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Test Bank for Basic Nursing, 6th Edition: Patricia A. Potter

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This is completed downloadable of Test Bank for Basic Nursing, 6th Edition: Patricia A. Potter

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ISBN-10 ‏ : ‎ 0323039375
ISBN-13 ‏ : ‎ 978-0323039376
Author: Patricia A. Potter

This user-friendly textbook provides complete coverage of the essential nursing principles, concepts, and skills that are the foundation of a solid nursing education. The 6th edition features enhanced readability, an engaging format, and a new Companion CD. It consistently follows the 5-step nursing process framework with a strong focus on critical thinking that provides readers with a solid base for clinicals. As readers follow case studies through each clinical chapter, concrete examples illustrate how to address cultural diversity, teaching, assessment, evidence-based practice, and much more.

Table of Content:

UNIT I Concepts in Health Care
CHAPTER 1 Health and Wellness
OBJECTIVES
Key Terms
CASE STUDY Jack
BOX 1-1 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
Figure 1-1 Maslow’s hierarchy of needs. (From Maslow AH: Motivation and personality, ed 3, Upper Saddle River, NJ, 1987, Prentice Hall.)
Definition of Health
Models of Health and Illness
Health Belief Model
Health Promotion Model
Figure 1-2 Health belief model. (Data from Becker MH, Maiman LA: Sociobehavioral determinants of compliance with health and medical care recommendations, Med Care 13[1]:10, 1975.)
Holistic Health Model
Figure 1-3 Health promotion model. (From Pender NJ and others: Health promotion in nursing practice, ed 5, Upper Saddle River, NJ, 2005, Pearson Education.)
Determinants of Health Status: Healthy People 2010
Figure 1-4 A model for a systematic approach to health improvement. (From U.S. Department of Health and Human Services, Public Health Service: Healthy people 2010: understanding and improving health, Washington, DC, 2000, U.S. Government Printing Office.)
Variables Influencing Health Beliefs and Health Practices
Internal Variables
DEVELOPMENTAL STAGE.
INTELLECTUAL BACKGROUND.
EMOTIONAL FACTORS.
SPIRITUAL FACTORS.
External Variables
FAMILY PRATICES.
SOCIOECONOMIC FACTORS.
CULTURAL BACKGROUND.
Health Promotion, Wellness, and Illness Prevention
TABLE 1-1 The Three Levels of Prevention
The Three Levels of Prevention
Risk Factors
Genetic and Physiological Factors
Age
Physical
Lifestyle
Figure 1-5 Clinical preventive services for normal-risk adults recommended by the U.S Preventive Services Task Force. (From U.S. Department of Health and Human Services: Put prevention into practice, Rockville, Md, 2004, Agency for Health Care Research and Quality, http://www.ahrq.gov/ppip/adulttm.htm.)
Risk Factor Identification
Risk Factor Modification and Changing Health Behaviors
Illness
TABLE 1-2 Stages of Health Behavior Change
Acute and Chronic Illness
Illness Behavior
Variables Influencing Illness Behavior
INTERNAL VARIABLES.
EXTERNAL VARIABLES.
Impact of Illness on Patient and Family
Behavioral and Emotional Changes
Impact on Body Image
Impact on Self-Concept
Impact on Family Roles and Family Dynamics
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 2 The Health Care Delivery System
OBJECTIVES
Key Terms
CASE STUDY Amy Sue Reilly
Health Care Regulation and Competition
BOX 2-1 Clinical Scenario of a DRG Example
Levels of Health Care
TABLE 2-1 Health Care Plans
Preventive and Primary Health Care Services
Figure 2-1 Spectrum of health services delivery. (Modified from Cambridge Research Institute: Trends affecting the U.S. health care system, 262, Health Planning Information Series, Human Resources Administration, Public Health Service, Department of Health, Education, and Welfare, Washington, DC, 1976, revised and updated 1992, U.S. Government Printing Office.)
BOX 2-2 Examples of Health Care Services
Preventive Care
Primary Care (Health Promotion)
Secondary Acute Care
Tertiary Care
Restorative Care
Continuing Care
Secondary and Tertiary Care
TABLE 2-2 Preventive and Primary Care Services
HOSPITALS.
Figure 2-2 Primary health care model: a multisectoral or intersectoral approach. (© 1996 by P. Hatcher, J. Shoultz, W. Patrick; from Shoultz J, Hatcher PA: Looking beyond primary care to primary health care: an approach to community-based action, Nurs Outlook 45[1]:23, 1997.)
BOX 2-3 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
INTENSIVE CARE.
SUBACUTE CARE.
PSYCHIATRIC FACILITIES.
RURAL HOSPITALS.
Restorative Care
HOME CARE.
BOX 2-4 Home Care Services
Wound Care
Respiratory Care
Vital Signs
Elimination
Nutrition
Rehabilitation
Medications
Intravenous Therapy
Laboratory Studies
REHABILITATION.
EXTENDED CARE FACILITIES.
Continuing Care
NURSING CENTERS OR FACILITIES.
BOX 2-5 Minimum Data Set and Examples of Resident Assessment Protocols
Minimum Data Set
Resident Assessment Protocols (Examples)
ASSISTED LIVING.
Figure 2-3 Providing nursing services in assisted living facilities promotes physical and psychosocial health.
RESPITE CARE.
ADULT DAY CARE CENTERS.
HOSPICE.
Issues in Health Care Delivery
Competency
Evidence-Based Practice
BOX 2-6 Pew Health Professions Commission Twenty-One Competencies for the Twenty-First Century
Quality Health Care
NURSING-SENSITIVE OUTCOMES.
PATIENT SATISFACTION.
Technology in Health Care
BOX 2-7 The Dimensions of Patient-Centered Care
Access
Respect for Patient’s Values, Preferences, and Expressed Needs
Coordination and Integration of Care
Information, Communication, and Education
Physical Comfort
Emotional Support and Relief of Fear and Anxiety
Involvement of Family and Friends
Transition and Continuity
Globalization of Health Care
The Future of Health Care
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 3 Community-Based Nursing Practice
OBJECTIVES
Key Terms
CASE STUDY Bosnian Community
Community-Based Health Care
Achieving Healthy Populations and Communities
Figure 3-1 Health services pyramid. (From Stanhope M, Lancaster J: Community and public health nursing, ed 6, St. Louis, 2004, Mosby.)
Community Health Nursing
SYNTHESIS IN PRACTICE
Nursing Practice in Community Health
Community-Based Nursing
Vulnerable Populations
Figure 3-2 These concentric circles represent the social interaction units of the human ecology model. (From Ayers M, Bruno AA, Lanford RW: Community-based nursing care: making the transition, St. Louis, 1999, Mosby.)
BOX 3-1 Guidelines for Assessing Members of Vulnerable Population Groups
Setting the Stage
Nursing History of an Individual or Family
Physical Examination and Home Assessment
POOR AND HOMELESS PERSONS.
ABUSED PATIENTS.
Figure 3-3 The homeless population has unique health care needs.
SUBSTANCE ABUSERS.
SEVERELY MENTALLY ILL PERSONS.
OLDER ADULTS.
Competency in Community-Based Nursing
Case Manager
TABLE 3-1 Major Health Problems in Older Adults and Community Health Nursing Roles and Interventions
Collaborator
Educator
Counselor
Patient Advocate
Change Agent
BOX 3-2 Success Factors in Adopting Change
Community Assessment
Changing Patients’ Health
BOX 3-3 Community Assessment
Structure
Population
Social System
EVALUATION
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 4 Legal Principles in Nursing
OBJECTIVES
Key Terms
Legal Limits of Nursing
Sources of Law
BOX 4-1 Anatomy of a Lawsuit
Proof of Negligence
Standards of Care
Civil Law
Intentional Torts
ASSAULT.
BATTERY.
Unintentional Torts
NEGLIGENCE AND MALPRACTICE.
BOX 4-2 Common Sources of Negligence
Malpractice Insurance.
BOX 4-3 Statutory Guidelines for Legal Consent for Medical Treatment
Consent
INFORMED CONSENT.
Statutory Laws
Good Samaritan Laws
Licensure
Student Nurses
Physician or Health Care Provider Orders
Figure 4-1 If an order creates questions, the nurse clarifies it with the physician or health care provider.
RESTRAINTS
CONFIDENTIALITY.
DEATH AND DYING.
ORGAN AND TISSUE DONATION.
AUTOPSIES.
ADVANCE DIRECTIVES.
Other Legal Issues in Nursing Practice
Quality Improvement, Risk Management, and Documentation
Patient Privacy Rights
Patient Abandonment and Delegation Issues
Controlled Substances
Reporting Obligations
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Statutes
Cases
Uncited reference
CHAPTER 5 Ethics
OBJECTIVES
Key Terms
CASE STUDY Anna Moreno
Basic Definitions
Ethical Principles
TABLE 5-1 Principles of Health Care Ethics
Codes of Ethics
BOX 5-1 American Nurses Association Code of Ethics
BOX 5-2 The ICN Code of Ethics for Nurses
Preamble
The Code
Elements of the Code
1. Nurses and People
2. Nurses and Practice
3. Nurses and the Profession
4. Nurses and Co-workers
Developing a Personal Point of View
Ethical Systems
Deontology
Utilitarianism
Feminist Ethics
Ethics of Care
How to Process an Ethical Dilemma
BOX 5-3 How to Process an Ethical Dilemma
Potential Ethical Problems in Nursing
Allocation of Scarce Resources: The Nursing Shortage
Managed Care
End-of-Life Issues
BOX 5-4 Using Evidence In Practice
Research Summary
Application to Nursing Practice
Cultural and Religious Sensitivity
Delegation
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
UNIT II Processes in Nursing Care
CHAPTER 6 Critical Thinking and Nursing Judgment
OBJECTIVES
Key Terms
CASE STUDY Mrs. Bryan
Clinical Decisions in Nursing Practice
Critical Thinking Defined
TABLE 6-1 Critical Thinking Skills
TABLE 6-2 Concepts for a Critical Thinker
CLINICAL SCENARIO
Reflection
BOX 6-1 Tips on Facilitating Reflection
CLINICAL SCENARIO
Language
Intuition
Thinking and Learning
Levels of Critical Thinking in Nursing
Basic Critical Thinking
Complex Critical Thinking
Commitment
Critical Thinking Competencies
Scientific Method
Problem Solving
TABLE 6-3 Using the Scientific Method to Solve Nursing Practice Questions
Decision Making
Diagnostic Reasoning
CLINICAL SCENARIO
Clinical Decision Making
BOX 6-2 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
The Nursing Process as a Competency
TABLE 6-4 Summary of Nursing Process
A Critical Thinking Model
Specific Knowledge Base
CLINICAL SCENARIO
Figure 6-1 Critical thinking model for nursing judgment. (Redrawn from Kataoka-Yahiro M, Saylor C: A critical thinking model for nursing judgment, J Nurs Educ 33[8]:351, 1994. Modified from Glaser E: An experiment in the development of critical thinking, New York, 1941, Bureau of Publications, Teachers College, Columbia University; Miller M, Malcolm N: Critical thinking in the nursing curriculum, Nurs Health Care 11:67, 1990; and Paul R: The art of redesigning instruction. In Willsen J, Blinker AJA, editors: Critical thinking: how to prepare students for a rapidly changing world, Santa Rosa, Calif, 1993, Foundation for Critical Thinking.)
Experience
BOX 6-3 Components of Critical Thinking in Nursing
Attitudes for Critical Thinking
Figure 6-2 Synthesis of critical thinking with the nursing process competency.
CONFIDENCE
THINKING INDEPENDENTLY.
FAIRNESS.
TABLE 6-5 Critical Thinking Attitudes and Applications in Nursing Practice
RESPONSIBILITY AND ACCOUNTABILITY.
RISK TAKING.
DISCIPLINE.
PERSEVERANCE.
CREATIVITY.
CURIOSITY.
INTEGRITY.
HUMILITY.
Standards for Critical Thinking
BOX 6-4 Examples of Evaluation Criteria
Synthesis in Practice
Assessment
Synthesis of Critical Thinking With the Nursing Process
Nursing Diagnosis
Planning
Implementation
Evaluation
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited reference
CHAPTER 7 Nursing Process
OBJECTIVES
Key Terms
CASE STUDY Mrs. Bryan
Nursing Process Overview
Figure 7-1 Five-step nursing process.
Assessment
Data Collection
BOX 7-1 Typology of 11 Functional Health Patterns
Types of Data
Sources of Data
PATIENT.
FAMILY AND SIGNIFICANT OTHERS.
TABLE 7-1 FOCUSED PATIENT ASSESSMENT
HEALTH CARE TEAM.
MEDICAL RECORDS.
OTHER RECORDS AND THE LITERATURE.
Methods of Data Collection
INTERVIEW AND HEALTH HISTORY.
Figure 7-2 Example of branching logic for selecting assessment questions.
Interviewing Techniques.
BOX 7-2 Basic Components for a Nursing Health History
PHYSICAL EXAMINATION.
OBSERVATION OF PATIENT’S BEHAVIOR.
DIAGNOSTIC AND LABORATORY DATA.
Interpreting Assessment Data and Making Nursing Judgments
DATA VALIDATION.
ANALYSIS AND INTERPRETATION.
DATA CLUSTERING.
BOX 7-3 Steps of Data Analysis
DATA DOCUMENTATION.
Nursing Diagnosis
Figure 7-3 Nursing diagnostic process.
NANDA International Diagnoses
Critical Thinking and the Nursing Diagnostic Process
Formulation of the Nursing Diagnosis
BOX 7-4 NANDA International Nursing Diagnoses
BOX 7-5 Examples of NANDA International-Approved Nursing Diagnoses With Defining Characteristics and Related Factors
COMPONENTS OF A NURSING DIAGNOSIS.
Diagnostic Label.
Related Factor.
TABLE 7-2 NANDA Nursing Diagnosis Format
Figure 7-4 Relationship between diagnostic label and etiology (related factor). (Redrawn from Hickey P: Nursing process handbook, St. Louis, 1990, Mosby.)
TABLE 7-3 Formulation of Nursing Diagnoses
Definition
Risk Factors.
Support of the Diagnostic Statement.
Mind Mapping Nursing Diagnosis
Figure 7-5 Mind map.
Sources of Diagnostic Errors
ERRORS IN DATA COLLECTION.
ERRORS IN INTERPRETATION AND ANALYSIS.
ERRORS IN DATA CLUSTERING.
ERRORS IN THE DIAGNOSTIC STATEMENT.
DOCUMENTATION
Planning
Establishing Priorities
Goals and Expected Outcomes
GOALS OF CARE.
Role of the Patient in Goal Setting.
EXPECTED OUTCOMES.
TABLE 7-4 Examples of Goal Setting With Expected Outcomes for Mrs. Bryan
TABLE 7-5 Examples of NANDA International Nursing Diagnoses and Suggested NOC Linkages
GUIDELINES FOR WRITING GOALS AND EXPECTED OUTCOMES.
Critical Thinking in Planning Nursing Care
TYPES OF INTERVENTIONS.
Selection of Interventions.
Nursing Interventions Classification.
BOX 7-6 Choosing Nursing Interventions
Characteristics of the Nursing Diagnosis
Expected Outcomes
Research Base
Feasibility of the Intervention
Acceptability to the Patient
Capability
Nursing Care Plan
TABLE 7-6 Nursing Interventions Classification (NIC) Taxonomy
STUDENT CARE PLANS.
CONCEPT MAPS.
BOX 7-7 Examples of Level 3 Interventions for Activity and Exercise Management
A. Activity and Exercise Management
Level 3 Interventions
BOX 7-8 Examples of Nursing Activities for Level 3 Interventions
Body Mechanics Promotion
Exercise Therapy: Joint Mobility
CRITICAL PATHWAYS.
Figure 7-6 Care plan.
Consulting Other Health Care Professionals
Figure 7-7 Concept map.
WHEN TO CONSULT.
HOW TO CONSULT.
Implementation
Types of Nursing Interventions
PROTOCOLS AND STANDING ORDERS.
Critical Thinking in Implementation
Implementation Process
REASSESSING THE PATIENT.
REVIEWING AND REVISING THE CARE PLAN.
ORGANIZING RESOURCES AND CARE DELIVERY.
Equipment
Personnel.
Environment.
TABLE 7-7 A Revised Nursing Care Plan
Patient.
ANTICIPATING AND PREVENTING COMPLICATIONS.
Identifying Areas of Assistance.
Implementation Skills
COGNITIVE SKILLS.
INTERPERSONAL SKILLS.
PSYCHOMOTOR SKILLS.
Direct Care
ACTIVITIES OF DAILY LIVING.
INSTRUMENTAL ACTIVITIES OF DAILY LIVING.
PHYSICAL CARE.
COUNSELING.
TEACHING.
CONTROLLING FOR ADVERSE REACTIONS.
Figure 7-8 Teaching patient discharge instructions.
PREVENTIVE MEASURES.
Indirect Care
DELEGATING, SUPERVISING, AND EVALUATING THE WORK OF OTHER STAFF MEMBERS.
Evaluation
Critical Thinking and Evaluation
The Evaluation Process
IDENTIFYING CRITERIA AND STANDARDS.
COLLECTING EVALUATIVE DATA.
INTERPRETING AND SUMMARIZING FINDINGS.
TABLE 7-8 Evaluation Measures to Determine the Success of Goals and Expected Outcomes
DOCUMENTING FINDINGS.
CARE PLAN REVISION.
Discontinuing a Care Plan.
Modifying a Care Plan.
Goals and Expected Outcomes.
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 8 Documentation and Reporting
OBJECTIVES
Key Terms
Confidentiality
Standards
Multidisciplinary Communication Within the Health Care Team
Purpose of Records
Communication
TABLE 8-1 Legal Guidelines for Recording
Legal Documentation
Financial Billing
Education
Research
Auditing and Monitoring
Guidelines for Quality Documentation and Reporting
Factual
Accurate
TABLE 8-2 Examples of Criteria for Reporting and Recording
Complete
Current
Figure 8-1 Comparison of 24 hours of military time and civilian time.
Organized
Methods of Recording
Narrative Documentation
Problem-Oriented Medical Records
DATABASE.
TABLE 8-3 Formats for Recording
PROBLEM LIST.
CARE PLAN.
PROGRESS NOTES.
SOAP Documentation.
PIE Documentation.
Focus Charting.
TABLE 8-4 Components of a Source Record
Source Records
Charting by Exception
Case Management Plan and Critical Pathways
Common Record-Keeping Forms
Admission Nursing History Forms
Flow Sheets and Graphic Records
Patient Education Record
Patient Care Summary or Kardex
Figure 8-2 Nursing assessment flow sheet. (Courtesy Ashland Community Hospital, Ashland, Ore.)
Acuity Recording
Standardized Care Plans
Discharge Summary Forms
Computerized Documentation
BOX 8-1 Discharge Summary Information
Home Care Documentation
Long-Term Care Documentation
Reporting
Change-of-Shift Report
Telephone Reports and Orders
TELEPHONE REPORTS.
TELEPHONE ORDERS AND VERBAL ORDERS.
Figure 8-3 Persons involved with telephone reports must verify that information is accurate.
Transfer Reports
BOX 8-2 Guidelines for Telephone Orders and Verbal Orders
Incident Reports
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 9 Communication
OBJECTIVES
Key Terms
CASE STUDY Robert Ruiz
The Power of Communication
Decision Making and Communication
Basic Elements of the Communication Process
BOX 9-1 Challenging Communication Situations
Figure 9-1 Communication as active process between sender and receiver.
Levels of Communication
Forms of Communication
Verbal Communication
VOCABULARY.
DENOTATIVE AND CONNOTATIVE MEANING.
PACING.
INTONATION.
CLARITY AND BREVITY.
TIMING AND RELEVANCE.
Nonverbal Communication
PERSONAL APPEARANCE.
POSTURE AND GAIT.
FACIAL EXPRESSION.
EYE CONTACT.
GESTURES.
TERRITORIALITY AND SPACE.
Factors Influencing Communication
The Nurse-Patient Helping Relationship
BOX 9-2 Nursing Actions Within the Zones of Personal Space and Touch
Zones of Personal Space
Intimate Zone (0 to 18 inches)
Personal Zone (18 inches to 4 feet)
Social Zone (4 to 12 feet)
Public Zone (12 feet and greater)
Zones of Touch
Social Zone (permission not needed)
Consent Zone (permission needed)
Vulnerable Zone (special care needed)
Intimate Zone (great sensitivity needed)
BOX 9-3 Contextual Factors Influencing Communication
Psychophysiological Context
Relational Context
Situational Context
Environmental Context
Cultural Context
BOX 9-4 Phases of the Helping Relationship
Preinteraction Phase
Orientation Phase
Working Phase
Termination Phase
Nurse–Health Team Member Relationships
Communication Within Caring Relationships
Professionalism
Courtesy
AVOID TERMS OF ENDEARMENT.
AVOID REFERRING TO PATIENTS BY DIAGNOSIS, ROOM NUMBER, OR OTHER ATTRIBUTE.
