Nursing Concepts 03 WEB-COLOR.pdf · B. Identify and make revisions to the nursing care plan. ......

Nursing Concepts

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PlanningA. Assign priority to the nursing care activities.B. Specifygoalsreflectingdesiredoutcomeofnursing care. 1. Developshort-termandlong-termgoals. 2. Identifynursinginterventionsforgoalattainment. 3. Establishoutcomecriteria.C. Develop the written nursing care plan. 1. Involveclientandfamilyinallaspectsofplanning. 2. Keepcareplancurrentandflexible.

ImplementingA. Initiateandcarryoutplannednursingactivities.B. Coordinateactivitiesofclientandfamilymembers alongwithhealthteammembers.C. Documentclient’sresponsestonursingactions.

EvaluatingA. Collectobjectiveandsubjectivedataanddetermineif goalswereachieved.B. Identifyandmakerevisionstothenursingcareplan.

A. Maslow’shierarchyofbasichumanneeds. 1. Humanbehaviorismotivatedbyasystemofneeds. 2. Clientswillfocusorattempttosatisfyneedsatthe baseofthepyramidbeforefocusingonthosehigher up (Figure 3-1). 3. Humanneedsareuniversal;however,somemaybe modifiedbyculturalinfluence. 4. Thenursingprocessisalwaysconcernedwithphys- iologicalneedsfirst;thenprogressestoteaching, decreasinganxiety,etc.Thisisalsotrueforthe clientwithpsychosocialneeds;theclient’sphysi- ologicalneedsmustbemetbeforeprogressingto thenextlevel.

NURSING PRIORITY: ✔ Pay attention to Maslow’s hierarchy of needs when answering test questions related to setting priorities. The physiological needs at the base of the pyramid must be satisfied first in order to focus on other needs—and remember that oxygenation is always the first physiological need or priority.

StepS of the NurSiNg proCeSSThe categories of the nursing process and the activities ✽

in each category vary somewhat according to nursing authors. The nursing process as presented here correlates with the categories of the NCLEX-PN.

Data CollectionA. Collectingdata. 1. Objectivedataarenursingobservations.Example: Client weighs 125 lb; 50 mL of green drainage via the nasogastric tube. 2. Subjectivedataareinformationgivenbytheclient.Example: “My side hurts; I am scared about surgery.” 3. Clientdataarecollectedusingthreeskills. a. Observation: what can be seen.Example: Is the client awake or asleep; is the client obese or underweight; is the client smiling or frowning? b. Auscultation:whatcanbeheard.Example: Is the client laughing; are there breath sounds pres-ent; do you hear hyperactive bowel sounds? c. Palpation: what can be felt.Example: Is the client’s skin warm and dry; does the client have a pedal pulse; is the client’s abdomen soft?

figure 3-1 Maslow’s hierarchy of needs. (From Zerwekh J, Claborn J, Miller CJ: Memory notebook of nursing, vol 1, ed 4, Ingram, 2008, Nursing Education Consultants.)

42 ChApter 3 Nursing Concepts

heAlth ASSeSSMeNt

Health History

TEST ALERT: Collect baseline physical data on admission.

The health history is a primary source of client ✽information. The source of the information can be the client, relatives, friends, old records, or any combination of these. A predetermined format should be used as a guide for the interview.A. Demographicdata. 1. Name,address,phonenumber,age,sex,marital status. 2. Race,religion,usualsourceofmedicalcare.B. Chiefcomplaint/reasonforvisit. 1. Chiefcomplaint(CC)ismainreasonclientsought health care. 2. CCisrecordedinclient’sownwords.Example: “I have been vomiting blood since this morning.”C. History of the present illness. 1. Chronological narrative story of the history of the present state of health. 2. Includesrelevantfamilyhistory.D. Past history. 1. Childhooddiseases. 2. Immunizations. 3. Allergies. 4. Hospitalizationsandseriousillnesses. 5. Accidentsandinjuries. 6. Medications. 7. Prenatal,laboranddelivery,orneonatalhistory (recordedforallchildrenunderage5andolder childrenwithacongenitalordevelopmental problem).E. Reviewofsystems(ROS). 1. Isaverballistingfromheadtotoeoftheclient’s overall state of health. 2. Containssubjectivedatagivenbytheclient;does notcontaininformationfromthephysicalexamina- tion.Specificassessmentdataforeachbodysystem canbefoundatthebeginningofeachchapter.

heAlth teAChiNg

Principles of Client EducationA. Commoncharacteristicsoftheadultlearner. 1. Theadultclient’sbackgroundofexperience,skills, andattitudeswillformthebasisforanynewinfor- mationreceived.Frequentlytheclienthashadno positiveexperiencesinahospitalenvironment. 2. Thelevelofadultdevelopmentwillgreatlyaffect theclient’sreadinesstolearn.Ifaclientisinamid- lifetransition,itmaybeverydifficulttolearnnew attitudesandskillsthatthreatenself-image.

