments, bones, blood vessels, nerves

Caused by strong pressure on a bone or damage to tissue that occurs w/a sprain o Visceral pain poorly localized & originates in body organs in thorax, cranium, & abdomen occurs as organs stretch abnormally & become distended, ischemic, or inflamed Guarding (reflex contraction/spasm of abdominal wall) may occur as protective mechanism to prevent addl trauma to underlying structures individual automatically tenses abdomen when an acute abdominal pain condition present, which prevents underlying tissues & organs from being palpated/touched Mode of Transmission o Referred pain originates in 1 part of body but perceived in area distant from point of origin o Ex. Pain assoc w/MI frequently referred to neck, shoulder or arms (esp left) o Transmitted to a cutaneous site different from where it originated b/c travels along affected nerve root Etiology o Neuropathic pain results from injury to or abnormal functioning of peripheral nerves or CNS o Exact cause unknown & can occur in many forms o Can be of short duration or lingering & often described as burning or stabbing o Allodynia pain that occurs after normally weak or nonpainful stimuli, such as light touch or cold drink (characteristic feature of neuropathic pain) o Pain syndromes that produce neuropathic pain include: Complex regional pain syndrome (causalgia) Postherpetic neuralgia Phantom limb pain Trigeminal neuralgia Diabetic neuropathy Often misdiagnosed nursing can play important role in early detection o Intractable pain resistant to therapy & persists despite variety of interventions o Phantom pain pain thats often referred to an amputated leg where receptors & nerves are clearly absent; w/o demonstrated physiologic or pathologic substance, but is a real experience for the pt Theory sensory misrepresentations from missing limb may still remain in brain o Psychogenic pain physical cause for pain cant be IDed Responses to Pain o Physiologic Increases in VS may occur briefly in acute pain & may be absent in chronic pain states o Behavioral Intense pain experienced briefly usu results in reflex action to escape cause o Affective Anxiety Physically & emotionally exhausted, depression, irritability Chronic fatigue (w/chronic pain) The Pain Process o Transduction activation of pain receptors; involves conversion of painful stimuli into electrical impulses that travel from the periphery to the SC at the dorsal horn o Nociceptors peripheral nerve fibers that transmit pain

Also when threshold for pain reached & when is injured tissue, this tissue releases chemicals that excite/activate nerve endings Ex. Damaged cell releases histamine excites nerve endings; lactic acid accumulates in tissues injured by lack of blood supply & excites nerve endings & causes pain or lowers threshold of nerve endings to other stimuli (e.g. heat or pressure) o Prolonged effect of pain stimuli acting on CNS can lead to sensitization threshold for activation of pain is lowered even harmless stimuli can trigger pain pain signals faster & more intense o Other substances that stimulate nociceptors: bradykinin, prostaglandins, substance P Bradykinin powerful vasodilator that increases capillary permeability & constricts smooth muscle; also triggers histamine & in combination w/it, produces redness, swelling, pain typically observed when inflammation present Prostaglandins hormone-like substances that send addl pain to CNS Substance P sensitizes receptors on nerves to feel pain & increases firing rate of nerves Neurotransmitters substances that either excite or inhibit target nerve cells (include prostaglandins, substance P, & serotonin hormone that can act to stimulate smooth muscles, inhibit gastric secretions, produce vasoconstriction) o Receptors in skin & superficial organs may also be stimulated by mechanical (friction, pressure), thermal (sunburn, cold water on tooth), chemical (acid burn), & electrical (jolt of static charge) agents Transmission of Pain Stimuli o Transmission Pain sensations from injury/inflammation conducted along pathways to SC & then to higher centers o Free nerve ending pain receptors include afferent fast-conducting A-delta-fibers & slow-conducting C fibers (larger A-delta transmit acute, well-localized pain; smaller Cfibers convey diffuse, visceral pain thats often described as burning & aching) o Protective pain reflex responsible for withdrawal of endangered tissue from damaging stimulus o Sensory impulses ravel over A-fibers through dorsal root ganglion to dorsal horn of SC sensory nerve impulse synapses w/motor neuron & impulse carried along efferent nerve pathways back to site of painful stimulus in reflex arc immediate muscle contraction Perception of Pain o Perception involves the sensory process that occurs when a stimulus for pain present includes persons interpretation of pain o Pain threshold threshold of perception; lowest intensity of a stimulus that causes subject to recognize pain (similar for everyone, but women may have lower thresholds than men) o Adaptation does occur pain threshold can be changed within certain range; also more immediate adaptation (for example when gradually warm water with hand already in it) Modulation of Pain o Modulation process by which sensation of pain inhibited/modified o Neuromodulators endogenous opioid cpds (naturally present, morphine-like chemical regulators in SC & brain that appear to have analgesic activity & alter perception of pain) o

Believed to produce analgesic effects by binding to specific opioid receptor sites throughout CNS blocking release/production of paintransmitting substances Both pain & stress capable of activating endogenous opioid system o Endorphins & enkephalins are opioid neuromodulators Endorphins produced at neural synapses at various points along CNS pathway; powerful pain-blocking chemicals that have prolonged analgesic effects & produce euphoria May be released when certain measures used to relieve pain (skin stimulation & relaxation techniques) & when certain pain-relieving drugs used Dynorphin has most potent analgesic effect Enkephalins widespread throughout brain & dorsal horn of SC; considered less potent than endorphins; thought to reduce pain sensation by inhibiting release of substance P from terminals of afferent neurons The Gate Control Theory of Pain o Gate control theory describes transmission of painful stimuli & recognizes a relation btwn pain & emotions; certain nerve fibers (those of small diameter) conduct excitatory pain stimuli toward the brain, but nerve fibers of a lg diameter appear to inhibit transmission of pain impulses from SC to brain Is a gating mechanism thats believed to be located in substantia gelatinosa cells in dorsal horn of SC Exciting & inhibiting signals at gate in SC determine impulses that eventually reach brain only limited amt sensory info can be processed by NS at any given moment when too much info sent through, certain cells in spinal column interrupt signal as if closing a gate o Brain can also influence gating mechanism past experiences & learned behaviors (interpreted by brain) regulate/adjust eventual behavioral responses to pain gating mechanism appears to be influenced by amt of activity in lg & small afferent fibers in addition to nerve impulses that descend from brain Helps explain why similar painful stimuli interpreted differently by different ppl Appears to explain why mechanical & electrical interventions or heat & pressure may provide effective pain relief (ex. Nursing measures like massage or warm compress stimulate lg nerve fibers to close the gate, thus blocking pain impulses from that area)