Confidentiality
Trust
Availability
Communication Within the Nursing Process
Assessment
Physical and Emotional Factors
BOX 9-5 Communication Through the Nursing Process
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation
Developmental Factors
Sociocultural Factors
Gender
Nursing Diagnosis
Planning
Goals and Outcomes
Setting Priorities
Continuity of Care
Implementation
Empathy
Sympathy
Listening and Responding
PROVIDE INFORMATION.
PARAPHRASE COMMUNICATION.
CLARIFY COMMUNICATION.
FOCUS COMMUNICATION.
SUMMARIZE COMMUNICATION
USE APPROPRIATE SELF-DISCLOSURE.
AVOID INATTENTIVE LISTENING.
AVOID MEDICAL VOCABULARY.
AVOID GIVING PERSONAL OPINIONS.
AVOID PRYING.
AVOID CHANGING THE SUBJECT.
Acceptance and Respect
ASKING FOR EXPLANATIONS.
Avoid Approval or Disapproval.
Avoid Arguing.
AVOID BEING DEFENSIVE.
Silence
Hope and Encouragement
AVOID FALSE REASSURANCE THAT CAN DO MORE HARM THAN GOOD.
Socializing
Avoid Inappropriate Socializing.
Assertiveness and Autonomy
AVOID PASSIVE RESPONSES.
AVOID AGGRESSIVE RESPONSES.
Humor
Touch
BOX 9-6 CULTURAL FOCUS
Communicating With Patients With Special Needs
BOX 9-7 USING EVIDENCE IN PRACTICE
Research Summary
Application in Nursing Practice
PROVIDING ALTERNATIVE COMMUNICATION METHODS.
COMMUNICATING WITH CHILDREN.
COMMUNICATING WITH OLDER ADULT PATIENTS.
Evaluation
Patient Care
BOX 9-8 Communicating With Patients Who Have Special Needs
Patients With Difficulty Hearing
Patients With Difficulty Seeing
Patients Who Are Mute or Cannot Speak Clearly
Patients Who Are Cognitively Impaired
Patients Who Are Unresponsive
Patients Who Do Not Speak English
Figure 9-2 Drawing helps children communicate.
Patient Expectations
BOX 9-9 CARE OF THE OLDER ADULT
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited reference
CHAPTER 10 Patient Education
OBJECTIVES
Key Terms
CASE STUDY Latinka Drusko
Standards for Patient Education
Purposes of Patient Education
BOX 10-1 JCAHO Education Standards for Hospitals
Standard PC.6.10
Elements of Performance for PC.6.10
Standard PC.6.30
Elements of Performance for PC.6.30
Standard PC.6.50
Elements of Performance for PC.6.50
Maintenance and Promotion of Health and Illness Prevention
Restoration of Health
Coping With Impaired Functioning
BOX 10-2 Topics for Health Education
Health Maintenance and Promotion and Illness Prevention
Restoration of Health
Coping With Impaired Function
Teaching and Learning
TABLE 10-1 Comparison of Terms Used in Communication and Teaching
Role of the Nurse in Teaching and Learning
Teaching as Communication
Domains of Learning
Basic Learning Principles
Motivation to Learn
BOX 10-3 CULTURAL FOCUS
Implications for Practice
Figure 10-1 Nurse instructing a patient with a glucose meter.
READINESS TO LEARN.
Ability to Learn
TABLE 10-2 Relationship Between Psychosocial Adaptation to Illness and Learning
DEVELOPMENTAL CAPABILITY.
AGE-GROUP.
PHYSICAL CAPABILITY.
BOX 10-4 Teaching Methods Based on Patient’s Developmental Capacity
Infant
Toddler
Preschooler
School-Age Child
Adolescent
Young or Middle Adult
Older Adult
Learning Environment
Figure 10-2 Choosing comfortable, pleasant environments enhances the learning experience. The nurse is explaining the breast self-examination procedure to the patient.
TABLE 10-3 Comparison of the Nursing and Teaching Processes
Integrating the Nursing and Teaching Processes
Assessment
LEARNING NEEDS.
MOTIVATION TO LEARN.
ABILITY TO LEARN.
TEACHING ENVIRONMENT.
RESOURCES FOR LEARNING.
TABLE 10-4 Teaching and Learning Principles and Related Nursing Interventions
TABLE 10-5 FOCUSED PATIENT ASSESSMENT
SYNTHESIS IN PRACTICE
CULTURAL CONSIDERATIONS.
PATIENT EXPECTATIONS.
Nursing Diagnosis
Planning
BOX 10-5 PATIENT TEACHING
Outcome
Teaching Strategies
Evaluation Strategies
SETTING PRIORITIES.
CARE PLAN Patient Education for Smoking Cessation
ASSESSMENT
Nursing Diagnosis
PLANNING
INTERVENTIONS
EVALUATION
Implementation
TIMING.
ORGANIZING TEACHING MATERIAL.
TEACHING APPROACHES.
Telling.
Selling.
Participating.
Entrusting.
Reinforcing.
INCORPORATING TEACHING WITH NURSING CARE.
TEACHING METHODS.
One-on-One Discussion.
Group Instruction.
Preparatory Instruction.
Demonstrations.
BOX 10-6 Teaching Methods Based on Patient’s Learning Needs
Cognitive
Discussion (One-on-One or Group)
Lecture
Question-and-Answer Session
Role Play, Discovery
Independent Project (Computer-Assisted Instruction), Field Experience
Affective
Role Play
Discussion (Group)
Discussion (One-on-One)
Psychomotor
Demonstration
Practice
Return Demonstration
Independent Project, Game
Analogies.
Role-Playing.
Discovery.
MAINTAINING ATTENTION AND PARTICIPATION.
THE PROBLEM OF ILLITERACY.
CULTURAL VARIABLES.
SPECIAL NEEDS OF CHILDREN AND OLDER ADULTS.
BOX 10-7 Patient Teaching Strategies for the Illiterate Patient
Evaluation
PATIENT CARE.
PATIENT EXPECTATIONS.
BOX 10-8 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
BOX 10-9 CARE OF THE OLDER ADULT
Documentation of Patient Teaching
EVALUATION
Documentation Note
TABLE 10-6 OUTCOME EVALUATION
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
UNIT III Principles for Nursing Practice
CHAPTER 11 Infection Control
OBJECTIVES
Key Terms
Scientific Knowledge Base
Nature of Infection
Chain of Infection
INFECTIOUS AGENT.
RESERVOIR.
TABLE 11-1 Common Pathogens and Some Infections or Diseases They Produce
Figure 11-1 Chain of infection.
PORTAL OF EXIT.
MODE OF TRANSMISSION.
PORTAL OF ENTRY.
BOX 11-1 Modes of Transmission
Routes and Means
Contact
Direct.
Indirect.
Droplet.
Air
Vehicles
Vector
Figure 11-2 Stages of the natural history of a condition and their relationship to primary, secondary, and tertiary levels of prevention. (From Clark MJ: Community health nursing: caring for populations, ed 4, Upper Saddle River, NJ, 2003, Pearson Education.)
SUSCEPTIBLE HOST.
Course of Infection
TABLE 11-2 Normal Body System Defense Mechanisms Against Infection
Defenses Against Infection
NORMAL FLORA.
BODY SYSTEM DEFENSES.
BOX 11-2 CARE OF THE OLDER ADULT
TABLE 11-3 Inflammation
INFLAMMATION.
IMMUNE RESPONSE.
BOX 11-3 Examples of Sites and Potential Causes for Health Care–Associated Infections*
Surgical or Traumatic Wound Infections
Primary Bloodstream Infection/Sepsis
Pneumonia
Urinary Tract Infection
Bone and Joint Infection
Cardiovascular System Infection
Central Nervous System Infection
Gastrointestinal System Infection
Skin and Soft Tissue
Health Care–Associated Infection
ASEPSIS.
Nursing Knowledge Base
Nursing Process
Assessment
PATIENT EXPECTATIONS.
Nursing Diagnosis
BOX 11-4 Factors Affecting Susceptibility to Infection
Age
Heredity
Cultural Practices
Nutritional Status
Stress
Rest and Exercise
Inadequate Defenses
Personal Habits
Environmental Factors
Immunization/Disease History
Medical Therapies
Clinical Appearance/Data
TABLE 11-4 Laboratory Tests to Screen for Infection
Planning
GOALS AND OUTCOMES.
SETTING PRIORITIES.
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION.
Nutrition.
Hygiene.
Immunization.
Adequate Rest and Regular Exercise.
ACUTE CARE.
Medical Asepsis.
Control or Elimination of Infectious Agents.
Cleaning.
Disinfection and Sterilization.
Control or Elimination of Reservoirs.
Control of Portals of Exit.
BOX 11-5 Categories for Sterilization, Disinfection, and Cleaning
Critical Items—Sterilization
Semicritical Items—Disinfection
Noncritical Items—Cleaning
Control of Transmission.
Hand Hygiene.
BOX 11-6 Control and Prevention to Reduce Reservoirs of Infection
Hand hygiene.
Bathing.
Dressing changes.
Contaminated articles.
Contaminated needles.
Bedside unit.
Bottled irrigation solutions.
Surgical wounds.
Drainage bottles and bags.
BOX 11-7 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
BOX 11-8 PROCEDURAL GUIDELINES FOR
Hand Hygiene
Step 5A Apply waterless antiseptic to hands.
Step 5B Rub hands thoroughly.
Step 6C Regulate flow of water.
Step 6G
Step 6G Lather hands thoroughly.
Step 6J Rinsing hands.
Step 6m Turning off faucet with clean, dry paper towel.
Isolation and Barrier Protection.
Protective Environment.
BOX 11-9 PROCEDURAL GUIDELINES FOR
Caring for a Patient on Isolation Precautions
Step 5c Nurse with protective equipment for contact and droplet infection.
Step 12b Secure soiled linen in a waterproof bag.
Step 14c Nurse removes gown.
Step 14a Removing disposable gloves. A, Nurse places gloved finger inside cuff to pull first glove off hand. B, Nurse removes second glove by sliding fingers inside glove cuff and pulling.
TABLE 11-5 CDC Isolation Guidelines
Figure 11-3 Disposable HEPA air-purifying respirator.
Figure 11-4 Nurse wearing an N-95 mask.
BOX 11-10 PROCEDURAL GUIDELINES FOR
Donning a Surgical Type of Mask
Step 2
Step 3
Personal Protective Equipment (PPE).
Specimen Collection.
Bagging.
Figure 11-5 Nurse wearing protective goggles and mask.
BOX 11-11 Specimen Collection Techniques*
Wound Specimen
Blood Specimen
Stool Specimen
Urine Specimen
Removal of Protective Equipment.
Transporting Patients.
Control of Portals of Entry.
Protection of the Susceptible Host.
BOX 11-12 Infection Control of Portals of Entry
Intact Skin and Mucosa
Urinary Tract
Invasive Tubes and Lines
Wound Care
Role of the Infection Prevention and Control Department.
Health Promotion in Health Care Workers and Patients.
Surgical Asepsis.
Preparation for Sterile Procedures.
Principles of Surgical Asepsis.
BOX 11-13 PROCEDURAL GUIDELINES FOR
Putting on Sterile Gloves
Step 11 Pulling glove over dominant hand.
Step 12 Using gloved dominant hand to pull glove onto nondominant hand.
Step 13 Interlock hands, touching only sterile sides.
Figure 11-6 Opening a commercially packaged sterile item.
Figure 11-7 Adding item to a sterile field.
RESTORATIVE CARE.
BOX 11-14 PROCEDURAL GUIDELINES FOR
Opening Wrapped Sterile Items
Step 4 Open outermost flap of sterile kit away from body
Step 6 Open first side flap, pulling to side.
Step 7 Open second side flap, pulling to side.
Step 9 Open last and innermost flap.
Long-Term Care.
BOX 11-15 PROCEDURAL GUIDELINES FOR
Preparation of a Sterile Field
Step 6 Hold corners of sterile drape up and away from body.
Step 7 Position bottom half of sterile drape over top half of work surface.
Step 8 Step 8 Allow top half of drape to be placed over bottom half of work surface.
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 12 Vital Signs
OBJECTIVES
Key Terms
CASE STUDY Ms. Coburn
Guidelines for Measuring Vital Signs
BOX 12-1 When to Measure Vital Signs
Body Temperature
Body Temperature Regulation
NEURAL AND VASCULAR CONTROL.
HEAT PRODUCTION.
HEAT LOSS.
BEHAVIORAL CONTROL.
Temperature Alterations
FEVER.
HYPERTHERMIA.
BOX 12-2 Patterns of Fever
TABLE 12-1 Classification of Hypothermia
HYPOTHERMIA.
Nursing Process
Assessment
TABLE 12-2 FOCUSED PATIENT ASSESSMENT
SITES.
THERMOMETERS.
SKILL 12-1 Measuring Body Temperature
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 3A(3) Disposable plastic cover is placed over the probe.
Step 3B(8) Probe removed smoothly from anus.
Step 3D(6) Tympanic membrane thermometer with probe cover placed in patient’s ear.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
BOX 12-3 Advantages and Limitations of Select Temperature Measurement Sites
Figure 12-1 Electronic thermometer used for oral, rectal, or axillary measurements.
Figure 12-2 Temporal artery thermometer scanning forehead.
Chemical Dot Thermometers.
BOX 12-4 PROCEDURAL GUIDELINES FOR
Measurement of Temporal Artery Temperature
Glass Thermometers.
Figure 12-3 Disposable, single-use thermometer strip.
BOX 12-5 PROCEDURAL GUIDELINES FOR
Preparation of Mercury-in-Glass Thermometer
Nursing Diagnosis
BOX 12-6 Steps to Take in the Event of a Mercury Spill
Planning
CARE PLAN Hyperthermia
Assessment
Nursing Diagnosis
EVALUATION
Implementation
HEALTH PROMOTION.
ACUTE CARE
Hyperthermia.
Heat Stroke.
Hypothermia.
BOX 12-7 Nursing Interventions for Patients With a Fever
Assessment
Interventions (Unless Contraindicated)
RESTORATIVE AND CONTINUING CARE.
Evaluation
TABLE 12-3 OUTCOME EVALUATION
Pulse
Locating the Peripheral Pulse
Figure 12-4 Location of peripheral pulses.
Stethoscope
TABLE 12-4 Pulse Sites
Figure 12-5 Parts of a single tubing stethoscope.
SKILL 12-2 Assessing the Radial and Apical Pulses
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
STEP 3A(2) Pulse check with patient’s forearm at side with wrist extended.
Step 3A(3) Hand placement for pulse checks.
Step 3B(4)A Locating the angle of Louis.
Step 3B(4)B Locating the left second intercostal space(2ICS).
Step 3B(4)C Moving down the left side of the sternum to fifth intercostal space (5ICS).
Step 3B(4)D Locating the PMI.
Step 3B(6) A, Location of PMI in adults. B, Stethoscope over the PMI.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Figure 12-6 Positioning the diaphragm of the stethoscope.
Assessment of Pulse
PULSE RATE.
Figure 12-7 Positioning the bell of the stethoscope.
TABLE 12-5 Acceptable Ranges of Heart Rate for Age
PULSE RHYTHM.
TABLE 12-6 Factors Influencing Pulse Rates
STRENGTH AND EQUALITY.
Blood Pressure
Physiology of Arterial Blood Pressure
Blood Pressure Variations
HYPERTENSION.
BOX 12-8 Factors Influencing Blood Pressure
Age
Sympathetic Stimulation
Gender
Ethnicity
Daily Variation
Medication
Activity
Weight
Smoking
HYPOTENSION.
TABLE 12-7 Classification of Blood Pressure for Adults Age 18 Years and Older
TABLE 12-8 Recommendations for Blood Pressure Follow-up
BOX 12-9 PROCEDURAL GUIDELINES FOR
Measuring Orthostatic Blood Pressure
Assessment of Blood Pressure
BLOOD PRESSURE EQUIPMENT.
SKILL 12-3 Measuring Blood Pressure
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 1 Patient’s forearm supported in bed.
Step 3 A, Nurse palpating patient’s brachial artery. B, Center bladder of cuff above artery. C, Blood pressure cuff wrapped around upper arm.
Step 5A(3) Stethoscope over brachial artery to measure BP.
Step 5A(5) Inflating the BP cuff.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Figure 12-8 Sphygmomanometers. Left, Mercury; right, aneroid.
AUSCULTATION.
TABLE 12-9 Common Mistakes in Blood Pressure Assessment
Figure 12-9 The sounds auscultated during blood pressure measurement can be differentiated into five Korotkoff phases. In this example, the blood pressure is 140/90.
BOX 12-10 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
BOX 12-11 PROCEDURAL GUIDELINES FOR
Palpating the Systolic Blood Pressure
ULTRASONIC STETHOSCOPE.
PALPATATION.
Figure 12-10 Electronic blood pressure machines vary in appearance.
BLOOD PRESSURE ASSESSMENT IN LOWER EXTREMITIES.
ASSESSMENT OF BLOOD PRESSURE IN CHILDREN.
BOX 12-12 Advantages and Limitations of Automatic Blood Pressure Machines
Advantages
Limitations
BOX 12-13 PROCEDURAL GUIDELINES FOR
Automatic Blood Pressure Measurement
Figure 12-11 Lower extremity blood pressure cuff positioned above popliteal artery at midthigh with knee flexed.
Respiration
Assessment of Ventilation
Measurement of Respiration
RESPIRATORY RATE.
VENTILATORY DEPTH.
BOX 12-14 Factors Influencing Character of Respirations
Exercise
Acute Pain
Anxiety
Smoking
Body Position
Medications
Neurological Injury
Hemoglobin Function
VENTILATORY RHYTHM.
Figure 12-12 Pulse oximeter connected to finger sensor.
TABLE 12-10 Acceptable Range of Respiratory Rates for Age
Measurement of Arterial Oxygen Saturation
SKILL 12-4 Assessing Respiration
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 3 Nurse’s hand over patient’s abdomen to check respiratory rate.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
SKILL 12-5 Measuring Oxygen Saturation (Pulse Oximetry)
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 4 Attaching sensor probe to monitoring site.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
BOX 12-15 Factors Affecting Determination of Pulse Oxygen Saturation
Interference With Light Transmission
Interference With Arterial Pulsations
BOX 12-16 PATIENT TEACHING
Temperature
Pulse Rate
Blood Pressure
Respiration
Patient Teaching and Vital Sign Measurement
BOX 12-17 CARE OF THE OLDER ADULT
Temperature
Pulse Rate
Blood Pressure
Respiration
Recording Vital Signs
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 13 Health Assessment and Physical Examination
OBJECTIVES
Key Terms
Purposes of Physical Examination
Gathering a Database
Cultural Sensitivity
Integration of Physical Examination With Nursing Care
Skills of Physical Assessment
Inspection
Palpation
Figure 13-1 A, During light palpation, gentle pressure against underlying skin and tissues can detect areas of irregularity and tenderness. B, During deep palpation, depress tissue to assess condition of underlying organs.
Percussion
Auscultation
Figure 13-2 A, Radial pulse is detected with pads of fingertips, the most sensitive part of the hand. B, Dorsum of hand detects temperature variations in skin. C, The bony part of the palm at the base of the fingers detects vibrations. D, Skin is grasped with fingertips to assess turgor.
Olfaction
Preparation for Examination
Environment
Equipment
BOX 13-1 Exercises to Increase Familiarity With the Stethoscope
TABLE 13-1 Assessment of Characteristic Odors
Patient
PHYSICAL PREPARATION.
BOX 13-2 Equipment and Supplies for Physical Assessment
POSITIONING.
PSYCHOLOGICAL PREPARATION.
Assessment of Age-Groups
TABLE 13-2 Positions for Examination
Physical Examination
General Survey
General Appearance and Behavior.
Vital Signs.
Height and Weight.
TABLE 13-3 Clinical Indicators of Abuse
BOX 13-3 Red Flags for Suspicion of Substance Abuse
Figure 13-3 Measuring infant length.
Integument
Skin
HEALTH HISTORY.
BOX 13-4 Principles for Nursing Practice
Research Summary
Application to Nursing Practice
COLOR.
TABLE 13-4 Skin Color Variations
TABLE 13-5 Physical Findings of the Skin Indicative of Substance Abuse
MOISTURE.
TEMPERATURE.
TEXTURE.
TURGOR.
VASCULARITY.
EDEMA.
Figure 13-4 Assessment of skin turgor.
LESIONS
Hair and Scalp
HEALTH HISTORY.
BOX 13-5 Types of Primary Skin Lesions
INSPECTION.
BOX 13-6 PATIENT TEACHING
Hair and Scalp Assessment
Nails
Figure 13-5 Pigmented bands in nail of patient with dark skin. (From Seidel HM and others: Mosby’s guide to physical examination, ed 5, St. Louis, 2003, Mosby.)
HEALTH HISTORY
INSPECTION AND PALPATION
BOX 13-7 Abnormalities of the Nail Bed
BOX 13-8 PATIENT TEACHING
Nail Care
Head and Neck
Head
HEALTH HISTORY.
INSPECTION AND PALPATION.
Eyes
HEALTH HISTORY.
VISUAL ACUITY.
Figure 13-6 Cross section of eye.
BOX 13-9 PATIENT TEACHING
Eye Health
VISUAL FIELDS.
EXTERNAL EYE STRUCTURES.
Position and Alignment.
Eyebrows.