64/65 Chapter: 35 Nursing Process Objective: 4 Components of a Pain Assessment (p1121) Components of a Pain Assessment Use guides to eliminate guesswork & biases when dealing w/pts pain to understand what pt experiencing, to analyze findings that will help prepare appropriate nursing response to pts pain, & to facilitate improved outcomes (fewer complications, shorter hospital stays, improved quality of life) Characteristics of pain generally assessed include: o Pts verbalization & description of pain o Duration of pain o Location of pain o Quantity & intensity of pain o Quality of the pain o Chronology of pain o Aggravating factors

o Alleviating factors o Physiologic indicators of pain o Behavioral responses o Effect of pain experience on activities & lifestyle Comprehensive pain assessment must also include discussion of pts expectations for pain relief pt & healthcare team need to select realistic goal or # on pain scale thats acceptable & satisfactory & facilitates recovery helps pt recognize & report pain thats unacceptable & allows caregivers to evaluate more readily effectiveness of pain management techniques o Continued assessment of pain & eval of pain control measures pain scale allows pt to rate effectively pain is experiencing on continual basis (numerical pain scale is natl standard) best to use same scale throughout hospital stay Basic assessment methods: o Pts self-report o Report of family member, other person close to pt, or caregiver whos familiar w/pt o Nonverbal behaviors (restlessness, grimacing, crying, clenching fists, protecting painful area) o Physiologic measures (increased BP & pulse) although most research verifies that reliance on VS to indicate presence of pain should be minimized. Absence of inc in VS doesnt mean pain isnt present Signs of sympathetic stimulation may occur w/acute pain but need not be present to verify presence of pain. Signs of parasympathetic stim (decreased BP & pulse, rapid & irregular respirations, pupil constriction, nausea & vomiting, & warm, dry skin) may occur esp in prolonged, severe pain, visceral, or deep pain Observe muscle tension & ask pt if is aware of any tight/tense muscles Any signs of anxiety evident? (decreased attn. span or ability to follow directions, frequent asking questions, shifting topics of conversation, avoidance of discussion of feelings, acting out, somatizing) Must not overlook pain in pts w/difficulty communicating Pain rating scales for pts who are nonverbal or have difficulty communicating verbally include Payen behavioral pain scale or use w/critically ill pts who are intubated & Face Legs Activity Cry and Consolability (FLACC) pain scale for use w/infants & young children (2 months 7 y/o) & w/older adults who cant speak Affective responses anxiety, depression, interactions w/others, degree to which pain interferes w/pts life, perception of pain & meaning to pt, adaptive mechanisms used to cope w/pain

66 Chapter: 35 Nursing Process Objective: 7/9 Patient-Controlled Analgesia (p1138) Patient-controlled analgesia (PCA) provides effective individualized analgesia & comfort may be used to manage acute & chronic pain in healthcare facility or home o Effectively relieves pain assoc w/operative procedures, labor & delivery, trauma situations, cancer o Most commonly used to deliver analgesics intravenously or via epidural route; most frequently prescribed drugs for PCA administration are morphine, fentanyl, & hydromorphone Consists of computerized portable infusion pump containing a chamber for a bag/syringe prefilled w/prescribed opioid analgesic initially loading dose administered to raise blood levels to therapeutic level & control pain When sensation of pain reoccurs pt pushes button that activates PCA device to deliver small preset bolus of analgesic

Dose interval programmed into PCA (usu 6-8 mins) that prevents reactivation of pump & admin of another dose during that time period Pump can also be programmed to deliver only a specified amt analgesic within given time interval (lock-out interval) most commonly every hour or occasionally every 4 hours limit possibility of overmedication & time provided for pt to evaluate effect of previous dose PCA pumps also have locked safety system to prohibit any tampering w/device o Suitable candidates include pts who are alert & capable of controlling the unit Joint Commission & ISMP ID individuals who arent recommended, which incl confused elderly pts, infants & young children, any cognitively impaired pt, those w/conditions where oversedation poses sig risk (ex asthma, sleep apnea), & pts taking other meds Advantages of PCA: consistent analgesic blood level maintained rather than inconsistent analgesia obtained w/periodic IM injections (results in sharp rises & falls of serum opoiod levels); analgesic delivered intravenously or epidurally so that absorption faster & more predictable than w/IM route; pt is in charge of pain management program; pt tends to use less medication b/c its self-administered before pain becomes too severe; pt able to ambulate earlier which promotes less pulmonary complications; pt is more satisfied & has improved pain relief PCA by proxy someone other than pt activates the pump (controversial) Unauthorized family members/caregivers who administer PCA by pushing dosage button can cause serious analgesic overdoses resulting in oversedation, respiratory depression, & death Setting up PCA system & ensuring its functioning properly are nursing responsibilities

68 Chapter: 36 Teaching/Learning Objective: 5 MyPyramid Food Guide (p1166) MyPyramid Food Guide April 2005: US Department of Agriculture (USDA) released MyPyramid: Steps to a Healthier You food guidance system graphic to help consumers implement 2005 dietary guidelines & RDA recommen. o It provides specific recommendations for making food choices to improve the American diet. o Goals of recommendations: intake of vitamins, minerals & dietary fiber intake of saturated fats, trans fats, & cholesterol intake of fruits, vegetables, & whole grains Support a caloric intake balanced with energy need to promote a healthy weight.

MyPyramid encourages eating a variety of foods from all food groups & being physically active every day. o Each color band represents 1/5 food groups & oils, showing variety. o Different widths = how much food a person should choose from each group; proportions are listed o Moderation = narrowing of each food group by narrowing of the color bars at the top of the pyramid. o Importance of activity =

represented by steps & person climbing them Steps to a Healthier You slogan & person climbing steps demonstrate the importance of personalization Info & educational materials are available on an interactive food guidance system that offers a customized food intake pattern for 12 different caloric levels, outlining the suggested daily amounts of food from each basic food group. o Visitors on website can customize a pyramid, entering their age, gender, & level of activity. o In addition, customized menu planning & an online dietary & physical activity assessment tool are available. o Caloric recommendations are available based on gender, age, & activity level, from children of toddler age adulthood.

69 Chapter: 37 Nursing Process Objective: 3 Bladder (p1224) Bladder Urinary bladder smooth muscle sac that serves as a temporary reservoir for urine.

Composed of 3 layers of muscle tissue, inner longitudinal layer, middle circular layer, & outer longitudinal layer. 3 layers = detrusor muscle o At base of bladder, middle circular layer of muscle tissue forms the internal or involuntary, sphincter, which guards the opening between the urinary bladder & urethra. o Urethra = conveys urine from bladder to exterior of body o Urinary bladder muscle = innervated by autonomic nervous system Sympathetic system carries inhibitory impulses to bladder & motor impulses to the internal sphincter. o These impulses cause the detrusor muscle to relax & internal sphincter to constrict, retaining urine in the bladder. Parasympathetic system carries motor impulses to the bladder & inhibitory impulses to the internal sphincter. o Impulses cause the detrusor muscle to contract & the sphincter to relax. Bladder normally contains urine under very little pressure. o As volume of urine , pressure s only slightly o Bladder wall is able to adapt to this pressure b/c of the muscle tissue in the bladder. This makes it possible for urine to continue to enter the bladder from the ureters against low pressure. When pressure becomes sufficient to stimulate nerves in the bladder wall (stretch receptors), the person feels a desire to empty the bladder. o

70 Chapter: 37 Nursing Process Objective: 2, 3 Effects of Aging (p 1227) Physiologic changes that accompany normal aging may affect urination in older adults. o These changes include: The ed ability of the kidney to concentrate urine may result in nocturia (urination during the night). ed bladder muscle tone may the capacity of the bladder to hold urine, resulting in ed frequency of urination. ed bladder contractility may lead to urine retention & stasis, which the likelihood of UTI. Neuromuscular problems, degenerative joint problems, alterations in thought processes, & weakness may interfere with voluntary control & the ability to reach a toilet in time. Meds prescribed for other health problems may interfere with bladder function. o Diuretics cause ed urine production, resulting in the need for ed urination & possibly urge incontinence. o Sedatives & tranquilizers may diminish awareness of the need to void. Individuals who view themselves as old, powerless, & neglected may stop valuing voluntary control over urination & find toileting too much bother no matter what the setting. o Incontinence may be the result. 71 Unknown Chapter OtherUnknown Kegal Exercises (p1240, 1627) Kegal Exercises Weakening of pelvic floor muscles is a common cause of urinary continence problems.

Pelvic floor muscle training (PFMT) can improve voluntary control of urination & can reduce or eliminate problems with stress incontinence by strengthening perineal & abdominal muscle tone. PFMT aka Kegel exercises target the inner muscles that lie under & support the bladder. These muscles can be toned, strengthened & made larger by a regular routine of tightening & relaxing. Often patients have difficulty determining which muscles to exercise. o These are the same muscles that the patient contracts to stop urinating in midstream or to control defecation. o Instruct patients to contract the pelvic floor muscles for 10 sec & to relax them for 10 sec. o Encourage the patient to perform Kegel exercises w/o involving the muscles in the abdomen, inner thigh & buttocks. When patient is familiar with these sensations, he/she should perform these exercises 3080x/day for at least 6 wks & possibly longer, depending on the response. o Exercises can be done anywhere. o Encourage patients to perform them during their daily activities. PFMT can also be done by using vaginal weights. o Patient inserts a small weighted cone into her vagina. She then contracts her pelvic floor musculature to prevent the cone from falling out. Cones can be gradually ed in weight as the muscles are strengthened. o Good exercise in developing body awareness Promote vaginal tone by localizing & strengthening the pubococcygeal muscle. A woman can locate this muscle by stopping a stream of urine midway through urination. Contracting this muscle can be repeated at any time of the day in any circumstance b/c its performance is undetectable. Some women who practice Kegel exercises have found their sexual satisfaction is improved. o

72 Chapter: 38 Nursing Process Objective: 1 Large Intestine (p1297) Large Intestine Connection btw ileum of the SI & LI is the ileocecal or ileocolic valve. o This valve prevents contents from entering the LI prematurely & prevents waste products from returning to the SI LI primary organ of bowel elimination is the lower or distal part of the GI tract. o LI aka colon extends from the ileocecal valve to the anus. o Colon in adults 5 ft; length & width vary o Narrowest pt colon is 1 in wide but can be up to 3 in o Diameter of colon from cecum to anus. From cecum 1st part of LI digestive contents enter colon which consists of several segments. o Ascending colon extends from cecum upward toward the liver, where it turns to cross the abdomen. This turn is called hepatic flexure. o Upon turning, this portion of the colon becomes transverse colon, crossing the abdomen from R to L. o Colon then turns at the splenic flexure to become the descending colon. o Descending colon passes down the L side of the body to the sigmoid, or pelvic colon.

Sigmoid colon has feces solid waste products that have reached the distal end of the colon & are ready for excretion. o Once excreted, feces are called stool. o Sigmoid colon empties into the rectum, the last part of the LI. o Rectum 12 cm (5in) long, 2.5 cm (1in) of which is the anal canal. o In the rectum, 3 transverse folds of tissue are present that may help to hold the fecal material in the rectum temporarily. o Vertical folds also are present, each of which contains an artery & a vein. o If the veins become abnormally distended, hemorrhoids occur. Rectum is empty except immediately before & during defecation (process of bowel elimination; a bowel movement). Feces are excreted from rectum thru anal canal; which is approx 2.5 3.8 cm (1 1.5 inc) long & out an opening anus. Fxns: o Absorption of water o Formation of feces o Expulsion of feces from body. Bacteria that reside in the LI act on food residue while it makes its way thru the LI. o Bacterial action produces Vit K & some of the B-complex vitamins. o Products of digestion, chyme, move from SI, passing thru the ileocecal valve & enter the cecum. Approx 1500 mL of chyme enters LI daily. Its contents are liquid or watery. o While passing thru LI, most water is absorbed 800 1000 mL of liquid is absorbed daily by the intestinal tract, allowing for the formed semisolid consistency of the normal stool. When absorption does not occur properly, stool is soft & watery (waste products may pass thru LI rapidly) Conversely, if the stool remains in the LI too long, or too much water is absorbed, stool becomes dry & hard.