Eyelids.
Lacrimal Apparatus.
Figure 13-7 Lacrimal apparatus.
Conjunctiva and Sclera.
Cornea.
Figure 13-8 Chart depicting pupillary size in millimeters.
Pupils and Irises.
INTERNAL EYE STRUCTURES.
Figure 13-9 A, To check pupil reflexes, first hold penlight to side of patient’s face. B, Illumination of pupil causes pupillary constriction.
Ears
HEALTH HISTORY.
AURICLES
EAR CANALS AND EARDRUMS.
Figure 13-10 Otoscopic examination. (From Seidel HM and others: Mosby’s guide to physical examination, ed 5, St. Louis, 2003, Mosby.)
BOX 13-10 PATIENT TEACHING
Ear and Hearing Health
Figure 13-11 Normal tympanic membrane. (Courtesy Dr. Richard A. Buckingham, Abraham Lincoln School of Medicine, University of Illinois, Chicago.)
HEARING ACUITY.
BOX 13-11 PATIENT TEACHING
Nose and Sinus Health
Nose and Sinuses
HEALTH HISTORY.
NOSE.
SINUSES.
Mouth and Pharynx
Figure 13-12 Palpation of maxillary sinuses.
HISTORY.
LIPS.
MUCOSA.
Figure 13-13 A, Inspection of inner oral mucosa of lower lip. B, Retraction allows for clear view of buccal mucosa.
GUMS AND TEETH.
BOX 13-12 PATIENT TEACHING
Mouth and Pharynx Health
TONGUE AND FLOOR OF MOUTH.
Figure 13-14 Tongue depressor allows view of pharynx and posterior soft palate.
PALATE.
PHARYNX.
Figure 13-15 Anatomical position of major neck structures.
Neck
HEALTH HISTORY.
NECK MUSCLES.
LYMPH NODES.
Figure 13-16 Lymphatic drainage system of the head and neck. (From Seidel HM and others: Mosby’s guide to physical examination, ed 5, St. Louis, 2003, Mosby.)
Figure 13-17 Supraclavicular lymph node palpation.
THYROID GLAND.
BOX 13-13 PATIENT TEACHING
Neck Assessment
Figure 13-18 Thyroid gland.
TRACHEA.
Thorax and Lungs
Health History
Figure 13-19 Anatomical chest wall landmarks. A, Posterior chest. B, Lateral chest. C, Anterior chest.
Figure 13-20 Anterior position of lung lobes in relation to anatomical landmarks.
Figure 13-21 Lateral position of lung lobes in relation to anatomical landmarks.
Figure 13-22 Posterior position of lung lobes in relation to anatomical landmarks.
Posterior Thorax
Figure 13-23 A, Position of hands for palpation of posterior thorax excursion. B, When the patient inhales, the movement of chest excursion separates the thumbs.
Figure 13-24 A to C, A systematic pattern (posterior-lateral-anterior) is followed for auscultation.
Lateral Thorax
Anterior Thorax
TABLE 13-6 Adventitious Sounds
BOX 13-14 PATIENT TEACHING
Lung Health
Heart
Figure 13-25 Anatomical position of the heart.
Figure 13-26 Cardiac cycle. MVC, Mitral valve closes; AVO, aortic valve opens; AVC, aortic valve closes, MVO, mitral valve opens.
Health History
Inspection and Palpation
BOX 13-15 PATIENT TEACHING
Heart Health
Figure 13-27 Anatomical sites for assessment of cardiac function.
Auscultation
Figure 13-28 Sequence of patient positions for heart auscultation. A, Sitting. B, Supine. C, Left lateral recumbent. (From Seidel HM and others: Mosby’s guide to physical examination, ed 5, St. Louis, 2003, Mosby.)
Vascular System
Health History
Carotid Arteries
Figure 13-29 Anatomical position of carotid artery.
Figure 13-30 Palpation of the internal carotid artery.
Jugular Veins
Figure 13-31 Position of patient to assess jugular vein distention. (From Thompson JM and others: Mosby’s clinical nursing, ed 5, St. Louis, 2001, Mosby.)
Peripheral Arteries
BOX 13-16 PATIENT TEACHING
Vascular Health
Figure 13-32 Anatomical positions of brachial, radial, and ulnar arteries.
Figure 13-33 Palpation of radial pulse.
Figure 13-34 Palpation of ulnar pulse.
Figure 13-35 Palpation of brachial pulse.
Figure 13-36 Anatomical position of femoral, popliteal, dorsalis pedis, and posterior tibial arteries.
Figure 13-37 Palpation of femoral pulse.
ULTRASOUND STETHOSCOPES.
Figure 13-38 Palpation of popliteal pulse.
Figure 13-39 Palpation of dorsalis pedis pulse.
Tissue Perfusion
Figure 13-40 Palpation of posterior tibial pulse.
TABLE 13-7 Signs of Venous and Arterial Insufficiency
Figure 13-41 Assessing for pitting edema. (From Seidel HM and others: Mosby’s guide to physical examination, ed 5, St. Louis, 2003. Mosby.)
Figure 13-42 Inguinal lymph nodes.
Peripheral Veins
Lymphatic System
Breasts
Female Breasts
BOX 13-17 FEMALE BREAST HEALTH
Breast Self-Examination
BOX 13-18 Normal Changes in the Breast During a Woman’s Life Span
Puberty (8 to 20 Years)*
Stage 1 (Preadolescent)
Stage 2
Stage 3
Stage 4
Stage 5 (Mature Breast)
Young Adulthood (20 to 30 Years)
Pregnancy
Menopause
Older Adulthood
HEALTH HISTORY.
Figure 13-43 Quadrants of the left breast and axillary tail of Spence. (From Seidel HM and others: Mosby’s guide to physical examination, ed 5, St. Louis, 2003, Mosby.)
INSPECTION.
PALPATION.
Figure 13-44 Anatomical position of axillary and clavicular lymph nodes.
Figure 13-45 Support the patient’s arm while palpating axillary lymph nodes.
Figure 13-46 Patient lies flat with arm abducted and hand under head to help flatten breast tissue evenly over the chest wall. Palpate each breast in systematic fashion.
Figure 13-47 Various methods for breast palpation. A, Palpate from top to bottom in vertical strips. B, Palpate in concentric circles. C, Palpate out from the center in wedge sections. (From Seidel HM and others: Mosby’s guide to physical examination, ed 5, St. Louis, 2003, Mosby.)
Male Breasts
Abdomen
Figure 13-48 A, Anterior view of abdomen divided by quadrants. B, Posterior view of abdominal sections.
Health History
Inspection
BOX 13-19 PATIENT TEACHING
Abdominal Health
Auscultation
Figure 13-49 Light palpation of the abdomen.
Palpation
Figure 13-50 Deep palpation of the abdomen.
Female Genitalia
Health History
Preparing the Patient
BOX 13-20 PATIENT TEACHING
Female Genitalia Health
External Genitalia
Figure 13-51 Female external genitalia.
Speculum Examination of Internal Genitalia
Male Genitalia
Health History
Sexual Maturity
BOX 13-21 MALE GENITALIA HEALTH
Male Genital Self-Examination
Genital Examination
Testicular Self-Examination
Prostate Health
Penis
Figure 13-52 Normal male genitalia (circumcised). (From Seidel HM and others: Mosby’s guide to physical examination, ed 5, St. Louis, 2003, Mosby.)
Figure 13-53 Palpating contents of scrotal sac. (From Seidel HM and others: Mosby’s guide to physical examination, ed 5, St. Louis, 2003. Mosby.)
Scrotum
Inguinal Ring and Canal
Rectum and Anus
BOX 13-22 PATIENT TEACHING
Colorectal and Anal Health
Health History
Inspection
Digital Palpation
Musculoskeletal System
A Health History
BOX 13-23 PATIENT TEACHING
Musculoskeletal Health
General Inspection
Palpation
Range-of-Joint Motion
Figure 13-54 Inspection of overall body posture. A, Anterior view. B, Posterior view. C, Lateral view. (From Seidel HM and others: Mosby’s guide to physical examination, ed 5, St. Louis, 2003, Mosby.)
Muscle Tone and Strength
Neurological System
TABLE 13-8 Terminology for Normal Range-of-Motion Positions
Figure 13-55 Assess muscle tone when moving the extremity passively.
Health History
Mental and Emotional Status
TABLE 13-9 Maneuvers to Assess Muscle Strength
TABLE 13-10 Muscle Strength
Level of Consciousness
BOX 13-24 MMSE Sample Questions
TABLE 13-11 Glasgow Coma Scale
Behavior and Appearance
Language
Intellectual Function
MEMORY.
KNOWLEDGE.
ABSTRACT THINKING.
JUDGMENT.
TABLE 13-12 Cranial Nerve Function and Assessment
Cranial Nerve Function
Sensory Function
Motor Function
BALANCE.
TABLE 13-13 Assessment of Sensory Nerve Function
BOX 13-25 PATIENT TEACHING
Neurological Health
COORDINATION.
After the Examination
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 14 Administering Medications
OBJECTIVES
Key Terms
Scientific Knowledge Base
Application of Pharmacology in Nursing Practice
NAMES.
CLASSIFICATION.
BOX 14-1 Ways to Prevent Medication Errors Associated With Look-Alike Drugs
MEDICATION FORMS.
Medication Legislation and Standards
GOVERNMENTAL REGULATION OF MEDICATIONS.
TABLE 14-1 Forms of Medication by Route of Administration
HEALTH CARE INSTITUTIONS AND MEDICATION LAWS.
MEDICATION REGULATIONS AND NURSING PRACTICE.
BOX 14-2 Guidelines for Safe Opioid Administration and Control
NONTHERAPEUTIC MEDICATION USE.
BOX 14-3 Nursing Interventions to Improve Compliance With Medications
Nonadherence.
BOX 14-4 Using Evidence in Practice
Research Summary
Application to Nursing Practice
Pharmacokinetics as the Basis of Medication Actions
ABSORPTION.
Route of Administration.
Ability of the Medication to Dissolve.
Blood Flow to the Area of Absorption.
Body Surface Area.
Lipid Solubility of the Medication.
DISTRIBUTION.
Circulation.
Membrane Permeability.
Protein Binding.
METABOLISM.
EXCRETION.
Types of Medication Action
THERAPEUTIC EFFECTS.
BOX 14-5 Factors Influencing Drug Actions
Genetic Differences
Physiological Variables
Environmental Conditions
Psychological Factors
Diet
SIDE EFFECTS/ADVERSE REACTIONS.
Toxic Effects.
Idiosyncratic Reactions.
Allergic Reactions.
Figure 14-1 Identification bracelet and medal.
TABLE 14-2 Mild Allergic Reactions
MEDICATION INTERACTIONS.
TABLE 14-3 Common Dosage Administration Schedules
TABLE 14-4 Terms Associated With Medication Actions
MEDICATION DOSE RESPONSES.
TABLE 14-5 Factors Influencing Choice of Administration Routes
Routes of Administration
Figure 14-2 Sublingual administration of a tablet.
Figure 14-3 Buccal administration of a tablet.
ORAL ROUTES.
Sublingual Administration.
Buccal Administration.
PARENTERAL ROUTES.
TOPICAL ADMINISTRATION.
Inhalation Route.
Intraocular Route.
Systems of Medication Measurement
METRIC SYSTEM.
TABLE 14-6 Equivalents of Measurement
HOUSEHOLD MEASUREMENTS.
SOLUTIONS.
Clinical Calculations
CONVERSIONS WITHIN ONE SYSTEM.
CONVERSION BETWEEN SYSTEMS.
DOSAGE CALCULATIONS.
PEDIATRIC DOSAGES.
Figure 14-4 Mosteller’s formula and West nomogram for estimation of surface areas in children. A straight line is drawn on West nomogram between height and weight. The point where the line crosses the surface area column is the estimated body surface area. (From Behrman RE and others: Nelson textbook of pediatrics, ed 17, Philadelphia, 2004, WB Saunders; modified from data of Boyd E, by West CD.)
Administering Medications
PRESCRIBER’S ROLE.
BOX 14-6 Recommendations to Reduce Medication Errors Associated With Verbal Medication Orders and Prescriptions (NCCMERP, 2001)
Preamble
Recommendations
TYPES OF ORDERS IN ACUTE CARE AGENCIES.
Standing Orders.
TABLE 14-7 Dangerous Abbreviations
prn Orders.
Single (One-Time) Orders.
Stat Orders.
Now Orders.
TABLE 14-8 Abbreviations Prohibited by JCAHO
PRESCRIPTIONS.
PHARMACIST’S ROLE.
DISTRIBUTION SYSTEMS.
Unit Dose.
Computer-Controlled Dispensing Systems.
Nurse’s Role.
Medication Errors
Figure 14-5 Example of a medication prescription.
Figure 14-6 Computer-controlled medication dispensing system.
Critical Thinking
Synthesis
KNOWLEDGE.
BOX 14-7 Steps to Take in Preventing Medication Errors
EXPERIENCE.
ATTITUDES.
STANDARDS.
Right Medication.
Right Dose.
Right Patient.
Figure 14-7 Before administering any medications, check the patient’s identification and allergy bracelets. (From deWit S: Fundamental concepts and skills for nursing, ed 2, Philadelphia, 2005, WB Saunders.)
Right Route.
Right Time.
Right Documentation.
Figure 14-8 Medication organization container to help patients remember to take medications.
MAINTAINING PATIENTS’ RIGHTS.
Nursing Process
Assessment
HISTORY.
History of Allergies.
Medication History.
Diet History.
PATIENT’S PERCEPTUAL OR COORDINATION PROBLEMS.
PATIENT’S CURRENT CONDITION.
PATIENT’S ATTITUDE ABOUT MEDICATION USE.
BOX 14-8 CULTURAL FOCUS
Patient’s Knowledge and Understanding of Medication Therapy.
PATIENT’S LEARNING NEEDS.
Nursing Diagnosis
BOX 14-9 PATIENT TEACHING
Outcome
Teaching Strategies
Evaluation Strategies
Planning
Implementation
HEALTH PROMOTION ACTIVITIES.
Patient and Family Teaching.
ACUTE CARE ACTIVITIES.
Receiving Medication Orders.
Correct Transcription and Communication of Orders.
BOX 14-10 Components of Medication Orders
Patient’s full name.
Date and time that the order is written.
Drug name.
Dosage.
Route of administration.
Time and frequency of administration.
Signature of prescriber.
Accurate Dosage Calculation and Measurement.
Correct Administration.
Recording Medication Administration.
RESTORATIVE CARE ACTIVITIES.
SPECIAL CONSIDERATIONS FOR ADMINISTERING MEDICATIONS TO SPECIFIC AGE-GROUPS.
Infants and Children.
Older Adults.
Polypharmacy.
Self-Prescribing of Medications.
Evaluation
Figure 14-9 Example of medication administration record (MAR). (Courtesy OSF Saint Francis Medical Center, Peoria, Ill.)
BOX 14-11 Tips for Administering Medications to Children
Oral Medications
Injections
Figure 14-10 The effects of aging on drug metabolism. (From Lewis SM and others: Medical-surgical nursing, ed 5, St. Louis, 2000, Mosby.)
BOX 14-12 CARE OF THE OLDER ADULT
TABLE 14-9 Example Evaluations for Patient Goals
BOX 14-13 Interventions to Prevent Aspiration of Medications in Patients With Dysphagia
Oral Administration
SKILL 14-1 Administering Oral Medications
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 1e Check the label of the medication with the patient’s MAR.
Step 1i(1) Place tablet in pillating device, and cut in half.
Step 1i(2) Place tablet into medicine cup without removing wrapper.
Step 1j(3)A Pour the desired volume of liquid so that base of meniscus is level with line on scale.
Step 1j(3)B Use needleless syringe to draw up volumes under 10 ml.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Topical Medication Applications
Skin Applications
BOX 14-14 PROCEDURAL GUIDELINES FOR
Administering Medications Through a Nasogastric Tube, G-Tube, J-Tube, or Small-Bore Feeding Tube
Nasal Instillation
Eye Instillation
BOX 14-15 PROCEDURAL GUIDELINES FOR
Administering Nasal Instillations
Step 14a(2) Position for instilling nose drops into ethmoid or sphenoid sinus.
Step 14a(3) Position for instilling nose drops into frontal and maxillary sinus.
SKILL 14-2 Administering Eye Medications
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 13a(1) Hold eye dropper above conjunctival sac.
Step 13b(2) Apply ointment along lower eyelid.
Step 13c(1)(a) Gently position the convex side of the disk against your fingertip.
Step 13c(1)(c) Place disk in the conjunctival sac between the iris and lower eyelid.
Step 13c(1)(d) Gently pull lower eyelid over the disk.
Step 13c(2)(d) Carefully pinch the disk to remove it from patient’s eye.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Ear Instillation
Vaginal Instillation
BOX 14-16 PROCEDURAL GUIDELINES FOR
Administering Ear Medications
Step 8c Instill prescribed drops holding dropper above ear canal.
Rectal Instillation
BOX 14-17 PROCEDURAL GUIDELINES FOR
Administering Vaginal Medications
Step 10c Insertion of a suppository into the vaginal canal.
Step 11c Instillation of medication in vaginal canal.
BOX 14-18 PROCEDURAL GUIDELINES FOR
Administering Rectal Suppositories
Step 12 Lubricate tip of rectal suppository with water-soluble jelly.
Step 14 Inserting a rectal suppository. (From deWit S: Fundamental concepts and skills for nursing, ed 2, Philadelphia, 2005, WB Saunders.)
Administering Medications by Inhalation
SKILL 14-3 Using Metered-Dose or Dry Powder Inhalers
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 7e(1) One technique for use of the inhaler. The patient opens lips and places inhaler in mouth with opening toward back ofthroat.
Step 7e(2) One technique for use of the inhaler. The patient positions the mouthpiece 1 to 2 inches from the mouth. This is considered the best way to deliver the medication.
Step 8d Have patient place mouthpiece in mouth and close lips, being careful to keep exhalation slots exposed.
Step 9d Have patient place mouthpiece of DPI between lips.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Administering Medications By Irrigation
Parenteral Administration of Medications
BOX 14-19 Preventing Infection During an Injection
Equipment
SYRINGES.
Figure 14-11 Types of syringes. A, Luer-Lok syringe marked in 0.1 (tenths). B, Tuberculin syringe marked in 0.01 (hundredths) for doses less than 1 ml. C, Insulin syringe marked in units (100). D, Insulin syringe marked in units (50).
Figure 14-12 Parts of a syringe.
NEEDLES.
Figure 14-13 Hypodermic needles (top to bottom): 19 gauge, 1½-inch length; 20 gauge, 1-inch length; 21 gauge, 1-inch length; 23 gauge, 1-inch length; and 25 gauge, ⅝-inch length.
DISPOSABLE INJECTION UNITS.
Figure 14-14 A, Carpuject syringe and prefilled sterile cartridge with needle. B, Assembling the Carpuject. C, The cartridge slides into the syringe barrel, turns, and locks at the needle end. The plunger then screws into the cartridge end. D, Expel excess medication to obtain accurate dose.
Figure 14-15 A, Medication in ampules. B, Medication in vials. Rubber top must be cleansed with alcohol when vial is opened or when it is reused.
Preparing an Injection From an Ampule
Preparing an Injection From a Vial
Mixing Medications
MIXING MEDICATIONS FROM A VIAL AND AN AMPULE.
MIXING MEDICATIONS FROM TWO VIALS.
SKILL 14-4 Preparing Injections
Delegation Considerations
Equipment
Medication in an Ampule
Medication in a Vial
Both
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 2A(1) Tapping ampule moves fluid down neck.
Step 2A(2) Gauze pad placed around neck of ampule.
Step 2A(3) Snapping neck away from hands.
Step 2A(6) A, Medication aspirated with ampule inverted. B, Medication aspirated with ampule on flat surface.
Step 2B(2) Syringe with needleless adapter.
Step 2B(3) Insert safety needle through center of vial diaphragm (with vial flat on table).
Step 2B(5) Withdraw fluid with vial inverted.
Step 2B(10) Hold syringe upright, tap barrel to dislodge air bubbles.
EVALUATION
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Figure 14-16 Steps in mixing medications from two vials.
BOX 14-20 Calculating Doses of U-500 Insulin
Insulin Preparation
TABLE 14-10 Comparison of Insulin Preparations
Administering Injections
BOX 14-21 PROCEDURAL GUIDELINES FOR
Mixing Two Kinds of Insulin in One Syringe
Figure 14-17 Sites recommended for Sub-Q injections.
SUBCUTANEOUS INJECTIONS.
SKILL 14-5 Administering Injections
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 12 Cleanse site with circular motion.
Step 15a Hold syringe as if grasping a dart.
Step 16A(4) Inject medication slowly.
Step 14C(4) Injection creates a small bleb.
Evaluation
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Figure 14-18 Giving Sub-Q heparin in the abdomen.
INTRAMUSCULAR INJECTIONS.
Figure 14-19 Comparison of angles of insertion for IM (90 degrees), Sub-Q (45 and 90 degrees), and ID (15 degrees) injections.
Sites.
Ventrogluteal.
BOX 14-22 Characteristics of Intramuscular Sites
Vastus Lateralis
Ventrogluteal
Deltoid
Vastus Lateralis.