73 Chapter: 38 Nursing Process Objective: 2 Food & Fluid (p1303) Food & Fluid Both type & amt of foots eaten & amt of fluids ingested affect elimination. o High fiber diet & daily fluid intake of 2,000 3,000 mL facilitates bowel elimination. o High fiber foods whole grains & bran, dried peas & beans, & fresh fruits & veggies bulk in fecal material. o Bulkier feces pressure on the intestinal wall, which serves as a stimulus for peristalsis. As a result, feces move more quickly thru the colon, allowing less time for water to be reabsorbed. In turn, stool is soft & easy to pass. o When stool moves quickly thru the colon there is also less time for toxins to be absorbed from feces by the colon. Toxins are believed to play an imp role in promoting the development of colon cancer. Therefore preventing their absorption by the colon is key. People digest & tolerate food differently & its determined by ones culture. o Travelers traveling to a foreign country who eat native food or drink water suffer severe indigestion & elimination probs, such as diarrhea. Food intolerance may alter bowel elimination, possibly resulting in diarrhea, gaseous distention, & cramping.

For ex. People who lack the enzyme lactase, which helps to break down the simple sugar lactose found in milk & milk products cant digest milk lactose intolerance. These people often experience excessive intestinal gas & diarrhea when they ingest milk. Certain foods have been associated w/ specific effects on bowel elimination. o These include: Constipating foods; processed cheese, lean meat, eggs, pasta Foods w/ laxative effect; certain foods & veggies (prune), bran, chocolate, spicy food, alcohol, coffee Gas-producing foods: onion, cabbage, beans, cauliflower o

74 Chapter: 38 Comm & Doc Objective: 3 Auscultation (p1307, 1560) Ausculatation - Using the diaphragm of a warmed stethoscope, listen for bowel sounds in all abdominal quadrants, using a systematic, clockwise approach - If the patient has a NG tube in place, disconnect it from suction during this assessment to allow for accurate interpretation of sounds - Note the frequency and character of bowel sounds, audible clicks and gurgles produced by the movement of air and flatus in the GI tract - They are usually high-pitched, gurgling, and soft - 5-34 bowel sounds per minute, depending on the rate of peristalsis - Significant findings include: hypoactive bowel sounds, a diminished rate of sounds, hyperactive bowel sounds and absent or infrequent bowel sounds - Hypoactive bowel sounds: diminished bowel motility, commonly caused by abdominal surgery or late bowel obstruction - Hyperactive bowel sounds indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction - Decreased or absent bowel sounds signify the absence of bowel motility, commonly associated with peritonitis or paralytic ileus 75 Chapter: 38 Bowel Elimination Objective : 5 Bowel Elimin. as Etiology (p1314, 1567) Bowel Elimination as Etiology - Problems of bowel elimination may also affect other areas of human functioning - Problems of bowel elimination are the etiology for other problems: o Delayed growth and development related to childs inability to attain bowel control secondary to inconsistency and lack of adequate parental knowledge o Imbalanced nutrition: less than body requirements related to loss of appetite from flatulence or impaction, prolonged diarrhea o Anxiety related to lack of voluntary control of fecal elimination and sifnificant others response to ostomy o Disturbed body image related to ostomy, need to wear disposable adult briefs, continuousepisodes of diarrhea o Deficient fluid volume related to prolonged diarrhea o Impaired skin integrity related to prolonged diarrhea, fecal incontinence o Ineffective coping related to inability to accept permanent ostomy o Deficient knowledge: bowel training related to no previous experience o Pain related to intestinal distention, prolonged constipation or impaction, fecal incontinence, hemorrhoids o Self-care deficit: toileting related to mobility deficit, weakness, and confusion

o Low self-esteem related to need for assistance with toileting, fecal incontinence o Sexual dysfunction related to perceived change in body image, lack of interest, loss of self-esteem 76 Chapter: 38 Nursing Process Objective: 8 Skill 38-1 Admiin Large V Clean (p1334, 1587) Skill 38-1: Administering a Large-Volume Cleansing Enema - Check it out in book for procedures and picture - Warm solution in the amt ordered and check the temperature with a bath thermometer if available - Add enema solution to the container, release clamp and allow fluid to progress, reclamp - Put bed in high position - Position patient on left side (Sims position) - Elevate solution so that it is higher than 18 inches above the level of the anus - Plan to give solution slowly over 5-10 mins - Slowly and gently insert enema tube 3-4inches for adult, direct it at an angle pointing toward the umbilicus, not bladder 77 Chapter: 38 Comm & Doc Objective: 11 Colostomy & Ileostamy Care Colostomy & Ileostamy Care - The following guidelines help to promote the ostomy patients physical and psychological comfort: o Keep the patient as free of odors as possible o Inspect the patients stoma regularly. It should be dark pink to red and moist A pale stoma may indicate anemia Dark or purple-blue stoma may reflect compromised circulation or ischemia o Note the size of the stoma, which usually stabilizes within 6-8wks o Keep the skin around the stoma site clean and dry o Measure the patients fluid intake and output Record intake and output every 4 hours for the first 3 days after surgery o Explain each aspect of care to the patient and explain what his or her role will be when he or she begins self-care o Encourage patient to participate in care and to look at the ostomy 78 Chapter: 39 Teaching/Learning Objective: 7 Pulmonary Function Studies (p1361) Pulmonary Function Studies - Pulmonary function studies encompass a group of tests used to evaluate patients with respiratory disorders and are routinely performed to evaluate pulmonary status and detect abnormalities - They provide evaluation of lung dysfunction, diagnosis disease, assess disease severity, assist in management of disease, and evaluate respiratory interventions - Spirometry: measure the volume of air in liters exhaled or inhaled by a patient over time o Evaluates lung function and airway obstruction through respiratory mechanics - A patient inhales deeply and exhales forcefully into a spirometer, an instrument that measures lung volumes and airflow - Peak expiratory flow rate (PEFR): refers to the point of highest flow during forced expiration o PEFR reflects changes in the size of pulmonary airways and is measured using a peak flow meter

o With the patient standing or sitting with the back positioned as straight as possible, the patient takes a deep breath and places the peak flowmeter in his or her mouth, closing the lips tightly around the mouthpiece o The patient forcibly exhales into the peak flowmeter, and an indicator on the meter rises to a number o The patient is asked to repeat 3xs and the highest number is recorded Vital Capacity (VC) The amt of air displaced by maximal exhalation Forced Expiratory The amt of air expelled from a point of maximal inspiration to a point of Vital Capacity maximal inspiration (FEVC) Forced Inspiratory The amt of air inhaled from a point of max exhalation to a point of max Vital Capacity (FIVC) expiration Forced Expiratory The forced expiratory volume that can be expressed in 1,2 or 3 seconds in Volume (FEV) the first second of the FEVC maneuver Total Lung Capacity The amt of air contained within the lungs at max inspiration (TLC) Residual Volume The amt of air left in the lungs at max expiration (RV) Peak expiratory flow The max flow attained during the forced expiratory maneuver rate (PEFR) 79 Chapter: 39 Nursing Process Objective : 7 Positioning (p1367, 1620) Positioning - Proper positioning is important to ease respirations - Sitting in a slumped position permits the abdominal contents to push upward on the diaphragm, decreasing lung expansion during inspiration - People with dyspnea and orthopnea are most comfortable in a high Fowlers position because accessory muscles can be easily used to promote respiration - Patients with pulmonary disease who are acutely ill, turning to the prone position on a regular basis promotes oxygenation 80 Chapter: 39 Teaching/Learning Objective : 7 Pursed- Lip Breathing (p1368, 1622) Pursed-Lip Breathing - Patients who experience dyspnea and feelings of panic can often reduce these symptoms by using pursed-lip breathing - Exhaling through pursed lips creates a smaller opening for air movement, effectively slowing and prolonging expiration - While sitting upright, the patient inhales through the nose while counting to three and then exhales slowly and evenly against pursed lips while tightening the abdominal muscles - Prolonged expiration is thought to result in decreased airway narrowing during expiration and prevent the collapse of small airways 81 Chapter: 39 Nursing Process Objective : 3 Focus on the Older Adult (p1356, 1610) Focus on the Older Adult - The tissue and airways of the respiratory tract become less elastic - The power of the respiratory and abdominal muscles is reduced and therefore the diaphragm moves less efficiently - The chest is unable to stretch as much, resulting in a decline in max inspiration and expiration - Airways collapse more easily - Focus on the older adult box (1610) 82 Chapter: 39 Caring Objective : 1 Respirations (p1352, 1606)

Respiration - Respiration, gas exchange, occurs at the terminal alveolar capillary system - Gases are exchanged between the air and blood via the dense network of capillaries in the respiratory portion of the lungs and the thin alveolar walls - Diffusion is the movement of gas or particles from areas of higher pressure or concentration to areas of lower pressure or concentration - Diffusion of gases in the lung is influenced by 4 factors: o Change in surface area available o Thickening of alveolar-capillary membrane o Partial pressure o Solubility and molecular weight of the gas - Incomplete lung expansion or the collapse of alveoli, known as atelectasis, prevents pressure changes and the exchange of gas by diffusion in the lungs - The partial pressure, or pressure resulting from any gas in a mixture depending on its concentration, can also affect diffusion - Finally, the solubility and molecular weight of the gas are factors in diffusion o CO2 has greater solubility in the respiratory membranes & diffuses more rapidly than O2 83 Chapter: 40 Nursing Process Objective : 7 Complete Blood Count (p1435, 1694) Complete Blood Count - Significant values include the following: o Increased hematocrit values: found in severe fluid volume deficit and shock o Decreased hematocrit values: found with acute, massive blood loss, and with hemolytic reaction after transfusion of incompatible blood or with fluid overload o Increased levels of hemoglobin: found in hemoconcentration of the blood o Decreased levels of hemoglobin: found with anemia states, severe hemorrhage, and after a hemolytic reaction 84 Chapter: 40 Nursing Process Objective : 4 Homeostatic Mechanisms (p1418, 1679) Homeostatic Mechanisms - The kidneys, frequently referred to as the master chemists of the body, normally filter 180L of plasma daily in the adult - The CV system is responsible for pumping and carrying nutrients and water throughout the body - The lungs regulate oxygen and carbon dioxide levels of the blood, regulation of CO2 level is especially crucial in maintaining acid-base balance - The adrenal glands secrete Aldosterone, a mineralocorticoid hormone that helps the body qa - Thyroxine, released by the thyroid gland, increases blood flow in the body, leading to increased renal circulation and resulting in increased glomerular filtration and urinary output - The parathyroid glands secrete parathyroid hormone, which regulates the level of Ca & phosphorus o It draws calcium into the blood from the bones, kidneys and intestine - The GI tract absorbs water and nutrients that enter the body through this route - The nervous system, acting as a switchboard to inhibit and stimulate mechanisms that influence fluid balance, functions chiefly as the regulator of sodium and water intake and excretion - The thirst center is located in the hypothalamus of the brain. ADH is manufactured in the hypothalamus and is stored in the posterior lobe of the pituitary gland

Neurons, called osmoreceptors, are sensitive to changes in the concentration of ECF, sending appropriate impulses to the pituitary gland to release ADH or inhibit its release to maintain ECF volume concentration