Figure 14-20 A, Landmarks for ventrogluteal site. B, Giving IM injection in ventrogluteal site.
Dorsogluteal.
Deltoid.
Figure 14-21 A, Landmarks for vastus lateralis site. B, Giving IM injection in vastus lateralis muscle.
Technique in Intramuscular Injections
Z-Track Method.
Figure 14-22 A, Landmarks for deltoid site. B, Giving IM injection in deltoid muscle.
INTRADERMAL INJECTIONS.
SAFETY IN ADMINISTERING MEDICATIONS BY INJECTION
Needleless Devices.
Figure 14-23 Z-Track method of injection prevents deposit of medication into sensitive tissues.
Figure 14-24 Needle with plastic guard to prevent needle sticks. A, Position of guard before injection. B, After injection, the nurse locks the guard in place, covering the needle.
Intravenous Administration
Figure 14-25 Sharps disposal using only one hand.
BOX 14-23 Recommendations for the Prevention of Needle-Stick Injuries
SKILL 14-6 Adding Medications to Intravenous Fluid Containers
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 3c Cleanse injection port with antiseptic swab.
Step 3d Inject medication through port.
Step 3g Affix label to IV bag.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
LARGE-VOLUME INFUSIONS.
INTRAVENOUS BOLUS.
VOLUME-CONTROLLED INFUSIONS.
Figure 14-26 Piggyback setup.
Piggyback.
SKILL 14-7 Administering Medications by Intravenous Bolus
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 7c Connecting syringe to IV line with blunt needleless cannula tip.
Step 7d Intravenous line pinched above injection port for medication infusion.
Step 7e Using a watch to time an IV push medication.
Step 8b(2) A, Intravenous catheter with saline lock adapter. B, Syringe inserted into injection port.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Volume-Control Administration.
Mini-infusion Pump.
INTERMITTENT VENOUS ACCESS.
SKILL 14-8 Administering Intravenous Medications by Piggyback, Intermittent Intravenous Infusion Sets, and Mini-infusion Pumps
Delegation Considerations
Equipment
Piggyback or Mini-infusion Pump
Volume-Control Administration Set
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 7A(3)(a) For the needleless system, insert tip of piggyback infusion tubing into port.
Step 7B(3) Ensure syringe is secure after placing it into miniinfusion pump.
Step 5C(4) A, Inject medication into device. B, Prepared dose.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 15 Fluid, Electrolyte, and Acid-Base Balance
OBJECTIVES
Key Terms
CASE STUDY Mrs. Reynolds
Scientific Knowledge Base
Distribution of Body Fluids
Composition of Body Fluids
Figure 15-1 Diffusion across a semipermeable membrane. (From Lewis SM and others: Medical-surgical nursing: assessment and management of clinical problems, ed 4, St. Louis, 2002, Mosby.)
Movement of Body Fluids
Figure 15-2 Osmosis through a semipermeable membrane. (From Lewis SM and others: Medical-surgical nursing: assessment and management of clinical problems, ed 4, St. Louis, 2002, Mosby.)
Figure 15-3 The sodium-potassium pump. (From Lewis SM and others: Medical-surgical nursing: assessment and management of clinical problems, ed 4, St. Louis, 2002, Mosby.)
Regulation of Body Fluids
FLUID INTAKE.
TABLE 15-1 Adult Average Daily Fluid Gains and Losses
HORMONAL REGULATION.
FLUID OUTPUT REGULATION.
Regulation of Electrolytes
CATIONS.
Sodium Regulation.
Potassium Regulation.
Calcium Regulation.
Magnesium Regulation.
ANIONS.
Chloride Regulation.
Bicarbonate Regulation.
Phosphorus-Phosphate Regulation.
Regulation of Acid-Base Balance
Disturbances in Electrolyte, Fluid, and Acid-Base Balance
ELECTROLYTE IMBALANCES
Sodium Imbalances.
Potassium Imbalances.
Calcium Imbalances.
TABLE 15-2 Electrolyte Imbalances
Magnesium Imbalances.
Chloride Imbalances.
FLUID DISTURBANCES.
ACID-BASE IMBALANCES.
pH.
PaCO2
PaO2.
TABLE 15-3 Fluid Disturbances
Oxygen Saturation.
Base Excess.
Bicarbonate.
Types of Acid-Base Imbalances.
TABLE 15-4 Acid-Base Imbalances
Nursing Knowledge Base
Critical Thinking in Patient Care
Synthesis
KNOWLEDGE.
EXPERIENCE.
ATTITUDES.
STANDARDS.
Nursing Process
Assessment
NURSING HISTORY.
PHYSICAL EXAMINATION.
MEASURING FLUID INTAKE AND OUTPUT.
BOX 15-1 Medications That Cause Fluid and Electrolyte and Acid-Base Disturbances
TABLE 15-5 Physical and Behavioral Nursing Assessment for Fluid, Electrolyte, and Acid-Base Imbalances
LABORATORY STUDIES.
TABLE 15-6 FOCUSED PATIENT ASSESSMENT
Figure 15-4 Graduated measuring containers. Clockwise from top left: “hat” receptacle, specimen, and measurement container.
SYNTHESIS IN PRACTICE
PATIENT EXPECTATIONS.
Nursing Diagnosis
BOX 15-2 Laboratory Data for Fluid, Electrolyte, and Acid-Base Imbalances
Fluid and Electrolytes
Metabolic Alkalosis
Metabolic Acidosis
Respiratory Alkalosis
Respiratory Acidosis
TABLE 15-7 Laboratory Profile: Acid-Base Assessment
Planning
GOALS AND OUTCOMES.
CARE PLAN Fluid and Electrolyte Imbalance
Assessment
Nursing Diagnosis
Planning
Evaluation
SETTING PRIORITIES.
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION.
ACUTE CARE.
Daily Weight and Intake and Output Measurement.
Enteral Replacement of Fluids.
Restriction of Fluids.
Parenteral Replacement of Fluids and Electrolytes.
Vascular Access Devices.
Total Parenteral Nutrition.
Intravenous Therapy.
Administration of Intravenous Therapy
Types of Solutions.
TABLE 15-8 Intravenous Solutions
Equipment.
Figure 15-5 Cephalic, basilic, and medial cubital veins are best for IV placement in adults.
Initiating the Intravenous Line.
BOX 15-3 CARE OF THE OLDER ADULT
BOX 15-4 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
Regulating the Infusion Flow Rate.
SKILL 15-1 Initiating a Peripheral Intravenous Infusion
Delegation Considerations
Equipment
For IV Start and Heparin Saline Lock
For IV Fluid Infusion
For Heparin or Normal Saline Lock
Transparent Dressing Only
Gauze Dressing Only
Figure 15-6 IV access device options. A, Scalp vein. B, Over-the-needle catheter (ONC).
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 5c A, Roller clamp in open position. B, Roller clamp in closed or off position.
Step 5d Remove protective covering from IV solution.
Step 5e Insertion of tubing spike into IV container.
Step 5f Squeezing drip chamber to fill with fluid.
Step 5h Remove air bubbles from tubing.
Step 7 Tourniquet placed on arm for initial vein selection.
Step 8e Palpate vein for resilience.
Step 14 Stabilize vein below insertion site.
Step 14b Puncture skin with VAD at 10 to 30 degrees above vein.
Step 15 A, Blood return in flashback chamber. B, Advance device into vein.
Step 16 A, Apply pressure above insertion site. B, Retract the stylet by pushing safety tab.
Step 17 Connecting end of saline lock.
Step 18 Flush injection cap.
Step 20b A, Place tape under catheter hub. B, Chevron applied before gauze dressing.
Step 21A(1) Applying transparent dressing.
Step 21A(2) Place tape over transparent dressing.
Step 21B(1) Place folded 2 × 2 gauze under cannula hub.
Step 21B(2) Apply 2 × 2 gauze dressing.
Step 22 Loop and secure tubing.
Step 24 Label IV dressing.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
TABLE 15-9 Infiltration Scale
TABLE 15-10 Phlebitis Scale
SKILL 15-2 Regulating Intravenous Flow Rate
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 3 IV fluid bag with time tape.
Step 5 Nurse counts drops infusing.
Step 6a Electronic eye placed over drip chamber.
Step 6b Insert IV tubing into chamber of control mechanism.
Step 6c Press start button.
Step 7a Volume-metric device.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Maintaining the System.
Figure 15-7 Potential sites for contamination of an intravascular device.
Complications of Intravenous Therapy.
Discontinuing Intravenous Infusions.
SKILL 15-3 Changing Intravenous Solution and Infusion Tubing
Delegation Considerations
Equipment
IV Infusion
Heparin Flush
Normal Saline Flush
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 3d(9) A, Disconnect old tubing. B, While compressing vein, attach end of new tubing. C, Make sure connection is secure.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
SKILL 15-4 Changing a Peripheral Intravenous Dressing
Delegation Considerations
Equipment
For Transparent Dressing
For Gauze Dressing
ASSESSMENT
Planning
Implementation
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Blood Replacement.
Blood Groups and Types.
Figure 15-8 IV catheter is withdrawn slowly, keeping catheter parallel to vein.
Autologous Transfusion.
Blood Transfusions.
Figure 15-9 Tubing for blood administration has an in-line filter.
Transfusion Reactions.
Interventions for Acid-Base Imbalances.
Arterial Blood Gases.
CONTINUING CARE.
BOX 15-5 Nursing Interventions for Blood Transfusion Reaction
Home Intravenous Therapy.
Nutritional Support.
Medication Safety.
BOX 15-6 PATIENT TEACHING
Home Intravenous Therapy
Outcome
Teaching Strategies
Evaluation Strategies
TABLE 15-11 OUTCOME EVALUATION
Evaluation
PATIENT CARE.
EVALUTION
Documentation Note
PATIENT EXPECTATIONS.
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
UNIT IV Principles for Caring
CHAPTER 16 Caring in Nursing Practice
OBJECTIVES
Key Terms
CASE STUDY Mrs. Levine
Theoretical Views on Caring
Caring Is Primary
The Essence of Nursing and Health
Transpersonal Caring
TABLE 16-1 Watson’s 10 Carative Factors
Swanson’s Theory of Caring
Summary of Theoretical Views
TABLE 16-2 Swanson’s Theory of Caring
Patients’ Perceptions of Caring
TABLE 16-3 Nursing Care Behavior (as Perceived by Patients)
Caring in Nursing Practice
Providing Presence
Figure 16-1 Nurse conveying presence to a patient.
Comforting
Touch
Figure 16-2 Nurse discusses patient’s health care needs with family.
Listening
Knowing the Patient
BOX 16-1 CARE OF THE OLDER ADULT
Healing Environments
Spiritual Caring
BOX 16-2 Nurse Caring Behaviors as Perceived by Families
Family Care
The Challenge of Caring
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 17 Cultural Diversity
OBJECTIVES
Key Terms
Health Disparities
Cultural Conflicts
Culture in Health and Illness
Comparative Worldviews About Health and Illness
TABLE 17-1 Comparative Cultural Worldviews About Health and Illness
Culturally Competent Care
TABLE 17-2 Cultural Healers
Figure 17-1 Leininger’s culture care theory and Sunrise Model. (Reprinted with permission of the McGraw-Hill Companies.)
Cultural Assessment
Intercultural Communication
Building Relationships
BOX 17-1 Questions Used in Cultural Care Assessment
BOX 17-2 Rules of Impression Management
Selected Components of Cultural Assessment
Ethnic Heritage and Ethnohistory
Biocultural History
Social Organization
Religious and Spiritual Beliefs
TABLE 17-3 Cultural Assessment Guide
Communication Patterns
BOX 17-3 CARE OF THE OLDER ADULT
Time Orientation
Caring Beliefs and Practices
CULTURAL PRACTICES DURING LIFE TRANSITIONS.
PREGNANCY.
BOX 17-4 PATIENT TEACHING
Outcome
Teaching Strategies
Evaluation Strategies
CHILDBIRTH.
NEWBORN.
POSTPARTUM PERIOD.
Grief and Loss
Experience With Professional Health Care
Culturally Competent Nursing Actions
BOX 17-5 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 18 Spiritual Health
OBJECTIVES
Key Terms
CASE STUDY Victoria Timms
Scientific Knowledge Base
Nursing Knowledge Base
Concepts in Spiritual Health
SPIRITUALITY.
Figure 18-1 The spiritual dimension: the unifying approach. (With kind permission of Springer Science and Business Media.)
FAITH.
RELIGION.
HOPE.
Spiritual Health
TABLE 18-1 Relationship Between Developmental Stage and Spiritual Beliefs
Spiritual Problems
ACUTE ILLNESS.
Figure 18-2 Spiritual distress often affects a person’s adjustment to illness.
CHRONIC ILLNESS.
TERMINAL ILLNESS.
NEAR-DEATH EXPERIENCE.
Critical Thinking
Synthesis
KNOWLEDGE.
BOX 18-1 CULTURAL FOCUS
Implications for Practice
EXPERIENCE.
ATTITUDES.
STANDARDS.
Nursing Process
Assessment
TABLE 18-2 FOCUSED PATIENT ASSESSMENT
FAITH/BELIEF.
LIFE AND SELF-RESPONSIBILITY.
TABLE 18-3 Religious Beliefs About Health
CONNECTEDNESS.
LIFE SATISFACTION.
FELLOWSHIP AND COMMUNITY.
RITUAL AND PRACTICE.
Figure 18-3 Praying together enhances the connectedness between parents and their children.
VOCATION.
PATIENT EXPECTATIONS.
SYNTHESIS IN PRACTICE
Nursing Diagnosis
Planning
GOALS AND OUTCOMES.
SETTING PRIORITIES.
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION.
Establishing Presence.
Supporting a Healing Relationship.
CARE PLAN Spirituality
ASSESSMENT
Nursing Diagnosis
PLANNING
EVALUATION
ACUTE CARE.
Support Systems.
Diet Therapies.
BOX 18-2 CARE OF THE OLDER ADULT
Supporting Rituals.
RESTORATIVE AND CONTINUING CARE
Prayer and Meditation.
BOX 18-3 PATIENT TEACHING
Outcome
Teaching Strategies
Evaluation Strategies
Evaluation
PATIENT CARE.
TABLE 18-4 OUTCOME EVALUATION
EVALUATION
Documentation Note
PATIENT EXPECTATIONS.
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 19 Growth and Development
OBJECTIVES
Key Terms
CASE STUDY Crystal Taylor
Scientific Knowledge Base
Growth and Development Theory
TABLE 19-1 Comparison of Major Development Theories
THEORIES OF HUMAN DEVELOPMENT.
Sigmund Freud.
Erik Erikson’s Eight Stages of Development.
Piaget’s Theory of Cognitive Development.
Figure 19-1 Loneliness in relation to Maslow’s hierarchy of needs. (Modified from Ebersole P, Hess P: Toward healthy aging: human needs and nursing responses, ed 6, St. Louis, 1998, Mosby.)
Kohlberg’s Moral Developmental Theory.
Abraham Maslow.
Carol Gilligan.
Nursing Knowledge Base
Conception and Fetal Development
HEALTH PROMOTION.
Neonate
HEALTH PROMOTION.
BOX 19-1 Health Promotion Guidelines for Parents of Newborns
Infant
HEALTH PROMOTION.
Figure 19-2 Playing with blocks helps to develop infant’s motor skills. (From Wong DL and others: Whaley and Wong’s nursing care of infants and children, ed 6, St. Louis, 1999, Mosby.)
Acute Care.
BOX 19-2 Health Promotion Guidelines for Parents of Infants
Toddler
HEALTH PROMOTION.
Acute Care.
BOX 19-3 Health Promotion Guidelines for Parents of Toddlers
Preschool Child
BOX 19-4 Health Promotion Guidelines for Parents of Preschool Children
HEALTH PROMOTION.
Acute Care.
School-Age Child
Figure 19-3 Coordination improves in school-age children as they gain control over their bodies.
HEALTH PROMOTION.
BOX 19-5 Health Promotion Guidelines for School-Agers and Their Parents
ACUTE CARE.
Preadolescent
Adolescent
PHYSICAL DEVELOPMENT.
PUBERTY.
Figure 19-4 Heterosexual relationships are an important part of adolescence. (From Hockenberry and others: Whaley and Wong’s nursing care of infants and children, ed 7, St. Louis, 2003, Mosby.)
HEALTH PROMOTION.
BOX 19-6 Health Promotion Guidelines for Adolescents and Their Parents
ACUTE CARE.
Young Adult
PHYSICAL DEVELOPMENT.
COGNITIVE DEVELOPMENT.
PSYCHOSOCIAL DEVELOPMENT.
HEALTH PROMOTION.
ACUTE CARE.
Middle-Age Adult
PHYSICAL CHANGES.
COGNITIVE DEVELOPMENT.
PSYCHOSOCIAL DEVELOPMENT.
TABLE 19-2 Physiological Changes in the Middle-Age Adult
HEALTH PROMOTION.
ACUTE CARE.
Older Adult
BOX 19-7 CULTURAL FOCUS
Implications for Practice
Figure 19-5 Quilting keeps this older adult active.
TABLE 19-3 Common Physical Changes of Aging
PHYSICAL DEVELOPMENT.
COGNITIVE DEVELOPMENT.
BOX 19-8 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
PSYCHOSOCIAL DEVELOPMENT.
Death.
Aloneness and Loneliness.
Housing and Environment.
HEALTH PROMOTION.
BOX 19-9 CARE OF THE OLDER ADULT
Health Care Services.
ACUTE CARE.
Critical Thinking
Synthesis
KNOWLEDGE.
EXPERIENCE.
ATTITUDES.
STANDARDS.
Nursing Process
Assessment
PATIENT EXPECTATIONS.
TABLE 19-4 FOCUSED PATIENT ASSESSMENT
SYNTHESIS IN PRACTICE
Nursing Diagnosis
Planning
GOALS AND OUTCOMES.
CARE PLAN Health-Seeking Behaviors
Assessment
Nursing Diagnosis
Planning
Evaluation
BOX 19-10 PATIENT TEACHING
Outcome
Teaching Strategies
Evaluation Strategies
SETTING PRIORITIES.
CONTINUITY OF CARE.
EVALUATION
Documentation Note
Implementation
Evaluation
PATIENT CARE.
TABLE 19-5 OUTCOME EVALUATION
PATIENT EXPECTATIONS.
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 20 Self-Concept and Sexuality
OBJECTIVES
Key Terms
CASE STUDY Paul Taylor
Scientific Knowledge Base
Development of Self-Concept
Components and Interrelated Terms of Self-Concept
BOX 20-1 Erikson’s Developmental Tasks and Impact on Self-Concept and Sexuality
Trust Versus Mistrust (Birth to 1 Year)
Autonomy Versus Shame and Doubt (1 to 3 Years)
Initiative Versus Guilt (3 to 6 Years)
Industry Versus Inferiority (6 to 12 Years)
Identity Versus Role Confusion (12 to 20 Years)
Intimacy Versus Isolation (Mid-20s to Mid-40s)
Generativity Versus Self-Absorption (Mid-40s to Mid-60s)
Ego Integrity Versus Despair (Late 60s to Death)
Figure 20-1 Sexuality is important across the life span.
Stressors Affecting Self-Concept and Sexuality
Figure 20-2 Common stressors that influence self-concept.
IDENTITY STRESSORS.
BOX 20-2 CULTURAL FOCUS
Implications for Practice
BODY IMAGE STRESSORS.
ROLE PERFORMANCE STRESSORS.
SELF-ESTEEM STRESSORS.
BOX 20-3 CARE OF THE OLDER ADULT
SEXUALITY STRESSORS.
BOX 20-4 Signs and Symptoms That Indicate Current Sexual Abuse or a History of Sexual Abuse
The Nurse’s Influence on the Patient’s Self-Concept and Sexuality
Figure 20-3 Nurses use touch and eye contact to enhance a patient’s self-esteem.
Critical Thinking in Patient Care
Synthesis
KNOWLEDGE.
EXPERIENCE.
BOX 20-5 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
ATTITUDES.
STANDARDS.
BOX 20-6 Behaviors Suggestive of Altered Self-Concept and Sexuality
Nursing Process
Assessment
TABLE 20-1 FOCUSED PATIENT ASSESSMENT
BOX 20-7 PLISSIT Assessment of Sexuality
SYNTHESIS IN PRACTICE
PATIENT EXPECTATIONS.
Nursing Diagnosis
Planning
GOALS AND OUTCOMES.
SETTING PRIORITIES.
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION.
CARE PLAN Self-Esteem
Assessment
Nursing Diagnosis
Planning
Evaluation
ACUTE CARE.
BOX 20-8 PATIENT TEACHING
Promoting Sexual Function for the Older Adult
Outcome
Teaching Strategies
Evaluation Strategies
RESTORATIVE AND CONTINUING CARE.
BOX 20-9 PATIENT TEACHING
Alterations in Self-Concept
Outcome
Teaching Strategies
Evaluation
Evaluation
PATIENT CARE.
EVALUATION
Documentation Note
TABLE 20-2 OUTCOME EVALUATION
PATIENT EXPECTATIONS.
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 21 Family Context in Nursing
OBJECTIVES
Key Terms
CASE STUDY The O’Connell Family
Scientific Knowledge Base
Concept of Family
Figure 21-1 Family celebrations and traditions strengthen the family.
Definition: What Is Family?
Family Forms
CURRENT TRENDS AND NEW FAMILY FORMS.
BOX 21-1 Family Forms
Nuclear Family
Extended Family
Single-Parent Family
Blended Family
Alternate Patterns of Relationships
FACTORS INFLUENCING FAMILY FORMS.
Economic Factors.
Homelessness.
Domestic Violence.
BOX 21-2 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
STRUCTURE AND FUNCTION.
TABLE 21-1 Stages of the Family Life Cycle
DEVELOPMENTAL STAGES.
FAMILY AND HEALTH.
Nursing Knowledge Base
Family Nursing: Family as Context, as Patient, and as System
FAMILY AS CONTEXT.
FAMILY AS PATIENT.
FAMILY AS SYSTEM.
Figure 21-2 Observing family interactions assists in understanding family functioning.
Critical Thinking
Synthesis
KNOWLEDGE.
EXPERIENCE.
ATTITUDES.
STANDARDS.
Nursing Process
Assessment
TABLE 21-2 FOCUSED PATIENT ASSESSMENT
SYNTHESIS IN PRACTICE
BOX 21-3 CULTURAL FOCUS
Implications for Practice
PATIENT EXPECTATIONS.
Nursing Diagnosis
Planning
GOALS AND OUTCOMES.
SETTING PRIORITIES.
CONTINUITY OF CARE.
Figure 21-3 Nurse and family members.
Implementation
HEALTH PROMOTION.
CARE PLAN Compromised Family Coping
Assessment
Nursing Diagnosis
Planning
Evaluation
BOX 21-4 CARE OF THE OLDER ADULT
ACUTE CARE.
RESTORATIVE AND CONTINUING CARE.
Evaluation
PATIENT CARE.
BOX 21-5 PATIENT TEACHING
Outcomes
Teaching Strategies
Evaluation Strategies
TABLE 21-3 OUTCOMES EVALUATION
EVALUATION
Documentation Note
PATIENT EXPECTATIONS.
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 22 Stress and Coping
OBJECTIVES
Key Terms
CASE STUDY Rhonda Bennett, RN
Scientific Knowledge Base
General Adaptation Syndrome
REACTION TO PSYCHOLOGICAL STRESS.
TABLE 22-1 Indicators of Stress
Types of Stress
BOX 22-1 Factors Influencing the Response to Stressors
Intensity
Scope
Duration
Number and Nature of Other Stressors Present
Predictability
Level of Personal Control
Feelings of Competence
Cognitive Appraisal
Availability of Social Supports
Nursing Knowledge Base
Nursing Theory and the Role of Stress
Situational, Maturational, and Sociocultural Factors
BOX 22-2 CARE OF THE OLDER ADULT
SITUATIONAL FACTORS.
MATURATIONAL FACTORS.
SOCIOCULTURAL FACTORS.
Posttraumatic Stress Disorder
Critical Thinking
Synthesis
KNOWLEDGE.
EXPERIENCE.
ATTITUDES.
STANDARDS.
Nursing Process
Assessment
SUBJECTIVE FINDINGS.
SYNTHESIS IN PRACTICE
OBJECTIVE FINDINGS.
PATIENT EXPECTATIONS.
TABLE 22-2 FOCUSED PATIENT ASSESSMENT
Nursing Diagnosis
Planning
GOALS AND OUTCOMES.
SETTING PRIORITIES.
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION.
Regular Exercise.
Support Systems.
Progressive Muscle Relaxation.
Cognitive Therapy.
Assertiveness Training.
Stress Management in the Workplace.
CARE PLAN Stress and Individual Coping
Assessment
Nursing Diagnosis
PLANNING
EVALUATION
BOX 22-3 PATIENT TEACHING
Outcome
Teaching Strategies
Evaluation Strategies
Figure 22-1 Sharing recreation with family and friends promotes relaxation. (Courtesy Michael S. Clement, MD, Mesa, Ariz.)
BOX 22-4 CULTURAL FOCUS
ACUTE CARE
Crisis Intervention.
BOX 22-5 UESING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
RESTORATIVE AND CONTINUING CARE.
Evaluation
PATIENT CARE.
TABLE 22-3 OUTCOME EVALUATION
EVALUATION
Documentation Note
Patient Expectations.
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 23 Loss and Grief
OBJECTIVES
Key Terms
CASE STUDY The Holloway Family
TABLE 23-1 Types of Loss
Scientific Knowledge Base
Loss
Grief
TABLE 23-2 The Grief Process
KU¨BLER-ROSS’S STAGES OF DYING.
BOWLBY’S PHASES OF MOURNING.
WORDEN’S FOUR TASKS OF MOURNING.
TYPES OF GRIEF.
Normal Grief.
Anticipatory Grief.
COMPLICATED GRIEF.
DISENFRANCHISED GRIEF.
Nursing Knowledge Base
Factors Influencing Loss and Grief
HUMAN DEVELOPMENT.
PSYCHOSOCIAL PERSPECTIVES OF LOSS AND GRIEF.
SOCIOECONOMIC STATUS.
PERSONAL RELATIONSHIPS.
Nature of the Loss.
CULTURE AND ETHNICITY.
BOX 23-1 CULTURAL FOCUS
Loss, Death, and Grieving
Implications for Practice
SPIRITUAL BELIEFS.
Coping With Grief and Loss
HOPE.
Critical Thinking
Synthesis
BOX 23-2 The Dying Person’s Bill of Rights
KNOWLEDGE.
EXPERIENCE.
ATTITUDES.
STANDARDS.
Nursing Process
Assessment
TABLE 23-3 FOCUSED PATIENT ASSESSMENT
Figure 23-1 Nurses assist family members in finding resources to help with the grieving process.
TYPE AND STAGES OF GRIEF.
BOX 23-3 Symptoms of Normal Grief
Feelings
Cognitions (Thought Patterns)
Physical Sensations
Behaviors
FACTORS THAT AFFECT GRIEF.
TABLE 23-4 Assessment of Factors Influencing Grieving
COPING RESOURCES.
END-OF-LIFE DECISIONS.
SYNTHESIS IN PRACTICE
NURSE’S EXPERIENCE WITH GRIEF.
PATIENT EXPECTATIONS.
Nursing Diagnosis
Planning
GOALS AND OUTCOMES.
SETTING PRIORITIES.
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION.
Figure 23-2 Concept map for a patient with depression following death of spouse.
Therapeutic Communication.
CARE PLAN Loss and Grief
Assessment
Nursing Diagnosis
Planning
Evaluation
Promoting Hope.
Facilitating Mourning.
ACUTE CARE
Palliative Care.
Symptom Control.
BOX 23-4 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
Maintaining Dignity and Self-Esteem.
Preventing Abandonment and Isolation.
Providing a Comfortable and Peaceful Environment.
Support for the Grieving Family.
TABLE 23-5 Promoting Comfort in the Terminally Ill Patient
Hospice Care.
BOX 23-5 PATIENT TEACHING
Preparing the Dying Patient’s Family
Outcome
Teaching Strategies
Evaluation Strategies
Care After Death.
BOX 23-6 Care of the Body After Death
Physician or Health Care Provider Responsibilities
Nurse Responsibilities
The Grieving Nurse.
Evaluation
PATIENT CARE.
TABLE 23-6 OUTCOME EVALUATION
PATIENT EXPECTATIONS.
EVALUATION
Documentation Note
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 24 Managing Patient Care
OBJECTIVES
Key Terms
CASE STUDY Jennifer
BOX 24-1 Entry-Level Staff Nurse Competencies
Professionalism
Registered Nurse Education
Advanced Education
Licensed Practical Nurse Education
Theory
Service
Autonomy
Code of Ethics
Standards of Nursing Practice
Standards of Care
TABLE 24-1 ANA Standards of Professional Performance
TABLE 24-2 ANA Standards of Practice
Building a Nursing Team
Nursing Care Delivery Models
FUNCTIONAL NURSING.
TEAM NURSING.
TOTAL PATIENT CARE.
PRIMARY NURSING.
CASE MANAGEMENT.
Decentralized Decision Making
BOX 24-2 Responsibilities of the Nurse Manager
STAFF INVOLVEMENT.
Figure 24-1 Nursing staff collaborating on practice issues.
Leadership Skills for Nursing Students
CLINICAL CARE COORDINATION.
Clinical Decisions.
Priority Setting.
Organizational Skills.
Use of Resources.
Time Management.
Evaluation.
TEAM COMMUNICATION.
DELEGATION.
BOX 24-3 The Five Rights of Delegation
Right Task
Right Circumstances
Right Person
Right Direction/Communication
Right Supervision
Quality Improvement
Figure 24-2 Framework for quality. (Data from Peters DA: Outcomes: the mainstay of a framework for quality care, J Nurs Care Qual 10[1]:61, 1995.)
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited reference
UNIT V Caring for Patients’ Basic Human Needs
CHAPTER 25 Exercise and Activity
OBJECTIVES
Key Terms
CASE STUDY Mr. Indelicato
BOX 25-1 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
Scientific Knowledge Base
Body Alignment
Body Balance
Coordinated Body Movement
Friction
Regulation of Movement
SKELETAL SYSTEM.
Joints.
Ligaments.
Tendons.
Cartilage.
SKELETAL MUSCLE.
Muscles Concerned With Movement.
Muscles Concerned With Posture.
Muscle Groups.
NERVOUS SYSTEM.
Proprioception.
Balance.
Principles of Body Mechanics
Pathological Influences on Body Alignment, Exercise, and Activity
CONGENITAL DEFECTS.
DISORDERS OF BONES, JOINTS, AND MUSCLES.
BOX 25-2 Principles of Body Mechanics
CENTRAL NERVOUS SYSTEM DAMAGE.
MUSCULOSKELETAL TRAUMA.
Nursing Knowledge Base
Growth and Development
Behavioral Aspects
Cultural and Ethnic Origin
BOX 25-3 General Guidelines for Initiating and Maintaining an Exercise Program
Critical Thinking
Synthesis
KNOWLEDGE.
EXPERIENCE.
ATTITUDES.
BOX 25-4 CULTURAL FOCUS
Implications for Practice
STANDARDS.
Nursing Process
Assessment
TABLE 25-1 FOCUSED PATIENT ASSESSMENT
BODY ALIGNMENT.
Standing.
Sitting.
Figure 25-1 Correct body alignment with standing.
Recumbent.
MOBILITY.
Range of Motion.
SYNTHESIS IN PRACTICE
Gait.
Exercise.
Activity Tolerance.
PATIENT EXPECTATIONS.
BOX 25-5 Effects of Exercise
Cardiovascular System
Pulmonary System
Metabolic System
Musculoskeletal System
Activity Tolerance
Psychosocial Factors
Nursing Diagnosis
BOX 25-6 Factors Influencing Activity Tolerance
Physiological Factors
Emotional Factors
Developmental Factors
Planning
GOALS AND OUTCOMES.
SETTING PRIORITIES.
CARE PLAN Impaired Physical Mobility
ASSESSMENT
Nursing Diagnosis
PLANNING
EVALUATION
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION.
Lifting Techniques.
ACUTE CARE
Positioning Techniques.
Fowler’s Position.
Figure 25-2 Incorrect (A) and correct (B) body position for lifting.
Supine Position.
TABLE 25-2 Devices Used for Proper Positioning
Figure 25-3 Trochanter roll.
Figure 25-4 Hand roll.
Figure 25-5 Patient using a trapeze bar.
SKILL 25-1 Moving and Positioning Patients in Bed
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 1C Fowler’s position with footboard in place.
Step 1E(8) Supine position with pillows in place.
Step 1G(2–3) Prone position with pillows in place.
Step 1G(5) Prone position with pillows supporting lower legs.
Step 1I(9) Lateral position with pillows in place.
Step 1J(7) Sandbag supporting foot in dorsiflexion.
Step 1K(3) Position nurses on each side of patient.
Step 1K(5) Move patient as a unit, maintaining proper alignment.
Step 1K(6) Place pillows along patient’s back for support.
Step 1K(7) Gently lean patient as a unit against pillows.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Prone Position.
Lateral Position.
Sims’ Position.
Transfer Techniques.
SKILL 25-2 Using Safe and Effective Transfer Techniques
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 1B(1) Side-lying position.
Step 1B(6) Nurse places arm over patient’s thighs.
Step 1B(8) Nurse shifts weight to rear leg and elevates patient.
Step 1C(5) Nurse flexes hips and knees, aligning knees with patient’s knees.
Step 1C(7) Nurse rocks patient to standing position.
Step 1C(10) Patient uses armrests for support.
Step 1C(11) Nurse eases patient into chair.
Step 1D(4) Proper positioning of lifters during three-person transfer.
Step 1E(17) Patient is raised off bed after being properly placed in the sling.
Step 1E (20) Use of hydraulic lift to lower patient into chair.
Evaluation
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Joint Mobility and Ambulation
Range-of-Motion Exercises.
BOX 25-7 CARE OF THE OLDER ADULT
Walking.
Assisting a Patient in Walking.
RESTORATIVE AND CONTINUING CARE.
Figure 25-6 Ease the patient down to the floor by bending the nurse’s knees, keeping the nurse’s back straight. (From Birchenall M, Streight ME: Mosby’s textbook for the home care aide, St. Louis, 1997, Mosby.)
Assistive Devices for Walking
Walkers.
Canes.
Figure 25-7 Patient using a walker.
Crutches.
Measuring for Crutches.
Figure 25-8 Base of quad cane.
Figure 25-9 Double adjustable Lofstrand or forearm crutch.
Crutch Gait.
BOX 25-8 PATIENT TEACHING
Crutch Safety
Outcomes
Teaching Strategies
Evaluation Strategies
Figure 25-10 Measuring crutch length.
Figure 25-11 Using the goniometer to verify correct degree of elbow flexion for crutch use.
Figure 25-12 Verifying correct distance between crutch pad and axilla.
Figure 25-13 Tripod position, basic crutch stance.
Crutch Walking on Stairs.
Figure 25-14 Four-point alternating gait. Solid feet and crutch tips show foot and crutch tip moved in each of the four phases. (Read from bottom to top).
Figure 25-15 Three-point gait with weight borne on unaffected leg. Solid foot and crutch tips show weight bearing in each phase. (Read from bottom to top).
Figure 25-16 Two-point gait with weight borne partially on each foot and each crutch advancing with opposing leg. Solid areas indicate leg and crutch tips bearing weight. (Read from bottom to top).
Figure 25-17 Ascending stairs. A, Weight is placed on crutches. B, Weight is transferred from crutches to unaffected leg on stairs. C, Crutches are aligned with unaffected leg on stairs.
Figure 25-18 Descending stairs. A, Body weight on unaffected leg. B, Body weight transferred to crutches. C, Unaffected leg aligned on stairs with crutches.
Figure 25-19 Sitting on chair. A, Both crutches are held by one hand. Patient transfers weight to crutches and unaffected leg. B, Patient grasps arm of chair with free hand and begins to lower herself into chair. C, Patient completely lowers herself into chair.
Sitting in a Chair With Crutches.
TABLE 25-3 OUTCOME EVALUTION
EVALUATION
Documentation Note
Evaluation
PATIENT CARE.
PATIENT EXPECTATIONS.
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 26 Safety
OBJECTIVES
Key Terms
CASE STUDY Mr. Gonzales
Scientific Knowledge Base
Basic Human Needs
OXYGEN.
NUTRITION.
TEMPERATURE.
HUMIDITY.
Physical Hazards
Pathogen Transmission
Nursing Knowledge Base
Developmental Level
INFANT, TODDLER, AND PRESCHOOLER.
SCHOOL-AGE CHILD.
ADOLESCENT.
ADULT.
OLDER ADULT.
Other Risk Factors
LIFESTYLE.
IMPAIRED MOBILITY.
SENSORY IMPAIRMENTS.
COGNITIVE IMPAIRMENTS.
SAFETY AWARENESS.
Risks in the Health Care Agency
FALLS.
BOX 26-1 JCAHO 2005 National Patient Safety Goals for Hospitals
BOX 26-2 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
BOX 26-3 Fall Assessment Tool
PATIENT-INHERENT ACCIDENTS.
PROCEDURE-RELATED ACCIDENTS.
EQUIPMENT-RELATED ACCIDENTS.
Critical Thinking in Patient Care
Synthesis
KNOWLEDGE.
EXPERIENCE.
ATTITUDES.
TABLE 26-1 FOCUSED PATIENT ASSESSMENT
STANDARDS.
Nursing Process
Assessment
BOX 26-4 Home Hazard Assessment
SYNTHESIS IN PRACTICE
BOX 26-5 CARE OF THE OLDER ADULT
Physical Assessment Findings in the Older Adult That Increase the Risk of Accidents
Musculoskeletal Changes
Nervous System Changes
Sensory Changes
Genitourinary Changes
PATIENT EXPECTATIONS.
Nursing Diagnosis
Planning
GOALS AND OUTCOMES.
CARE PLAN Risk for Injury
Assessment
Nursing Diagnosis
Planning
EVALUATION
SETTING PRIORITIES.
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION.
DEVELOPMENTAL INTERVENTIONS
Infant, Toddler, and Preschooler.
School-Age Child.
Adolescent.
Adult.
Older Adult.
ENVIRONMENTAL INTERVENTIONS.
General Preventive Measures.
BOX 26-6 PATIENT TEACHINING
Outcome
Teaching Strategies
Evaluation Strategies
BOX 26-7 CARE OF THE OLDER ADULT
TABLE 26-2 Measures to Prevent Falls in Older Adults
Specific Safety Concerns.
Falls.
Restraints.
BOX 26-8 Alternatives to Restraints
SKILL 26-1 Use of Restraints
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 5a Vest restraint securely attached to bed frame. (Courtesy JT Posey Co, Arcadia, Calif.)
Step 5b Roll belt restraint tied to the bed frame and to an area that does not cause the restraint to tighten when the side rail is raised or lowered. (From Sorrentino SA: Mosby’s textbook for nursing assistants, ed 6, St. Louis, 2004, Mosby.)
Step 5c Placement of wrist restraint.
Step 5d Mitten restraint.
Step 6 Tie restraint strap to bed frame.
Step 7 Straps of vest restraint secured at back of chair.
Step 8 The Posey quick-release tie. (Courtesy JT Posey Co, Arcadia, Calif.)
Step 9 Place two fingers under restraint to check tightness.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Side Rails.
Figure 26-1 Behavioral restraint flow sheet. (Courtesy Holy Family Hospital and Medical Center, Methuen, Mass.)
Fires.
Poisoning.
Bioterrorism.
BOX 26-9 PROCEDURAL GUIDELINES FOR
Intervening in Accidental Poisoning
Electrical Hazards.
BOX 26-10 Mercury Spill Cleaup Procedure
Evaluation
PATIENT CARE.
PATIENT EXPECTATIONS.
TABLE 26-3 OUTCOME EVALUTION
EVALUATION
Documentation Note
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 27 Hygiene
OBJECTIVES
Key Terms
CASE STUDY Mrs. Foster
Scientific Knowledge Base
TABLE 27-1 Functions of the Skin and Implications for Care
Skin
Feet and Nails
Oral Cavity and Teeth
Hair
Care of the Eyes, Ears, and Nose
Nursing Knowledge Base
Body Image
Social Practices
Personal Preferences
BOX 27-1 CULTURAL FOCUS
Implications for Practice
Socioeconomic Status
Cultural Variables
Health Beliefs and Motivation
Physical Condition
Critical Thinking in Patient Care
Synthesis
KNOWLEDGE.
EXPERIENCE.
ATTITUDES.
STANDARDS.
Nursing Process
Assessment
ASSESSMENT OF THE SKIN.
TABLE 27-2 FOCUSED PATIENT ASSESSMENT
SYNTHESIS IN PRACTICE
Developmental Changes.
TABLE 27-3 Common Skin Problems
Cultural Factors.
BOX 27-2 CARE OF THE OLDER ADULT
Skin Changes With Aging
Assessment of Self-Care Ability.
ASSESSMENT OF FEET AND NAILS.
BOX 27-3 Skin Assessment for the Patient With Darkly Pigmented Intact Skin
ASSESSMENT OF THE MOUTH.
ASSESSMENT OF HAIR.
TABLE 27-4 Common Foot and Nail Problems
TABLE 27-5 Risk Factors for Hygiene Problems
BOX 27-4 Common Oral Problems
Dental Caries (Cavities)
Periodontal Disease (Pyorrhea)
Other Problems
Cultural Practices.
ASSESSMENT OF EYES, EARS, AND NOSE.
BOX 27-5 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
Use of Sensory Aids.
PATIENTS AT RISK FOR HYGIENE PROBLEMS.
TABLE 27-6 Hair and Scalp Problems
BOX 27-6 Assessment of Hair Care
Physical Changes
Self-Care Ability
Hair-Care Practices
PATIENT EXPECTATIONS.
Nursing Diagnosis
Planning
GOALS AND OUTCOMES.
SETTING PRIORITIES.
CARE PLAN Skin Care
Assessment
Nursing Diagnosis
Planning
Interventions
Rationale
EVALUATION
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION, ACUTE CARE, AND RESTORATIVE AND CONTINUING CARE.