85 Chapter: 40 Nursing Process Objective : ABG Interpretation (p1435, 1685) ABG interpretation - Arterial Blood gases (ABG) are lab tests commonly used in the assessment and treatment of acid-balance imbalance - The pH of the plasma or blood indicates balance or impending acidosis or alkalosis Normal Acid Base pH 7.35-7.45 < 7.35 > 7.45 PaCO2 35-45 mm Hg > 45 mm Hg <35 mm Hg HCO3 22-26 mEq/L <22mEq/L >26mEq/L - Steps for interpretation: - Step 1: Look at pH If < 7.35, diagnose as acidosis If > 7.45, diagnose as alkalosis - Step 2: Check for the cause of change in pH In respiratory acid-base imbalance, pH and PaO2 are inversely abnormal: Respiratory acidosis: pH < 7.35 // increased PaO2 // Normal HCO3 Respiratory alkalosis: pH > 7.45 // decreased PaO2 // Normal HCO3 In metabolic acid-base imbalance pH and HCO3- are both or : Metabolic acidosis: pH < 7.35 // decreased HCO3- // Normal PaO2 Metabolic alkalosis: pH > 7.45 // increased HCO3- // Normal PaO2 - Step 3: Determine if body is compensating for pH change - Respiratory problem: or HCO3- (by renal system) - Metabolic problem: or CO2 (by respiratory system) - When compensation occurs PaO2 and HCO3- point in same direction: focus is to return - pH to normal range Respiratory acidosis: increased HCO3- = compensation attempt Respiratory alkalosis: decreased HCO3- = compensation attempt Metabolic acidosis: decreased PaO2 = compensation attempt Metabolic alkalosis: increased PaO2 = compensation attempt - Step 4: Look at the total picture and determine whether compensation has occurred. - Compensation is classified as follows: - Uncompensated/ absent: pH abnormal One component abnormal Second component within normal range - Partial if: pH abnormal One component abnormal Second component beginning to change - Complete if: pH within normal range One component abnormal Second component to move pH within normal range - A respiratory disturbance alters the carbonic acid portion: Refer to PaCO2 level of ABG - Respiratory acidosis and alkalosis are the results of respiratory disturbances

Compensation for a respiratory disturbance occurs when the lungs attempt to either retain or eliminate paCO2 from the body or when the kidneys attempt to restore balance through the conservation, formation or excretion of HCO3 A metabolic or nonrespiratory disturbance alters the bicarbonate portion: refer to HCO3 level of ABG Metabolic acidosis and alkalosis are almost entirely the result of metabolic processes Both the lungs and the kidneys attempt to compensate for this disorder by either excreting or retaining PaCO2 (the lungs) and/or HCO3 and H ions (the kidneys) Although compensation is the bodys natural attempt to restore balance, correction may also be required Respiratory Acidosis: primary excess of carbonic acid in the ECF o High PaCO2 because of alveolar hypoventilation Respiratory alkalosis: low PaCO2 because of alveolar hyperventilation Metabolic acidosis: low bicarbonate. Nonvolatile acid is present to use up HCO3 in disproportionate amounts or HCO3 is lost in similar amounts Metabolic alkalosis: high bicarbonate. Nonvolatile acid is lost and is not using up HCO3 or HCO3 is gained in disproportionate amounts

86 Chapter: 43 Caring Objective : 3 Responses to Dying & Death (p1549, 987) Responses to Dying and Death - Engels 6 stages of grief: o 1. Shock/Disbelief Refusal to accept loss/numb response o 2. Developing awareness Anger/feeling empty; why me o 3. Restitution Religious/cultural/ social expressions of mourning Resolving the loss Dealing with the void left behind o 4. Idealization Exaggeration of the good qualities the person had o 5. Acceptance of the loss Lessened need to focus on it o 6. Outcome Dealing with loss as common life occurrence - Kubler-Ross Five stages of dying: denial and isolation, anger, bargaining, depression and acceptance Denial and isolation: the patient denies that he or she will dies, may repress what is discussed and may isolate himself from reality In the anger stage: the patient expresses rage and hostility and adopts a why me attitude Bargaining stage: the patient tries to barter for more time, if I can just make it to my grandsons graduation Ill be satisfied Depression: the patient goes through a period of grief before death Acceptance; the patient feels tranquil 87 Chapter: 43 Teaching/Learning (p1551, 990) Advanced Directives Objective : 4 Advance Directives

Two kinds of written advance directives can minimize difficulties by allowing individuals to state in advance what their choice would be for healthcare should certain circumstances develop Livings wills provide specific instructions about what kinds of healthcare that should be provided or foregone in particular situations A durable power of attorney for healthcare appoints an agent the person trusts to make decisions in the event of subsequent incapacity one popular directive titled Five Wishes: o the person I want to make care decisions for me when I cant o the kind of medical treatment I want or dont want o how comfortable I want to be o how I want people to treat me o what I want my loved ones to know the patient self-determination act of 1990 requires all hospitals to inform their patients about advance directive because the status of advance directives varies from state to state, it is important for nurses to be familiar with federal and state laws concerning these directives nurses can also be instrumental in developing institutional policies that ensure that patients on admission are encouraged to talk with family, significant others and healthcare professionals about their treatment

88 Chapter: 43 Nursing Process Objective : 4 Do-Not-Resuscitate (p1551, 993) Do-Not-Resuscitate or No-Code Orders - to prevent the improper use of cardiopulmonary resuscitation, which is designed to prevent unexpected death, some physicians will write do not resuscitate (DNR) or no ocde, n the chair of a patient if the patient or surrogate has expressed a wish that there be no attempts to resuscitate the patient - a DNR means simply that: no attempts are to be made to resuscitate a patient who stops breathing or whose heart stops beating 89 Chapter: 43 Nursing Process Objective : 4/5 Active & Passive Euthanasia (p1555) Active & Passive Euthanasia Euthanasia good dying o 2 types: Active euthanasia taking specific steps to cause a pts death. Doing something to end pts life In assisted suicide (which could be considered active euthanasia), clinician provides the pt with the means to cause his or her own death (ex provides a prescription for a lethal dose of barbiturates). Clinician directly cause the death of the pt (administers a lethal dose of med) Passive euthanasia withdrawing medical tx w/ the intention of causing the pts death. Not doing something to preserve a pts life. Until recently, most societies maintained the distinction btw killing & allowing to die was morally relevant o This meant that passive eu, the withholding or withdrawing of medically ineffective or disproportionately burdensome therapies, was morally & legally justified even when this hastened or directly caused a pts death.

On the other hand, making a lethal combo of drugs available to a pt wishing to die (assisted suicide) or administering a lethal injection or CO, even when performed w/ compassionate intent at the request of a pt (active eu), was deemed both immoral & illegal. Some are questioning the validity of this distinction today, & there are efforts to legalize assisted suicide & active eu in many countries. o US physician-assisted suicide is legal in Oregan. o Its imp for nurses to understand the arguments for & against assisted suicide & active eu to clarify what they believe. ANA (1994) issued position statements stating that assisting in suicide & participating in active eu are in violation of the Code for Nurses, the ethical traditions & goals of the profession, & its covenant w/ society. o Nurses may be confronted by pts who seek assistance in ending their lives. o Unless nurses think thru this issue carefully, they will be unprepared to respond to the request Nurse, please help me die.

90 Chapter: 43 Comm & Doc Objective : 7 Developing a trusting (p1559, 1003) Developing a Trusting Nurse-Patient Family Relationship - communication is a lifelong need up to the moment of death and should be maintained at all times with the patient and family - the nurse must develop a trusting relationship with the patient - the nurse needs to develop listening skills and the ability to recognize both verbal and nonverbal cues given by the patient and family - nurse should be willing to discuss the patients fears and doubts openly and to serve as a nonjudgemental listener - a caring nurse feels at ease in crying with the grieving person and sharing experiences with fears, loneliness, and death - nonverbal communication is equally important o a smile, touching hand or stroke, and eye to eye contact are all meaningful 91 Chapter: 43 Nursing Process Objective : 9 Caring for the Body(p1567, 1008) Caring for the body - after the patient has been pronounced dead, the nurse is responsible for preparing the body for discharge - the body is placed in normal anatomic position to avoid pooling of blood, soiled dressing are replaced, and tubes are removed - if an autopsy is to be performed, any tubes that were in place should not be removed - the nurse is legally responsible for placing ID tags on either the shroud or garment the body is clothed in and the ankle to ensure that the body can be ID even if it separated from its shroud - the nurse should also place an ID tag on the patient dentures or other prostheses to ensure that the mortician receives these 92 Chapter: 43 Nursing Process Objective : 2/8 Signs of Impend Death (p1549, 986) Signs of Impending Death - the clinical signs of impending or approaching death include: o inability to swallow o pitting edema o decreased GI and urinary tract activity o bowel and bladder incontinence o loss of motion, sensation and reflexes o elevated temperature, but cold or clammy skin; cyanosis

o o o

lowered blood pressure noisy or irregular respiration Cheyne-Stokes respirations

93 Chapter: 44Nursing Process Objective: 3 Sensory Overload (p 1579) Sensory Overload Sensory Overload condition that results when a person experiences so much sensory stimuli that the brain is unable to either respond meaningfully or ignore the stimuli. o Person feels out of control & may exhibit all of the manifestation observed in sensory deprivation. o Amt & quality of stimuli necessary to produce overload may differ greatly from 1 individual to another & is influenced by factors such as age, culture, personality, & lifestyle. In some pts, esp those coming from a quiet environment with unvarying stimuli, experience of being hospitalized quickly results in sensory overload. o In such pts, brain is assaulted by the constant presence of strangers who dont only demand to be spoken to, but also touch & poke at the body; by the strange sights, odors, sounds, & feels of the unfamiliar environment; by the constant presence of pain or discomfort from dressings, IV lines, drainage tubes, or endotracheal tubes; and by the worries about the meaning & course of the illness. Nurses focus on reducing stressful stimuli & help pt gain control over the environment. o Maintain sufficient level of arousal by increasing sensory stimuli from all sensory modalities. o Visual colorful stimuli, call person by name, conversate, have TV, season food, backrubs/hugs, orient pt to environment & encourage them to participate in self care, encourage them to share emotions/fears 94 Chapter: 44: Nursing Process Objective: 3 Sensory Deprivation (p 1579) Sensory Deprivation Sensory deprivation results when a person experiences decreased sensory input or input that is monotonous, unpatterned or meaningless. o With ed sensory input, the RAS (reticular activating system) is no longer able to project a normal level of activation to the brain. o As a result, the individual may hallucinate simply to maintain an optimal level of arousal. o Factors placing a pt at high risk for sensory deprivation incl: An environment w/ ed or monotonous stimuli (such as institutionalized pts or those confined to a small living area at home, or bed rest, or in isolation) Impaired ability to receive environment stimuli (pts with impaired vision or hearing; with bandages or casts that interfere w/ vision, hearing, or tactile stimulation; or w/ affective disorders who close out the environment o Inability to process environmental stimuli (pts w/ spinal cord injuries or brain damage, those who are confused or disoriented, or are taking prescribed or recreational drugs affecting the CNS) Sensory deprivation can lead to perceptual, cognitive, & emotional disturbances. o Perceptual responses result from inaccurate perception of sights, sounds, tastes, smells, & body position, coordination, & equilibrium. These responses can range from mild distortions such as daydream, to gross distortions such as hallucinations. o Cognitive responses involve pts inability to control the direction of thought content. Typically, attn span & ability to concentrate are decreased

Pt may demonstrate difficulty w/ memory, prob solving, & task performance. Emotional responses typically are manifested by apathy, anxiety, fear, anger, belligerence, panic, or depression. Rapid mood changes may also occur Among visual impairment, loss of hearing, & cognitive fxn in older adults, cognitive capacity & nonimpaired sensory fxn were closely related to higher cortical fxns