BATHING AND SKIN CARE.
BOX 27-7 Types of Baths
Perineal Care.
BOX 27-8 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
SKILL 27-1 Bathing and Perineal Care
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 1e(3) A, Remove patient’s gown. B, Remove IV from pole, C, Slide IV tubing and bag through arm of patient’s gown. D, Rehang IV bag.
Step 1h(2) Steps for folding washcloth to form a mitt.
Step 1h(3) Wash eye from inner to outer canthus.
Step 1i(2) Positioning the patient’s arm to wash the axilla.
Step 1m(3) Wash patient’s leg.
Step 1o(2)(a) Drape the patient for perineal care.
Step 1o(2)(d) Cleanse from perineum to rectum (front to back).
Step 1o (3)(d) Use circular motion to cleanse tip of penis.
Step 1q(4) Cleanse buttocks from front to back.
Step 2a Bag Bath. A, Patient uses individual wipes to bathe. B, Bag Bath package.
Step 11h Shower seat for patient safety.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Back Rub.
NAIL AND FOOT CARE.
SKILL 27-2 Performing Nail and Foot Care
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 8 Clean under fingernails with orange stick.
Step 9 Clip fingernails straight across. Use a nail clipper.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
ORAL HYGIENE.
Brushing.
SKILL 27-3 Providing Oral Hygiene
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 5 Direction for toothbrush placement. A, Forty-five-degree angle brushes gum line. B, Parallel position brushes biting surfaces. C, Lateral position brushes side of teeth.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Oral Hygiene for the Unconscious and/or Orally Intubated (Artificial Airway) Patient.
Flossing.
Denture Care.
SKILL 27-4 Performing Mouth Care for an Unconscious or Debilitated Patient
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 8 Insertion of oral airway.
Step 12 Application of water-soluble moisturizer to lips.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
BOX 27-9 PROCEDURAL GUIDELINES FOR
Cleaning Dentures
Step 4 Brush surface of dentures.
Hair Care
Brushing and Combing.
Shampooing.
Shaving.
Mustache and Beard Care.
Hair and Scalp Care.
CARE OF EYES, EARS, NOSE.
Basic Eye Care.
BOX 27-10 PROCEDURAL GUIDELINES FOR
Shampooing Hair of Bed-Bound Patient
Step 4 Patient positioned for shampoo.
Step 9 Rinsing of hair.
Eyeglasses.
Contact Lenses.
Ear Care.
Figure 27-1 Apply new fixative device over feeding tube.
Nose Care.
Evaluation
PATIENT CARE.
PATIENT EXPECTATIONS.
Patient’s Room Environment
TABLE 27-7 OUTCOME EVALUATION
Maintaining Comfort
EVALUATION
Documentation Note
BOX 27-11 PATIENT TEACHING
Outcome
Teaching Strategies
Evaluation Strategies
Room Equipment
BEDS.
Figure 27-2 A, Footboard. B, Foot boot. C, Foot boot with lower leg extension.
Bed Making.
Linens.
TABLE 27-8 Common Bed Positions
BOX 27-12 PROCEDURAL GUIDELINES FOR
Making an Unoccupied Bed
Step 21 Modified mitered corner.
SKILL 27-5 Making an Occupied Bed
Delegation Considerations
Equipment (Figure 27-3)
Figure 27-3 Equipment for making an occupied bed.
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 11 Old linen tucked under patient.
Step 13b Clean linen applied to bed.
Step 14c Top edge of sheet picked up.
Step 14d Sheet on top of mattress in a triangular fold.
Step 14e Lower edge of sheet tucked under mattress.
Step 14f A and B, Triangular fold placed over side of mattress. C, Linen tucked under mattress.
Step 16 Optional drawsheet.
Step 19 Assisting patient to roll over folds of linen.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 28 Oxygenation
OBJECTIVES
Key Terms
CASE STUDY Mr. King
Scientific Knowledge Base
Cardiopulmonary Physiology
Structure and Function
REGULATION OF BLOOD FLOW.
Figure 28-1 Schematic representation of blood flow through the heart. Arrows indicate direction of flow. (From Lewis SM and others: Medical surgical nursing: assessment and management of clinical problems, ed 6, St. Louis, 2004, Mosby.)
CONDUCTION SYSTEM.
Figure 28-2 Conduction system of the heart. AV, Atrioventricular; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; SA, sinoatrial. (From Lewis SM and others: Medical surgical nursing: assessment and management of clinical problems, ed 6, St. Louis, 2004, Mosby.)
TABLE 28-1 Regulation of Blood Flow
Figure 28-3 Normal ECG waveform. (Modified from Canobbio MM: Cardiovascular disorders, St. Louis, 1990, Mosby.)
Gas Exchange
STRUCTURE AND FUNCTION.
Figure 28-4 Structures of the pulmonary system. The circles denotes the alveoli. (Modified from Wilson SF, Thompson JM: Mosby’s clinical nursing series: respiratory disorders, St. Louis, 1990, Mosby.)
REGULATION OF RESPIRATION.
OXYGEN TRANSPORT.
BOX 28-1 Neural and Chemical Regulation of Respiration
Neural Regulation
Cerebral Cortex
Medulla Oblongata
Chemical Regulation
Chemoreceptors
CARBON DIOXIDE TRANSPORT.
Factors Affecting Oxygenation
DECREASED OXYGEN-CARRYING CAPACITY.
DECREASED INSPIRED OXYGEN CONCENTRATION.
HYPOVOLEMIA.
INCREASED METABOLIC RATE.
CONDITIONS AFFECTING CHEST WALL MOVEMENT.
Musculoskeletal Abnormalities.
Nervous System Diseases.
Trauma.
Chronic Disease.
Alterations in Cardiac Functioning
DISTURBANCES IN CONDUCTION.
DECREASED CARDIAC OUTPUT.
MYOCARDIAL ISCHEMIA.
LEFT-SIDED HEART FAILURE.
RIGHT-SIDED HEART FAILURE.
IMPAIRED VALVULAR FUNCTION.
Alterations in Respiratory Functioning
HYPERVENTILATION.
HYPOVENTILATION.
TABLE 28-2 Common Basic Cardiac Dysrhythmias
HYPOXIA.
Nursing Knowledge Base
Developmental Factors
PREMATURE INFANTS.
INFANTS AND TODDLERS.
SCHOOL-AGE CHILDREN AND ADOLESCENTS.
YOUNG AND MIDDLE-AGE ADULTS.
OLDER ADULTS.
Lifestyle Factors
NUTRITION.
EXERCISE.
TABLE 28-3 Changes in the Aging Cardiopulmonary System
CIGARETTE SMOKING.
SUBSTANCE ABUSE.
ANXIETY AND STRESS.
Critical Thinking
Synthesis
KNOWLEDGE.
EXPERIENCE.
ATTITUDES.
STANDARDS.
Nursing Process
Assessment
BOX 28-2 Interview Questions for Assessing Cardiopulmonary Risk Factors
NURSING HISTORY.
Risk Factors.
Fatigue.
SYNTHESIS IN PRACTICE
Pain.
Breathing Patterns.
Respiratory Infections.
Medication Use.
TABLE 28-4 Inspection of Cardiopulmonary Status
PATIENT EXPECTATIONS.
PHYSICAL EXAMINATION.
TABLE 28-5 Assessment of Abnormal Chest Wall Movement
TABLE 28-6 Respiratory Patterns
DIAGNOSTIC TESTS.
TABLE 28-7 FOCUSED PATIENT ASSESSMENT
BOX 28-3 Tuberculosis Skin Testing
Nursing Diagnosis
Planning
GOALS AND OUTCOMES.
CARE PLAN Oxygenation
Assessment
Planning
Evaluation
SETTING PRIORITIES.
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION.
Influenza and Pneumococcal Vaccine.
BOX 28-4 PATIENT TEACHING
Cardiopulmonary Health Promotion
Outcome
Teaching Strategies
Evaluation Strategies
Environmental Modifications.
BOX 28-5 CARE OF THE OLDER ADULT
Care of the Older Adult
ACUTE CARE.
Dyspnea Management.
Maintenance of a Patent Airway.
Coughing Techniques.
Cascade Cough.
Huff Cough.
Quad Cough.
Suctioning Techniques.
SKILL 28-1 Suctioning
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 4a(2) Pouring sterile saline into tray.
Step 7 Attaching catheter to suction
Step 9b(2) Pathway for nasotracheal catheter progression.
Step 9c(3) Suctioning tracheostomy.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
BOX 28-6 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
Oropharyngeal and Nasopharyngeal Suctioning.
Orotracheal and Nasotracheal Suctioning.
Tracheal Suctioning.
Figure 28-5 Oropharyngeal suctioning. (From Perry AG, Potter PA: Clinical nursing skills and techniques, ed 6, St. Louis, 2006, Mosby.)
Figure 28-6 Ballard tracheal care closed suction.
Artificial Airways.
Oral Airway.
BOX 28-7 PROCEDURAL GUIDELINES FOR
Closed (In-Line) Suctioning
Step 4 a Suctioning tracheostomy with closed system suction catheter.
Figure 28-7 Artificial oral airways.
Tracheal Airway.
Mobilization of Pulmonary Secretions.
Hydration.
Humidification.
Nebulization.
Maintenance or Promotion of Lung Expansion.
Positioning.
Incentive Spirometry.
Chest Physiotherapy.
BOX 28-8 Assessment Criteria for Chest Physiotherapy
Chest Percussion.
Vibration.
Figure 28-8 Hand position for chest wall percussion during physiotherapy.
Figure 28-9 Chest wall percussion, alternating hand motion against the patient’s chest wall.
Postural Drainage.
Chest Tubes.
TABLE 28-8 Positions for Postural Drainage
Special Considerations.
Chest Tube Removal.
SKILL 28-2 Care of Patients With Chest Tubes
Delegation Considerations
Equipment
Figure 28-10 Disposable waterless chest drainage system with suction.
ASSESSMENT
PLANNING
TABLE 28-9 Problem Solving With Chest Tubes
IMPLEMENTATION
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Noninvasive Ventilation.
Figure 28-11 Mask suitable for either continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) device.
BOX 28-9 Problems Associated With CPAP
SKILL 28-3 Care of the Patient With Noninvasive Ventilation
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 2 A, Mask sizing. B, Full face mask with quick-release restraining straps.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Maintenance and Promotion of Oxygenation.
Safety Precautions With Oxygen Therapy.
Oxygen Supply.
Methods of Oxygen Delivery.
Home Oxygen.
Restoration of Cardiopulmonary Functioning.
Cardiopulmonary Resuscitation.
RESTORATIVE AND CONTINUING CARE.
Respiratory Muscle Training.
Breathing Exercises.
TABLE 28-10 Oxygen Delivery Systems
Simple face mask.
Plastic face mask with inflated reservoir bag.
Venturi mask.
BOX 28-10 Automated External Defibrillator
EVALUATION
Documentation Note
TABLE 28-11 OUTCOME EVALUATION
Evaluation
PATIENT CARE.
PATIENT EXPECTATIONS.
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 29 Sleep
OBJECTIVES
Key Terms
CASE STUDY Walter Murphy
Scientific Knowledge Base
Sleep and Rest
Physiology of Sleep
CIRCADIAN RHYTHMS.
SLEEP-WAKE REGULATION.
Figure 29-1 The RAS and BSR control sensory input, intermittently activating and suppressing the brain’s higher centers to control sleep and wakefulness.
Stages of Sleep.
Sleep Cycle.
BOX 29-1 Stages of the Sleep Cycle
NREM Stage 1
NREM Stage 2
NREM Stage 3
NREM Stage 4
REM Sleep
Figure 29-2 The stages of the adult sleep cycle.
Functions of Sleep
DREAMS.
Nursing Knowledge Base
Normal Sleep Requirements and Patterns
Factors Affecting Sleep
PHYSICAL ILLNESS.
DRUGS AND SUBSTANCES.
LIFESTYLE.
TABLE 29-1 Illnesses and Conditions That Can Alter Sleep
BOX 29-2 Effect of Medications and Other Substances on Sleep
Hypnotics
Diuretics (Administered Late in the Day)
Antidepressants and Stimulants
Alcohol
Caffeine
Beta-Adrenergic Blockers
Benzodiazepines
Narcotics (Opiates)
Antihistamines
Nasal Decongestants
USUAL SLEEP PATTERNS AND EXCESSIVE DAYTIME.
EMOTIONAL STRESS.
ENVIRONMENT.
SOUND.
EXERCISE AND FATIGUE.
FOOD AND CALORIC.
Sleep Disorders
INSOMNIA.
SLEEP APNEA.
BOX 29-3 Classification of Select Sleep Disorders
Insomnias
Sleep-Related Breathing Disorder
Central Sleep Apnea Syndromes
Obstructive Sleep Apnea Syndromes
Hypersomnias Not Due To a Sleep-Related Breathing Disorder
Parasomnias
Disorders of Arousal
Parasomnias Usually Associated With REM Sleep
Other Parasomnias
Circadian Rhythm Sleep Disorders
Primary Circadian Rhythm Sleep Disorders
Behaviorally Induced Circadian Rhythm Sleep Disorders
Sleep-Related Movement Disorders
Isolated Symptoms, Apparently Normal Variants, and Unresolved Issues
Other Sleep Disorders
NARCOLEPSY.
SLEEP DEPRIVATION.
PARASOMNIAS.
Critical Thinking
Synthesis
KNOWLEDGE.
EXPERIENCE.
ATTITUDES.
STANDARDS.
Nursing Process
Assessment
SOURCES FOR SLEEP ASSESSMENT.
SLEEP HISTORY.
Sleep Pattern.
Description of Sleeping Problems.
TABLE 29-2 FOCUSED PATIENT ASSESSMENT
Sleep Log.
Physical Illness.
Current Life Events.
Emotional and Mental Status.
Bedtime Routines.
Bedtime Environment.
Behaviors of Sleep Deprivation.
SYNTHESIS IN PRACTICE
PATIENT EXPECTATIONS.
Nursing Diagnosis
Planning
GOALS AND OUTCOMES.
SETTING PRIORITIES.
CASE STUDY Disturbed Sleep Pattern
Assessment
Nursing Diagnosis
Planning
Evaluation
BOX 29-4 CARE OF THE OLDER ADULT
Sleep-Wake Pattern
Environment
Medications
Diet
Physiological/Illness Factors
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION.
Environmental Controls.
BOX 29-5 PATIENT TEACHING
Outcome
Teaching Strategies
Evaluation Strategies
Promoting Bedtime Routines.
Promoting Comfort.
Promoting Activity.
BOX 29-6 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
Stress Reduction.
BOX 29-7 CULTURAL FOCUS
Implications for Practice
Bedtime Snacks.
Pharmacological Approaches to Promoting Sleep.
Managing Specific Sleep Disturbances.
ACUTE CARE.
Managing Environmental Stimuli.
Safety.
Comfort Measures.
RESTORATIVE AND CONTINUING CARE.
Maintaining Activity.
TABLE 29-3 OUTCOME EVALUATION
Reducing Sleep Disruption.
Evaluation
PATIENT CARE.
EVALUATION
Documentation Note
PATIENT EXPECTATIONS.
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 30 Promoting Comfort
OBJECTIVES
Key Terms
CASE STUDY Mrs. Ellis
Scientific Knowledge Base
Comfort
Nature of Pain
BOX 30-1 Common Biases and Misconceptions About Pain
Physiology of Pain
TRANSDUCTION.
TRANSMISSION.
PERCEPTION.
MODULATION.
Figure 30-1 Spinothalamic pathway that conducts pain stimuli to the brain.
Figure 30-2 Protective pain reflex. Sensory impulse directly stimulates motor nerves, bypassing the brain, causing withdrawal from pain stimulus.
BOX 30-2 Neurophysiology of Pain: Neurotransmitters
Excitatory Neurotransmitters
Substance P
Serotonin
Prostaglandins
Inhibitory Neurotransmitters
Endorphins, Enkephalins, and Dynorphins
Bradykinin
Neurotransmitters.
TABLE 30-1 Physiological Reactions to Acute Pain
Gate Control Theory of Pain.
Physiological Responses.
Behavioral Responses.
Nursing Knowledge Base
Acute and Chronic Pain
ACUTE PAIN.
CHRONIC PAIN.
Factors Influencing Pain
AGE.
GENDER.
CULTURE.
MEANING OF PAIN.
ATTENTION.
ANXIETY.
DEPRESSION.
FATIGUE.
PREVIOUS EXPERIENCE.
COPING STYLE.
BOX 30-3 CULTURAL FOCUS
Implications for Practice
FAMILY AND SOCIAL SUPPORT.
Critical Thinking
Synthesis
KNOWLEDGE.
EXPERIENCE.
ATTITUDES.
STANDARDS.
Nursing Process
Assessment
SYNTHESIS IN PRACTICE
TABLE 30-2 FOCUSED PATIENT ASSESSMENT
TABLE 30-3 Implications of Pain Assessment for Nursing Interventions
BOX 30-4 Routine Clinical Approach to Pain Assessment and Management “ABCDE”
PATIENT’S EXPRESSION OF PAIN.
TABLE 30-4 Classification of Pain by Quality
CHARACTERISTICS OF PAIN.
Precipitating Factors.
Quality.
Figure 30-3 Sample pain scales. A, Numerical. B, Descriptive. C, Visual analog.
Relieving Factors.
Region Location.
Severity.
BOX 30-5 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
Figure 30-4 Wong-Baker FACES Pain Rating Scale. (From Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, and Schwartz P: Wong’s essentials of pediatric nursing, ed 6, St. Louis, 2001, Copyrighted by Mosby. Reprinted by permission.)
Timing (Onset, Duration, and Pattern).
Effect of Pain on Patient.
CONCOMITANT SYMPTOMS.
PATIENT EXPECTATIONS.
BOX 30-6 Assessing the Influence of Pain on Activities of Daily Living
Sleep
Hygiene
Eating
Sexual Functioning
Home Management and Work Activities
Social Activities
DOCUMENTATION.
Nursing Diagnosis
Planning
Goals and Outcomes.
CARE PLAN Chronic Pain
Assessment
Nursing Diagnosis
Planning
Evaluation
SETTING PRIORITIES.
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION.
Maintaining Wellness.
BOX 30-7 Guidelines for Individualized Pain Therapy
Nonpharmacological Pain-Relief Measures.
Reducing Pain Reception and Perception.
Anticipatory Guidance.
Distraction.
Cutaneous Stimulation.
Relaxation.
BOX 30-8 Procedural Guidelines
Massage
Figure 30-6 Back massage pattern.
ACUTE CARE.
Pharmacological Pain Therapy.
Analgesics.
Patient-Controlled Analgesia.
BOX 30-9 Nursing Principles for Administering Analgesics
Know the Patient’s Previous Response to Analgesics
Select Proper Medications When More Than One Is Ordered
Know the Accurate Dosage
Assess the Right Time and Interval for Administration
Choose the Right Route
BOX 30-10 CARE OF THE OLDER ADULT
Figure 30-7 A, PCA pump with syringe chamber. B, Patient learns to use PCA pump.
Placebo Effect.
BOX 30-11 PATIENT TEACHING
Preparation for Patient-Controlled Analgesia
Outcome
Teaching Strategies
Evaluation Strategies
Local Anesthetics.
Epidural Analgesia.
Figure 30-8 A, Epidural catheter inserted into L4 and L5 space. B, Anatomical drawing of epidural space.
TABLE 30-5 Nursing Care of Patients With Epidural Infusions
Invasive Pain-Relieving Devices.
Patients With Cancer Pain.
Figure 30-9 Flowchart: continuing pain management in patients with cancer. (From Jacox A and others: Management of cancer pain, Clinical practice guideline No. 9, AHCPR Pub No. 94-0592, Rockville Md, March 1994, AHCPR, USDHHS, PHS.)
Figure 30-10 WHO analgesic ladder is a three-step approach to using drugs in cancer pain management. ±adjuvant, With or without adjuvant medications. (From World Health Organization: Cancer pain relief and palliative care, Report of a WHO expert committee, WHO Technical Report Series No. 804, Geneva, Switzerland, 1990, WHO.)
RESTORATIVE AND CONTINUING CARE.
Opioid Infusions.
BOX 30-12 PATIENT TEACHING
Ambulatory Infusion Pumps
Outcome
Teaching Strategies
Evaluation Strategies
Palliative Care.
Hospice.
End-of-Life Care.
TABLE 30-6 OUTCOME EVALUATION
EVALUATION
Documentation Note
Evaluation
PATIENT CARE.
PATIENT EXPECTATIONS.
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 31 Nutrition
OBJECTIVES
Key Terms
CASE STUDY Mrs. Gonzalez
Scientific Knowledge Base
Principles of Nutrition
NUTRIENTS.
Carbohydrates.
Proteins.
Lipids.
Vitamins.
Minerals.
Water.
DIGESTION.
ABSORPTION.
METABOLISM.
STORAGE.
ELIMINATION.
Foundations of Nutrition
U.S. DEPARTMENT OF AGRICULTURE FOOD GUIDE PYRAMID.
DIETARY GUIDELINES FOR AMERICANS.
DIETARY REFERENCE INTAKES.
Figure 31-1 Sample food guide pyramid for adults. (From U.S. Department of Agriculture: Center for Nutrition Policy and Promotion, April 2005, http://www.MyPyramid.gov.)
BOX 31-1 Dietary Guidelines for Americans
OTHER DIETARY GUIDELINES.
Nursing Knowledge Base
BOX 31-2 Examples of Nutrition Objectives from Healthy People 2010
Alternative Food Patterns
BOX 31-3 Culture and Religious Factors Influencing Dietary Patterns
Culture
Religion
Developmental Needs
Critical Thinking
Synthesis
KNOWLEDGE.
EXPERIENCE.
ATTITUDES.
STANDARDS.
SYNTHESIS IN PRACTICE
Nursing Process
Assessment
SCREENING.
NUTRITION ASSESSMENT.
Diet History.
Medication History.
Figure 31-2 Mini Nutritional Assessment (MNA). (Reprinted with permission by Nestle Nutrition.)
TABLE 31-1 FOCUSED PATIENT ASSESSMENT
BOX 31-4 Information Contained in a Diet History
PATIENTS AT RISK FOR NUTRITIONAL PROBLEMS.
PHYSICAL EXAMINATION.
ANTHROPOMETRY.
Figure 31-3 Nutrition Risk Assessment (NRA). (Reprinted with permission by Consultant Dietitians in Health Care Facilities Practice Group of the American Dietetic Association.)
BOX 31-5 Indicators of Risk for Malnutrition in Adults
TABLE 31-2 Physical Signs of Nutritional Status
BOX 31-6 Causes of Dysphagia
DYSPHAGIA.
Dysphagia Screening.
LABORATORY VALUES.
SKILL 31-1 Aspiration Precautions
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
PATIENT EXPECTATIONS.
Nursing Diagnosis
Planning
GOALS AND OUTCOMES.
SETTING PRIORITIES.
CARE PLAN Nutrition
Assessment
Nursing Diagnosis
Planning
Evaluation
CONTINUITY OF CARE.
TABLE 31-3 Hospital Therapeutic Diets
Implementation
HEALTH PROMOTION.
TABLE 31-4 Food-Borne Illness
ACUTE CARE.
BOX 31-7 PATIENT TEACHING
Outcome
Teaching Strategies
Providing a Comfortable Environment.
Assisting Patients With Feeding.
Dysphagia.
Dysphagia Treatment.
Diet Management.
Patient Positioning.
Disabled Patients.
Enteral Tube Feedings.
BOX 31-8 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
Figure 31-4 Percutaneous endoscopic gastrostomy tube.
Feeding Tube Insertion.
Figure 31-5 Endoscopic insertion of jejunostomy tube.
Gastrostomy/Jejunostomy Tube Feedings.
Providing PN.
SKILL 31-2 Intubating the Patient With a Nasogastric or Nasointestinal Feeding Tube
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
Step 5 Determine length of tube you will insert.
IMPLEMENTATION
Step 4 NG tube inserted through nose and esophagus into stomach.
Step 12a(3) Wrapping tape to anchor nasoenteral tube.
Step 12b(2) Slip connector around feeding tube.
Step 12b(1) Applying tube fixation patch to bridge of nose.
Step 13 Fastening feeding tube to patient’s gown.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
SKILL 31-3 Verifying Feeding Tube Placement
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 4 A, Obtaining gastric aspirate. B, Typical color of aspirates from stomach, intestine, and airway. (Used with permission from Metheny NA and others: pH, color, and feeding tubes, RN 61(1):25, 1998.)
Step 5 Compare color on test strip with color on pH chart.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
SKILL 31-4 Administering Enteral Nutrition via a Feeding Tube
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
Step 3d Pour formula into feeding container.
Step 3 Check for gastric residual (small-bore tube).
IMPLEMENTATION
Step 5a(3) Fill syringe with formula.
Step 5a(4) Administer feeding.
Step 5b(3) Connect tubing through infusion pump.
BOX 31-9 Advancing the Rate of Tube Feeding
Intermittent
Continuous
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
BOX 31-10 PROCEDURAL GUIDELINES FOR
Administering Enteral Feedings via Gastrostomy or Jejunostomy Tube
Initiating PN.
Caring for the Patient Receiving PN.
TABLE 31-5 OUTCOME EVALUATION
RESTORATIVE AND CONTINUING CARE
Diet Therapy in Disease Management.
Home Care.
Evaluation
PATIENT CARE.
EVALUATION
Documentation Note
PATIENT EXPECTATIONS.
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 32 Urinary Elimination
OBJECTIVES
Key Terms
CASE STUDY Mrs. Vallero
Scientific Knowledge Base
Urinary Elimination
KIDNEYS.
URETERS.
BLADDER.
URETHRA.
Act of Urination
Factors Influencing Urination
Common Urinary Elimination Problems
URINARY RETENTION.
BOX 32-1 Factors Influencing Urinary Elimination
Growth and Development
Sociocultural Factors
Psychological Factors
Personal Habits
Muscle Tone
Figure 32-1 Bedside commode. (From Sorrentino S: Mosby’s textbook for nursing assistants, St. Louis, 2004, Mosby.)
Fluid Intake
Pathological Conditions
Surgical Procedures
Medications
Diagnostic Examinations
TABLE 32-1 Urinary Disorders
URINARY TRACT INFECTIONS.
URINARY INCONTINENCE.
TABLE 32-2 Types of Urinary Incontinence
Urinary Diversions
Figure 32-2 Types of incontinent and continent urinary diversions.
Nursing Knowledge Base
Infection Control and Hygiene
Developmental Considerations
Psychosocial Implications
BOX 32-2 CULTURAL FOCUS
Critical Thinking
Synthesis
KNOWLEDGE.
EXPERIENCE.
ATTITUDES.
STANDARDS.
Nursing Process
Assessment
NURSING HISTORY.
Pattern of Urination.
Symptoms of Urinary Alterations.
TABLE 32-3 Common Symptoms of Urinary Alterations
TABLE 32-4 FOCUSED PATIENT ASSESSMENT
Factors Affecting Urination.
PATIENT EXPECTATIONS.
PHYSICAL ASSESSMENT
Skin and Mucosa.
Kidneys.
Bladder.
Urethral Meatus.
Assessment of Urine.
Intake and Output.
Characteristics.
Figure 32-3 Urine hat.
Figure 32-4 Urometer. (Courtesy Michael Gallager, RN, BSN, MSN, OSF Saint Francis Medical Center, Peoria, Ill.)
Color.
Clarity.
Odor.
LABORATORY AND DIAGNOSTIC TESTING.
Specimen Collection.
Urinalysis Sample.
Clean-Voided or Midstream Specimen.
TABLE 32-5 Routine Urinalysis Values
Sterile Specimen.
Twenty-Four-Hour Urine Specimen.
Common Urine Tests.
Specific Gravity.
Urine Culture.
Diagnostic Examinations.
Noninvasive Procedures
Abdominal Roentgenogram.
Intravenous Pyelogram.
Renal Scan.
Computerized Axial Tomography.
Renal Ultrasound.
Invasive Procedures
Endoscopy.
SYNTHESIS IN PRACTICE
Arteriogram (Angiogram).
Urodynamic Testing.
Nursing Diagnosis
Planning
GOALS AND OUTCOMES.
SETTING PRIORITIES.
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION.
CARE PLAN Urinary Retention
Assessment
Nursing Diagnosis
Planning
Evaluation
Normal Micturition
Stimulating the Micturition Reflex.
BOX 32-3 Urinary Elimination Health Promotion/Restoration Activities
Adequate Hydration
Micturition Habits
Personal Hygiene
Complete Bladder Emptying
Infection Prevention
Skin Integrity
BOX 32-4 PATIENT TEACHING
Outcome
Teaching Strategies
Evaluation Strategies
Figure 32-5 Types of male urinals.
Maintaining Elimination Habits.
Maintaining Adequate Fluid Intake.
BOX 32-5 CARE OF THE OLDER ADULT
Promotion of Bladder Emptying.
TABLE 32-6 Treatment Options for Incontinence
Strengthening Pelvic Floor Muscles.
Manual Bladder Compression.
Drug Therapy.
ACUTE CARE.
Catheterization.
BOX 32-6 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
Types of Catheterization.
Indications for Use.
Catheter Insertion.
Closed Drainage Systems.
SKILL 32-1 Inserting a Straight or Indwelling Catheter
Delegation Considerations
Equipment
Figure 32-6 Indwelling and straight urinary catheters
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 8A(1) Draping female for catheterization.
Step 8B(1) Draping male for catheterization.
Step 16 Inserting fluid to test catheter balloon.
Step 20A(2) Cleansing technique (female).
Step 20 B(2) Cleansing technique (male).
Step 22A(1) Inserting the catheter.
Step 22B(1) Position of penis perpendicular to body for catheter insertion.
Step 25 A, Inflating the balloon (indwelling catheter) B, Position of balloon in bladder.
Step 26 Drainage bag below level of bladder.
Step 27A(1) Securing the female indwelling catheter.
Step 27B(1) Securing the male indwelling catheter.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Routine Catheter Care.
Alternatives to Urethral Catheterization.
Figure 32-7 Cleansing the catheter during catheter care. (From Sorrentino S: Mosby’s textbook for nursing assistants, St. Louis, 2004, Mosby.)
Figure 32-8 Placement of suprapubic catheter above the symphysis pubis.
BOX 32-7 Procedural Guidelines for Applying a Condom Catheter
Step 10 Distance between end of penis and tip of condom.
Step 11 Apply elastic tape in a spiral fashion to secure the condom catheter to the penis.
Figure 32-9 Potential sites for introduction of infection.
RESTORATIVE AND CONTINUING CARE.
Preventing Infection.
Promotion of Comfort.
BOX 32-8 Tips for Preventing Infection in Catheterized Patients
Maintenance of Skin Integrity.
TABLE 32-7 OUTCOME EVALUATION
Evaluation
PATIENT CARE.
EVALUATION
Documentation Note
PATIENT EXPECTATIONS.
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 33 Bowel Elimination
OBJECTIVES
Key Terms
CASE STUDY Mr. Gutierrez
Scientific Knowledge Base
Anatomy and Physiology of the Gastrointestinal Tract
MOUTH.
ESOPHAGUS.
STOMACH.
SMALL INTESTINE.
Figure 33-1 Segmented and peristaltic waves.
LARGE INTESTINE.
Figure 33-2 Divisions of the large intestine.
ANUS.
DEFECATION.
Nursing Knowledge Base
Common Bowel Elimination Problems
BOX 33-1 Factors Influencing Bowel Elimination
Age
Diet
Position During Defecation
Pregnancy
Diagnostic Tests
Fluid Intake
Activity
Psychological Factors
Personal Habits
Pain
Medications
Surgery and Anesthesia
CONSTIPATION.
BOX 33-2 Common Causes of Constipation
IMPACTION.
DIARRHEA.
INCONTINENCE.
FLATULENCE.
HEMORRHOIDS.
TABLE 33-1 Conditions That Cause Diarrhea
BOWEL DIVERSIONS.
Ostomies.
Figure 33-3 A, A temporary transverse loop colostomy supported by a loop ostomy bridge. B, Abdominal view of loop colostomy in transverse colon. (A courtesy Hollister Incorporated, Libertyville, Ill. Permission to use this copyrighted material has been granted by the owner, Hollister Incorporated. B from Hampton BG, Bryant RA: Ostomies and continent diversions: nursing management, St. Louis, 1992, Mosby.)
Figure 33-4 End colostomy. A, Cross-sectional view of end stoma. B, Cross-sectional view of end stoma with distal bowel oversewn and secured to anterior peritoneum at stoma site. C, Sigmoid colostomy. Distal bowel is oversewn and left in place to create Hartmann’s pouch. (From Hampton BG, Bryant RA: Ostomies and continent diversions: nursing management, St. Louis, 1992, Mosby.)
Alternative Procedures.
Figure 33-5 Double-barrel colostomy. A, Double-barrel colostomy in the descending colon. B, Cross-sectional view of double-barrel stoma. (From Hampton BG, Bryant RA: Ostomies and continent diversions: nursing management, St. Louis, 1992, Mosby.)
Figure 33-6 Ileoanal reservoirs (IARs). A, S-shaped configuration. B, J-shaped configuration. (From Hampton BG, Bryant RA: Ostomies and continent diversions: nursing management, St. Louis, 1992, Mosby.)
Critical Thinking
Synthesis
KNOWLEDGE.
Figure 33-7 Construction of Kock continent ileostomy—Kock pouch. A, Two 15-cm limbs are used to create pouch, and one 15-cm limb is used to fashion a nipple valve and stoma. B, Distal limb is intussuscepted into reservoir to create a one-way valve and accomplish continence. Sutures or staples or both are placed to stabilize and maintain nipple. Anterior surface of reservoir is anchored to anterior peritoneal wall. (From Hampton BG, Bryant RA: Ostomies and continent diversions: nursing management, St. Louis, 1992, Mosby.)
EXPERIENCE.
ATTITUDES.
STANDARDS.
BOX 33-3 CULTURAL FOCUS
Implications for Practice
Nursing Process
Assessment
HEALTH HISTORY.
PHYSICAL ASSESSMENT.
LABORATORY AND DIAGNOSTIC EXAMINATIONS
Laboratory Tests.
TABLE 33-2 FOCUSED PATIENT ASSESSMENT
TABLE 33-3 Fecal Characteristics
SYNTHESIS IN PRACTICE
BOX 33-4 PROCEDURAL GUIDELINES FOR
Measuring Fecal Occult Blood
Step 4 Equipment needed for fecal occult blood testing.
Step 5a Application of fecal specimen on guaiac paper.
Step 5b Application of Hemoccult developing solution on the guaiac paper on the reverse side of test kit.
BOX 33-5 Screening for Colon Cancer
Fecal Specimens.
Diagnostic Examinations.
PATIENT EXPECTATIONS.
BOX 33-6 Radiological and Diagnostic Tests
Direct Visualization
Endoscopy
Indirect Visualization
Plain Film of Abdomen/Kidneys, Ureter, Bladder
Barium Swallow/Enema
Ultrasound
Computed Tomography Scan
Magnetic Resonance Imaging
Nursing Diagnosis
Planning
GOALS AND OUTCOMES.
SETTING PRIORITIES.
Figure 33-8 Concept map for patient with postoperative hysterectomy and constipation.
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION.
Diet.
CARE PLAN Constipation
Assessment
Nursing Diagnosis
EVALUATION
BOX 33-7 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice*
Exercise.
Timing and Privacy.
Promotion of Normal Defecation.
ACUTE CARE.
Figure 33-9 Types of bedpans. From left: Regular bedpan and fracture pan.
Positioning on Bedpan.
Medications.
Figure 33-10 Positions on a bedpan. A, Improper positioning of a patient. B, Proper position reduces patient’s back strain.
BOX 33-8 PROCEDURAL GUIDELINES FOR
Assisting Patient On and Off a Bedpan
Step 10 Place one hand against bedpan; place other hand around patient’s fore hip.
Enemas.
SKILL 33-1 Administering a Cleansing Enema
Delegation Considerations
Equipment
Enema Bag Administration
Prepackaged Enema
ASSEMENT
PLANNING
IMPLENENTATION
Step 9A(6) Insertion of rectal tube into rectum.
EVALUATION
Recording and Reporting
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Impaction Removal.
Inserting and Maintaining a Nasogastric Tube for Gastric Decompression.
BOX 33-9 PROCEDURAL GUIDELINES FOR
Digital Removal of Stool
CONTINUING AND RESTORATIVE CARE.
Bowel Training.
Ostomy Care.
SKILL 33-2 Inserting and Maintaining a Nasogastric Tube for Gastric Decompression
Delegation Considerations
Equipment
ASSEMENT
PLANNING
IMPLEMENTATION
Step 6a Technique for measuring distance to insert NG tube.
Step 11 Insert NG tube with curved end pointing downward.
Step 20c Aspiration of gastric contents.
Step 20d Checking pH of gastric aspirate.
Step 21b(2) Tape is crossed over and around NG tube.
Step 21b(3) Patient with tube fixation device.
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Figure 33-11 Examples of pouching systems. A, Two-piece detachable system. (note: Skin barrier would need to be cut by the patient according to stoma size obtained by self-measurement.) The pouch opening is already precut by the manufacturer to fit the size of the flange on the skin barrier. B, One-piece pouch with skin barrier.
BOX 33-10 PATIENT TEACHING
Stoma Care (Conventional Incontinent Ileostomy)
Care of Hemorrhoids.
Maintenance of Skin Integrity.
Evaluation
PATIENT CARE.
SKILL 33-3 Pouching an Ostomy
Delegation Considerations
Equipment
ASSEMENT
Step 3 Normal bud stoma. (Courtesy Hollister, Incorporated, Libertyville, Ill. Permission to use this copyrighted material has been granted by the owner, Hollister International.)
PLANNING
IMPLEMENTATION
Step 5 Measuring a stoma.
Step 6 A, Cut-to-fit, one-piece drainable ostomy pouch. B, Removing the backing paper for the barrier of a one-piece pouch. C, Applying barrier paste to a one-piece ostomy pouch. (Courtesy ConvaTec, Princeton, NJ.)
Step 7A(2) Applying a one-piece pouch. (Courtesy ConvaTec, Princeton, NJ.)
Step 7B(1) Application ofa barrier-paste flange. (Courtesy ConvaTec, Princeton, NJ.)
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
TABLE 33-4 OUTCOME EVALUATION
EVALUATION
Documentation Note
PATIENT EXPECTATIONS.
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
UNIT VI Caring for Patients’ Special Needs
CHAPTER 34 Immobility
OBJECTIVES
Key Terms
CASE STUDY Mr. Stapp
Scientific Knowledge Base
Mobility
BED REST.
Immobility
PHYSIOLOGICAL EFFECTS.
RESPIRATORY CHANGES.
CHANGES IN METABOLISM.
BOX 34-1 Pathophysiology of Immobility
Physiological Outcomes
Psychological Outcomes
Developmental Outcomes
FLUID AND ELECTROLYTE BALANCES.
GASTROINTESTINAL CHANGES.
CARDIOVASCULAR CHANGES.
MUSCULOSKELETAL CHANGES.
Figure 34-1 Flexion contracture of elbow resulting in permanent flexion of joint. Normally the elbow is able to extend to a 90-degree angle (dotted line) and to a 180-degree angle (not shown).
Figure 34-2 Footdrop. Ankle is fixed in plantar flexion.
INTEGUMENT CHANGES.
URINARY ELIMINATION CHANGES.
Nursing Knowledge Base
Psychosocial Effects
Developmental Effects
Critical Thinking
Synthesis
KNOWLEDGE.
EXPERIENCE.
ATTITUDE.
STANDARDS.
Nursing Process
Assessment
MOBILITY.
RESPIRATORY SYSTEM.
METABOLIC SYSTEM.
CARDIOVASCULAR SYSTEM.
TABLE 34-1 FOCUSED PATIENT ASSESSMENT
MUSCULOSKELETAL SYSTEM.
SKIN INTEGRITY.
ELIMINATION SYSTEM.
PSYCHOSOCIAL CONDITION.
TABLE 34-2 Range-of-Motion Exercises
DEVELOPMENT.
BOX 34-2 USING EVIDENCE IN PRACTICE
Research Summary
Application to Nursing Practice
Nursing Diagnosis
SYNTHESIS IN PRACTICE
Planning
GOALS AND OUTCOMES.
SETTING PRIORITIES.
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION.
Respiratory System.
Promoting Expansion of the Chest and Lungs.
Preventing Stasis of Pulmonary Secretions.
Metabolic System.
CARE PLAN Impaired Physical Mobility
Assessment
Nursing Diagnosis
Planning
Evaluation
Figure 34-3 Concept map for patient with a spinal cord injury and quadriplegia.
BOX 34-3 CARE OF THE OLDER ADULT
BOX 34-4 Guidelines for Assisting Patients With Exercising
Cardiovascular System.
Reducing Orthostatic Hypotension.
Preventing Thrombus Formation.
BOX 34-5 CULTURAL FOCUS
Implications for Practice
Musculoskeletal System.
BOX 34-6 Incorporating Active Range-of-Joint-Motion Exercises Into Activities of Daily Living
BOX 34-7 PATIENT TEACHING
Outcome
Teaching Strategies
Evaluation Strategies
Skin Integrity.
Elimination System.
Psychosocial Problems.
Developmental Changes.
ACUTE CARE.
Respiratory System.
Maintaining a Patent Airway.
Cardiovascular System.
BOX 34-8 PROCEDURAL GUIDELINES FOR
Applying Antiembolic Elastic Stockings
Step 11b Place toes into foot of stocking.
Step 11c Slide heel of stocking over foot.
Step 11d Slide stocking up leg until completely extended.
Musculoskeletal System.
Psychosocial Problems.
Developmental Changes.
BOX 34-9 PROCEDURAL GUIDELINES FOR
Applying Sequential Compression Devices
Step 5 Correct leg position on inner lining.
Step 7 Check fit of SCD sleeve.
Step 5b Position back of patient’s knee with the popliteal opening.
Step 8 Align arrows when connecting to mechanical unit.