95 Chapter: 44Nursing Process Objective: 6 Implementing (p 1588) Implementing Assist patients to improve sensory functioning by teaching methods for sensory stimulation, teach appropriate self-care behaviors & interact therapeutically w/ those experiencing sensory impairment o Make sure environment free of danger & help patient develop new self-care behaviors to compensate for current impairment Preventing Disturbed Sensory Perception & Stimulating the Senses o Key to prevention is create functional & meaningful environment while keeping in mind patients limitations o Promote patients well-being by offering care that provides rest & comfort; control patient o discomfort when possible o Be aware of need for aids/prosthetic devices: eyeglasses, hearing aids, dentures, canes, prosthetic limbs & make these items available o Encourage social activities w/ family members o Encourage physical activity/exercise decreases likelihood of sensory alterations o Provide stimulation for as many senses as possible Teaching About Sensory Experiences o Explain procedures before performing patient does not feel space or body is being invaded; informed patient better able to deal w/ fears, frustration & confusion o Discuss cognitive alterations w/ patient & reassure that the experiences are normal & usually temporary eases anxiety **SEE PG. 1591 FOR ADDITIONAL TEACHING TIPS: SPECIFIC SENSES & SENSORY OVERLOAD/DEPRIVATION** Promoting Health Literacy o Risk factors for inadequate health literacy: advanced age, low educational level, poverty, illiteracy, learning disabilities & lack of proficiency in English language Meeting Needs of Patients with Reduced Vision o Always check if visual problem temporary, permanent, partial or complete & degree to which problem likely to affect ADLs o Teach the following self-care behaviors to maintain vision & prevent blindness: Avoid: rubbing eyes; eyestrain; damage from UV rays; non-prescription eye drops; cleaning eyes/contact lenses w/ dirty articles Protect from foreign bodies Keep glasses clean, protected & adjusted o Visit physician frequently if prone to eye problems o Know danger signs for serious eye problems: persistent eye redness; pain/discomfort; visual disturbances; crossing eyes; growth on/near eyes; discharge/increased tearing & pupil irregularities - Guidelines for communication: Acknowledge your presence in patients room Speak in normal tone of voice Explain reason for touching person before doing so

Call bell near person & bed in lowest position Orient person to: sounds in environment; arrangement of room Assist w/ ambulation by walking slightly ahead & person hold onto your arm Stay in persons field of vision if partial/reduced peripheral vision Indicate when conversation has ended & you are leaving room Meeting Needs of Patients with Reduced Hearing o Temporary hearing losses most often conductive (due to problem w/ external or middle ear; wax build-up, foreign body obstruction, infection); sensorineural hearing losses caused by inner ear or CNS problems may not be completely correctable o Teach the following to prevent hearing problems: Avoid: excessive noise; inserting sharp objects in ear; excessive ear cleaning; practices that can cause infection Know symptoms of hearing loss: asking to repeat statements; inability to hear at distance; need to see who is talking; leaning forward/turning ear to speaker; answering inappropriately; talking too loud; strained facial expression Guidelines for communication: Orient person to your presence move to be seen or touch the person Decrease background noises Position self so person can see lips & expressions Talk directly while facing person or angle chair so voice reaches ear that hears best Demonstrate/pantomime ideas; sign language; finger spelling Aids for those w/ reduced hearing: infrared systems, computers, voice amplifiers, amplified telephones, low-frequency door-bells & telephone ringers, closed-caption TV, flashing alarms/ smoke detectors Communicating with a Patient Who is Confused o Nursing Interventions Use frequent face-to-face contact to communicate the social process Speak calmly, simply & directly Orient & reorient patient to environment & fill personal space w/ many personal objects Use conversation, watches, clocks, TV, radio & other devices to orient X3 Keep emphasis on patient strengths instead of deficiencies Vary environmental stimuli gradually Use objects from patients past to initiate discussions Reinforce reality if patient is delusional Communicating with a Patient Who is Unconscious Guidelines for communication: Hearing is last sense lost be careful what is said in presence b/c person likely to hear; assume person can hear talk in normal tone Speak before touching Keep environmental noises at low level

96 Chapter : 46 Caring Objective: 3 Faith (p 1646) Faith Faith confident belief in something for which there is no proof or material evidence. o Can involve person, idea, or thing & is usually followed by action related to the ideals or values of that belief. o For ex. Faith in dr

Pts who believe in a loving & all powerful being who knows them & care for them are often better able to cope w/ the suffering related to injury & illness World Conference of the Religions of Peace in Kyoto, Japan (1970) ex of confident belief that something for which there is no proof or material evidence. o Bahai, Buddhist, Confusion, Christian, Hindu, Jain, Jew, Muslim, Shintoist, Sikh discovered that things that unite them were more imp that those that divided them. o They discovered that they shared: A conviction of the fundamental unity of the human family, of the quality & dignity of all human beings Sense of sacredness of the individual person & his conscience Sense of the value of the human community Belief that love, compassion, unselfishness, force of inner truthfulness & of the spirit have ultimately greater power than hate, enmity, & self-interest Sense of obligation to stand on the side of the poor & the oppressed as against the rich & the oppressors o Profound hope that good will finally prevail Faith term also used to describe a cultural or institutional religion such as Judaism, Muslim, or Confucianism o Atheist = person who denies existence of a higher power o Agnostic = one who holds that nothing can b known abt the existence of a higher power They deserve respect for what they choose to believe, just as do those accept a particular religious creed o

97 Chapter: 46Caring Objective: 3 Source of Conflict (p 1653) Source of Conflict Sometimes religious beliefs conflict with prevalent healthcare practices. o For ex. Doctrine of Jehovahs Witnesses prohibit blood transfusion o In Islam humans are regarded as largely helpless in controlling their environment, & illness is accepted as their fate rather than something against which action might be taken. o Navajos use lengthy religious ceremony to cure certain diseases, such as TB. For some, illness is viewed as a punishment for sin & is inevitable. o Such beliefs may require healthcare workers to modify tx plan to accommodate the persons religion. In some instances, acknowledgement of the pts religious convictions & efforts by health practitioners to accommodate pts beliefs can result in quality of healthcare w/o violating the persons religious practices. In other situations objective explanation of alt. txs & predicted consequences of each may help the pt determine acceptable therapy. o Whatever the persons decision abt healthcare, remember that each person is unique & has a right to pursue his/her own convictions, even tho they may differ from those of the healthcare provider. Healthcare prof can dec. conflict by attempting to understand how particular religious culture influences peoples thinking abt basic qs of biology & ethics. o Some of the major qs that religious beliefs, attitudes, & values can affect are: What is the meaning of suffering? How should we regard the physical body & its fxn? What is the meaning & role of gender differences, sexuality, & reproduction? How are we to understand & respond to birth, aging, & death?

What constitutes the self, & how is selfhood to be assessed? How are sin & moral culpability understood? What makes something sinful & how is sin relieved or absolved? What are the traditions specific bioethical teachings?