TABLE 34-3 Devices Used for Proper Positioning
Figure 34-4 Trochanter roll.
Figure 34-5 Patient using a trapeze bar.
Figure 34-6 Continuous passive range-of-motion machine.
RESTORATIVE AND CONTINUING CARE.
Evaluation
PATIENT CARE.
EVALUATION
Documentation Note
PATIENT EXPECTATIONS.
TABLE 34-4 OUTCOME EVALUATION
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 35 Skin Integrity and Wound Care
OBJECTIVES
Key Terms
CASE STUDY Mr. Ahmed
Scientific Knowledge Base
Pressure Ulcers
Figure 35-1 Pressure ulcer with tissue necrosis.
CONTRIBUTING FACTORS TO PRESSURE ULCER FORMATION.
Shear.
BOX 35-1 USING EVIDENCE IN PRACTICE
Research Summary
Results
Application to Nursing Practice
Friction.
Moisture.
Figure 35-2 A, Check for blanching by applying fingertip pressure. B, Area of blanchable hyperemia.
Figure 35-3 A, Blanchable hyperemia. B and C, In nonblanchable hyperemia the area is darker than the surrounding skin and does not blanch with fingertip pressure.
Figure 35-4 Shear exerted in the sacral area.
Nutrition.
Infection.
Age.
Origins of Pressure Ulcers
Wound Classification
Figure 35-5 A, Stage I pressure ulcer. B, Stage II pressure ulcer. C, Stage III pressure ulcer. D, Stage IV pressure ulcer. (Courtesy Laurel Wiersema-Bryant, RN, MSN, Clinical Nurse Specialist, Barnes Hospital, St. Louis.)
Wound Healing Process
PARTIAL-THICKNESS WOUND REPAIR.
Inflammatory Response.
Epidermal Repair.
Dermal Repair.
FULL-THICKNESS WOUND REPAIR.
Inflammatory Phase.
BOX 35-2 Factors Influencing Wound Healing
Age
Nutrition
Infection
Obesity
Extent of Wound
Tissue Perfusion
Smoking
Immunosuppression
Diabetes Mellitus
Radiation
Wound Stress
Proliferative Phase.
Remodeling Phase.
Complications of Wound Healing
HEMORRHAGE.
INFECTION.
DEHISCENCE.
EVISCERATION.
FISTULAS.
Nursing Knowledge Base
Prediction and Prevention
Critical Thinking
Synthesis
KNOWLEDGE.
TABLE 35-1 Braden Scale for Predicting Pressure Sore Risk
EXPERIENCE.
ATTITUDES.
STANDARDS.
Nursing Process
Assessment
PRESSURE ULCERS.
BOX 35-3 CULTURAL FOCUS
Skin Assessment for the Patient With Intact Darkly Pigmented Skin
Assess Localized Skin Color Changes
Importance of Lighting Source
Tissue Consistency
Sensation
Assess Skin Temperature
Skin.
BOX 35-4 Pressure Ulcer Prevention Points
Assessment
Skin Care and Early Treatment
Support Surfaces/Pressure Reduction
Nutrition
Patient/Caregiver Education
Mobility.
Nutritional Status.
WOUNDS.
TABLE 35-2 FOCUSED PATIENT ASSESSMENT
BOX 35-5 CARE OF THE OLDER ADULT
SKILL 35-1 Assessment of Patient for Pressure Ulcer: Risk and Skin Assessment
Delegation Considerations
Equipment
ASSESSMENT
Figure 35-6 A, Bony prominences most frequently underlying pressure ulcers. B, Pressure ulcer sites. (From Trelease CC: Developing standards for wound care, Ostomy Wound Manage 20:46, 1988.)
IMPLEMENNTATION
EVALUATION
Recording and Reporting
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
BOX 35-6 Nutritional Assessment and Management of Pressure Ulcers: WOCN 2003 Guideline Recommendations
Emergency Setting.
Stable Setting.
Figure 35-7 Penrose drain.
Wound Cultures.
PATIENT EXPECTATIONS.
BOX 35-7 Recommendations for Standardized Techniques for Wound Cultures
Needle Aspiration Procedure (Anaerobic Culture)
Quantitative Swab Procedure (Aerobic Culture)
Nursing Diagnosis
SYNTHESIS IN PRACTICE
Planning
GOALS AND OUTCOMES.
SETTING PRIORITIES.
CARE PLAN Skin Integrity and Wound Care
Assessment
Planning
Evaluation
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION.
Topical Skin Care.
Figure 35-8 Hollister® Fecal Incontinence Collector. (Permission to use this copyrighted material has been granted by the owner, Hollister Incorporated.)
Figure 35-9 Thirty-degree lateral position to avoid pressure points. (From Pieper B: Mechanical forces: pressure, shear, friction. In Bryant RA, editor: Acute and chronic wounds: nursing management, ed 2, St. Louis, 2000, Mosby.)
Positioning.
Support Surfaces.
Figure 35-10 Formation of pressure ulcer on heel resulting from external pressure from mattress of bed. (Courtesy Janice Colwell, RN, MS, CWOCN, Clinical Nurse Specialist, University of Chicago Hospitals.)
TABLE 35-3 Support Surfaces
ACUTE CARE
Pressure Ulcers.
BOX 35-8 WOCN 2003 Pressure Reduction/Relief Recommendations
Figure 35-11 Flow diagram for ordering speciality surfaces. (From Thomas C: Specialty beds: decision making made easy, Ostomy Wound Manage 23:51, 1989.)
BOX 35-9 Guidelines for Patient Education Regarding Therapeutic Surfaces
BOX 35-10 Wound Healing Principles
Wounds
First Aid for Wounds.
Hemostasis
SKILL 35-2 Treating Pressure Ulcers
Delegation Considerations
Equipment
ASSEMENT
PLANNING
Step 6b-d Measuring length, width, and depth of pressure ulcer.
IMPLEMENTATION
EVALUTION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
TABLE 35-4 Treatment Options by Ulcer Stage
CLEANSING.
BOX 35-11 PATIENT TEACHING
Outcome
Teaching Strategies
Evaluation Strategies
PROTECTION.
Dressings.
Purposes.
Types.
Changing Dressings.
Securing Dressings.
Comfort Measures.
SKILL 35-3 Applying Dressings: Dry or Wet-to-Dry and Transparent
Delegation Considerations
Equipment
Assessment
PLANNING
Implementation
Step 6 Abdominal wound, with beefy red granulation tissue present and attached wound edges. (From Bryant RA: Acute and chronic wounds: nursing management, ed 2, St.Louis, 2000, Mosby.)
Step 9 Sterile supplies on bedside table.
Step 15b(2) A, Packing wound. B, Wound packed loosely, until wound is filled.
Step 16 A, Application of roll gauze. B, Securing Montgomery ties.
EVALUTION
Recording and Reporting
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
SKILL 35-4 Wound Vacuum Assisted Closure
Delegation Considerations
Equipment
Figure 35-12 The V.A.C.® System. Top to bottom: V.A.C. System itself, connective tubing to go between V.A.C. system and dressing, absorbent foam dressing. (Courtesy Kinetic Concepts, Inc [KCI], San Antonio, Tex.)
ASSEMENT
PLANNING
IMPLEMENTATION
Step 14 Dressing application. Properly sized foam to cover wound.
Step 17 B, Foam dressing, transparent dressing, and V.A.C.® System tubing secured over existing wound. (Courtesy Kinetic Concepts, Inc [KCI], San Antonio, Tex.)
Steps 15 A, Wrinkle-free transparent dressing applied over foam. B, Secure tubing to the foam and transparent dressing unit (see step 17). (Courtesy Kinetic Concepts, Inc [KCI], San Antonio, Tex.)
EVALUTION
Recording and Reporting
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Figure 35-13 Methods for cleansing wound site.
Figure 35-14 Cleansing of drain site.
Wound Cleansing.
Figure 35-15 Wound irrigation using 35-ml syringe and 10-gauge catheter to facilitate removal of necrotic slough tissue.
Wound Irrigation.
Suture Care.
SKILL 35-5 Performing Wound Irrigation
Delegation Considerations
Equipment
ASSEMENT
PLANNING
IMPLEMENTATION
Step 3a Position of patient for abdominal wound irrigation.
EVALUATION
Recording and Reporting
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Figure 35-16 Wound closed with staples.
Drainage Evacuation.
Bandages and Binders.
Figure 35-17 Steri-Strips placed over incision for closure.
Principles for Application of Bandages and Binders.
Figure 35-18 Examples of suturing methods. A, Intermittent. B, Continuous. C, Blanket continuous. D, Retention.
Figure 35-19 Jackson-Pratt drain and reservoir.
Binder Application.
BREAST BINDER.
ABDOMINAL BINDER.
SLINGS.
Bandage Application.
Heat and Cold Therapy.
Body Responses to Heat and Cold.
TABLE 35-5 Principles for Bandage and Binder Application
Local Effects of Heat and Cold.
Factors Influencing Heat and Cold Tolerance.
Assessment for Temperature Tolerance.
BOX 35-12 PROCEDURAL GUIDELINES FOR
Applying Abdominal or Breast Binders
Patient Education and Safety.
Applying Heat and Cold.
Choice of Moist or Dry.
Warm Moist Compresses.
Figure 35-20 Abdominal binder secured with Velcro.
BOX 35-13 PROCEDURAL GUIDELINES FOR
Applying Elastic Bandages
Warm Soaks.
Figure 35-21 Application of a sling.
Sitz Bath.
TABLE 35-6 Conditions That Increase Risk of Injury From Heat and Cold Application
TABLE 35-7 Therapeutic Effects of Heat and Cold Applications
Aquathermia (Water-Flow) Pads.
BOX 35-14 Safety Suggestions for Applying Heat or Cold Therapy
Commercial Hot Packs.
Hot-Water Bottles.
Electric Heating Pads.
Cold Moist Compresses.
Figure 35-22 Aquathermia pad.
Cold Soaks.
Ice Bag or Collar.
Commercial Cold Packs.
RESTORATIVE AND CONTINUING CARE.
TABLE 35-8 OUTCOME EVALUATION
EVALUATION
Documentation Note
Evaluation
PATIENT CARE.
PATIENT EXPECTATIONS.
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 36 Sensory Alterations
OBJECTIVES
Key Terms
CASE STUDY Mrs. Alicea
Scientific Knowledge Base
Normal Sensation
Types of Sensory Alterations
SENSORY DEFICITS.
SENSORY DEPRIVATION.
SENSORY OVERLOAD.
Nursing Knowledge Base
BOX 36-1 Factors That Influence Sensory Function
Age
Infants
Children
Adults
Older Adults
Medications
Environment
Preexisting Illnesses
Smoking
Noise Levels
BOX 36-2 Common Sensory Deficits
Visual
Hearing
Balance
Taste
Neurological
BOX 36-3 Examples of Medications Reported to Cause Ototoxicity
Antibiotics
Analgesics/NSAIDs
Diuretics
Antineoplastic Agents
Critical Thinking
Synthesis
KNOWLEDGE.
BOX 36-4 USING EVIDENCE PRACTICE
Research Summary
Application to Nursing Practice
EXPERIENCE.
ATTITUDES.
STANDARDS.
Nursing Process
Assessment
PATIENTS AT RISK.
SENSORY STATUS.
TABLE 36-1 FOCUSED PATIENT ASSESSMENT
PATIENT’S LIFESTYLE.
SOCIALIZATION.
SELF-CARE MANAGEMENT.
PSYCHOSOCIAL ADJUSTMENT.
HEALTH PROMOTION PRACTICES.
HAZARDS.
MEANINGFUL STIMULI.
SYNTHESIS IN PRACTICE
ENVIRONMENT.
COMMUNICATION METHODS.
PHYSICAL EXAMINATION.
PATIENT EXPECTATIONS.
Nursing Diagnosis
TABLE 36-2 Behaviors Indicating Sensory Deficits
Planning
GOALS AND OUTCOMES.
CARE PLAN Sensory Alteration
Assessment
Nursing Diagnosis
Planning
Evaluation
SETTING PRIORITIES.
CONTINUITY OF CARE.
Implementation
HEALTH PROMOTION.
Screening and Prevention.
Use of Assistive Aids.
Promoting Meaningful Stimulation.
BOX 36-5 Care of Hearing Aids
BOX 36-6 Promoting Sensory Stimulation
Creating a Safe Environment.
Visual Adaptations.
Hearing Adaptations.
Smell and Tactile Adaptations.
Communication.
BOX 36-7 PATIENT TEACHING
Outcome
Teaching Strategies
Evaluation Strategies
ACUTE CARE.
Orientation to the Environment.
Safety Measures.
Controlling Sensory Stimuli.
Figure 36-1 Nurse assists visually impaired patient with ambulation.
RESTORATIVE AND CONTINUING CARE.
Promoting Self-Care.
BOX 36-8 Introducing Stimuli Into the Care Setting
Visual
Auditory
Taste and Smell
Socialization.
Figure 36-2 Arrange food on a plate and orient patient to placement based on numbers on a clock face.
Evaluation
PATIENT CARE.
PATIENT EXPECTATIONS.
BOX 36-9 Therapies to Reduce Loneliness
EVALUATION
Documentation Note
TABLE 36-3 OUTCOME EVALUATION
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
CHAPTER 37 Surgical Patient
OBJECTIVES
Key Terms
CASE STUDY Mr. Korloff
TABLE 37-1 Classification for Surgical Procedures
Scientific Knowledge Base
Classification of Surgery
Surgical Risk Factors
AGE.
TABLE 37-2 Physiological Factors That Place the Older Adult at Risk During Surgery
NUTRITION.
OBESITY.
IMMUNOCOMPETENCE.
FLUID AND ELECTROLYTE BALANCE.
PREGNANCY.
Nursing Knowledge Base
Critical Thinking
Synthesis
KNOWLEDGE.
EXPERIENCE.
ATTITUDES.
STANDARDS.
Preoperative Surgical Phase
Nursing Process
Assessment
NURSING HISTORY.
Medical History.
TABLE 37-3 Medical Conditions That Increase the Risks of Surgery
Previous Surgeries.
Medication History.
Allergies.
TABLE 37-4 Drugs With Special Implications for the Surgical Patient
Smoking Habits.
Alcohol and Controlled Substance Use and Abuse.
Family Support.
Occupation.
Feelings.
Cultural and Spiritual Factors.
Coping Resources.
BOX 37-1 CULTURAL FOCUS
Implications for Practice
Body Image.
Patient Expectations.
PHYSICAL EXAMINATION.
General Survey.
Head and Neck.
Skin
Thorax and Lungs.
Heart and Vascular System.
Abdomen
Neurological Status.
TABLE 37-5 FOCUSED PATIENT ASSESSMENT
SYNTHESIS IN PRACTICE
RISK FACTORS.
DIAGNOSTIC SCREENING.
TABLE 37-6 Common Laboratory Blood Tests
Nursing Diagnosis
Planning
GOALS AND OUTCOMES.
SETTING PRIORITIES.
CONTINUITY OF CARE.
Implementation
INFORMED CONSENT.
HEALTH PROMOTION.
Preoperative Teaching.
CARE PLAN Surgery
Assessment
Nursing Diagnosis
Planning
Evaluation
BOX 37-2 PATIENT TEACHING
Perioperative Patient Preparation
Timing.
BOX 37-3 USING EVIDENCE IN PRACTICE
Research Summary
Application to Practice
Content.
Surgical Procedure
Preoperative Routines.
Intraoperative Routines
Postoperative Routines.
Sensory Preparation.
Pain Relief.
Postoperative Exercises.
SKILL 37-1 Teaching Postoperative Exercises
Delegation Considerations
Equipment
ASSESSMENT
PLANNING
IMPLEMENTATION
Step 1A(3) Deep breathing exercise: placement of hands during inhalation. (From Mosby’s medical, nursing, and allied health dictionary, ed 6, St. Louis, 2002, Mosby.)
Step 1B(4) Patient demonstrating incentive spirometry.
Step 1B(5) Diagram of use of incentive spirometer.
Step 1C(3) Diagram of use of positive expiratory pressure device.
Step 1D(2) Techniques for splinting incision. (From Lewis S and others: Medical-surgical nursing: assessment and management of clinical problems, ed 6, St. Louis, 2004, Mosby.)
Step 1E(1) Buttocks lift. (From Lowdermilk D, Perry SE: Maternity nursing, ed 6, St. Louis, 2003, Mosby.)
Step 1E(3) Leg position for turning. (From Lowdermilk D, Perry SE: Maternity nursing, ed 6, St. Louis, 2003, Mosby.)
Step 1F(2–5) Leg exercises. (From Lewis S and others: Medical-surgical nursing:assessment and management of clinical problems, ed 6, St. Louis, 2004, Mosby.)
EVALUATION
RECORDING AND REPORTING
UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS
Activity Resumption.
Promotion of Nutrition.
Promotion of Rest.
ACUTE CARE.
Minimize Risk of Surgical Wound Infection.
Prevention of Bowel Incontinence and Contamination.
Interventions on Day of Surgery.
Documentation
Assessment of Vital Signs.
Figure 37-1 Surgical/Procedure Checklist. (Courtesy Barnes-Jewish Hospital, St. Louis, Missouri.)
Hygiene.
Preparation of Hair and Removal of Cosmetics.
Removal of Prostheses.
Preparation of Bowel and Bladder.
Application of Antiembolism Devices.
Promotion of Patient’s Dignity.
Performing Special Procedures.
Safeguarding Valuables.
EVALUATION
Documentation Note
Administering Preoperative Medications.
Evaluation
PATIENT CARE.
PATIENT EXPECTATIONS.
Transport to the Operating Room
Intraoperative Surgical Phase
Nurse’s Role During Surgery
PREANESTHESIA CARE UNIT.
Admission to the Operating Room
Figure 37-2 Nurses in the operating room. (Courtesy OFS Healthcare.)
Nursing Process
Assessment
TABLE 37-7 FOCUSED PATIENT ASSESSMENT
Nursing Diagnosis
Planning
GOALS AND OUTCOMES.
Implementation
ACUTE CARE
Physical Preparation.
Psychological Support.
Introduction of Anesthesia.
TABLE 37-8 Examples of Complications of Anesthesia
General Anesthesia.
Regional Anesthesia.
Local Anesthesia.
Moderate Sedation/Analgesia (Conscious Sedation).
Positioning
Documentation of Intraoperative Care.
TABLE 37-9 Intraoperative Nursing Care
EVALUATION
Evaluation
PATIENT CARE.
PATIENT EXPECTATIONS.
Postoperative Surgical Phase
Recovery
Figure 37-3 Nurse in postanesthesia care unit (PACU).
POSTANESTHESIA CARE IN AMBULATORY SURGERY.
Convalescence
BOX 37-4 Information Given to Ambulatory Surgical Patients
Nursing Process
Assessment
RESPIRATION.
TABLE 37-10 FOCUSED PATIENT ASSESSMENT
CIRCULATION.
TEMPERATURE CONTROL.
NEUROLOGICAL FUNCTION.
FLUID AND ELECTROLYTE BALANCE.
SKIN INTEGRITY AND CONDITION OF THE WOUND.
GENITOURINARY FUNCTION.
SYNTHESIS IN PRACTICE
Postoperative Assessment and Planning
GASTROINTESTINAL FUNCTION.
COMFORT.
Nursing Diagnosis
Planning
GOALS AND OUTCOMES.
SETTING PRIORITIES.
CONTINUITY OF CARE.
Implementation
RESPIRATION
Figure 37-4 Concept map for surgical patient with abdominal surgery.
CIRCULATION.
TABLE 37-11 Common Postoperative Complications
BOX 37-5 PATIENT TEACHING
Outcome
Teaching Strategies
Evaluation Strategies
Figure 37-5 Position of patient during recovery from general anesthesia. (From Lewis S and others: Medical-surgical nursing: assessment and management of clinical problems, ed 6, St. Louis, 2004, Mosby.)
BOX 37-6 CARE OF THE OLDER ADULT
TEMPERATURE CONTROL.
NEUROLOGICAL FUNCTION.
FLUID AND ELECTROLYTE BALANCE.
GENITOURINARY FUNCTION.
GASTROINTESTINAL FUNCTION.
COMFORT.
PROMOTING WOUND HEALING.
MAINTAINING SELF-CONCEPT.
RESTORATIVE AND CONTINUING CARE.
TABLE 37-12 OUTCOME EVALUATION
Evaluation
PATIENT CARE.
PATIENT EXPECTATIONS.
EVALUATION
Documentation Note
Key Concepts
Critical Thinking in Practice
NCLEX® Review
References
Uncited references
Back Title
Glossary
Appendix A Common Abbreviations
Appendix B Overview of CDC Hand Hygiene Guidelines*
Follow These Guidelines in the Care of All Patients
Method for Decontaminating Hands
Follow These Guidelines for Surgical Hand Antisepsis
General Recommendations for Hand Hygiene
Answers for NCLEX® Review Questions
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
Chapter 19
Chapter 20
Chapter 21
Chapter 22
Chapter 23
Chapter 24
Chapter 25
Chapter 26
Chapter 27
Chapter 28
Chapter 29
Chapter 30
Chapter 31
Chapter 32
Chapter 33
Chapter 34
Chapter 35
Chapter 36
Chapter 37

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