Example: A man in his early 40s may have difficulty accept-ing any education regarding his colostomy.B. Factors contributing to the teaching-learning process. 1. Readinesstolearn. a. Theclientmustfeelthematerialisrelevantto his/herhealth,andmustbewillingtoputforth the effort to learn. b. Theclientmusthavethementalcapacityto learn,aswellasthephysicalabilitytoperform theskills. c. Theclientmusthavephysicalandsafetyneeds metbeforefocusingonlearning.Ifaclient exertsallofhis/herenergytocopewiththe physicalstress,thenhe/shehaslittleenergy for learning. d. Comfort. (1) Physicalcomfort:discomforts(suchas pain,nausea,hunger,needtovoid)are distractorstothelearningprocess. (2) Psychologicalcomfort:anger,frustrations, fear,andguiltseverelyhamperthelearning process. e. Before the teaching-learning process can begin, theclientandthenurseneedtodiscussand agreeonspecificlong-termandshort-termgoals. Thenursemustcarefullyevaluatetheclient’s knowledgeoftheproblem.C. Factors relating to the presentation. 1. Statethespecificobjectiveofeachteachingsession: exactlywhattheclientistogain. 2. Usevocabularyandterminologyappropriatetothe client’sunderstandingandtohisorherdevelopmen- tallevel.Usecorrecttermsforbodyparts. 3. Trytostimulateasmanysensesaspossible.Use charts,handouts,andpiecesofequipmentwhen appropriate. 4. Repetitionisanintegralpartoflearning.Beready torepeatthematerialortohavetheclientrepeatthe skilluntilhe/shedoesitcorrectlyandbecomes comfortablewiththeskill. 5. Themoreactivetheclientisintheprocess,the betterhe/shewillretaintheinformation. 6. Planshortsessions;donotoverwhelmtheclient withtoomuchinformationatonetime. 7. Whenappropriate,activelyinvolvethefamilyand significantothers. 8. Begenerouswithpositivereinforcement.D. Pediatricfactorsinfluencingthelearningprocess. 1. Intellectualdevelopmentmovesfromtheconcrete to the abstract. 2. Thenurseneedstoassessthedevelopmentallevel ofthechildbeforeplanningtheeducational approach. a. Preschool client. (1) Thepreschoolchildfrequentlyexperiences fearsofbodyinjury.Explanationsshouldbe simple.

ChApter 3 Nursing Concepts 43

B. Bathing. 1. Types of bath. a. Bedbath. b. Partial bath. c. Shower. d. Therapeuticbath:sitzbathormedicatedbath. 2. Nursingimplications. a. Roomshouldbekeptwarm,bathshouldbegin withcleanareasandprogresstodirtyareas. b. Topreventdryskin,irritation,andinfection, carefullyrinseallsurfaceareasanddrythem. c. Keepclientwarmbyusingabathblanketand controllingroomtemperature. d. Ensurequietandprivacy. e. Moisturizeskinwithlotion.

NURSING PRIORITY: ✔ Clients who are receiving external radiation therapy should not be bathed with soap over the area of the radiation, which will be marked. Lotions and powders should not be used on the area.

3. Levels of personal care. a. Completecare:Clientrequirestotalassistance fromnursebecauseclientisabletodolittleor nothing without assistance. b. Partialcare:Clientperformsasmuchofhisor her own care as possible; nurse usually completesremainingcare. c. PMcare(bedtimeorhourofsleep):Isprovided toprepareclientforarelaxing,uninterrupted periodofsleep;includesoralcare,possible partialbathing,skincare,soothingbackmass- age,straighteningorchangingthebedlinen,and offeringthebedpanorurinal.C. Oral hygiene. 1. Includescareoftheclient’steethordentures,gums, tongue,andlips. 2. Whenprovidingoralcaretounconsciousclient, turntheclient’sheadtothesidetopreventaspira- tion.D. Hair care. 1. Newborninfantsneedscalpscrubbeddailytopre- ventcradlecap. 2. Adolescentsusuallyrequiremorefrequentsham- pooing because of increase in oily secretions. 3. Olderadultclientswillneedtoshampoolessoften.

Body Alignment and Range of Motion (ROM)A. Characteristicsofcorrectbodyalignmentinbed. 1. Headupwitheyeslookingstraightforward. 2. Neckandbackstraight. 3. Armsrelaxedandsupportedatsides. 4. Legsparalleltohipswithkneesslightlyflexed. 5. Feetseparatedandparalleltothelegswiththetoes pointedupwardandslightlyoutward.

(2) Separationanxietyisaprobleminthisage group;includeparentsinteachingsession. (3) Thepreschoolchildisawareofthephysical andmechanicalcausesofproblemshe/she cansee;thechildisunawareofphysical andmechanicalforcesthathe/shecannot see. b. School-age client. (1) Benefitsfromtours,drawings,anatomical dolls. (2) Learnswellfromrole-playingandpuppets. (3) Needstoincludeparentsinteaching sessionforreinforcementandtomaintain consistency. c. Adolescentclient. (1) Needstobeasindependentaspossiblein managementofhealthproblem. (2) Needsassistanceincopingwithlossofin- dependenceandself-direction. (3) Educationalprogramsneedtohelpado- lescentdealwithchangesinbodyimage andinmaintainingego.E. Olderadultclient. 1. Determinetheolderadultclient’sfunctionallosses (i.e.,hearingorvisionimpairment,memoryloss). 2. Identifysocialsupporttoaidtheolderadult;this oftenincreasescompliancewithinformationbeing taught. 3. Determinehearingandvisualacuityandmake adjustmentstoleaningprocess. 4. Determineiftheclientisexperiencinganyconfu- sionordisorientation.Askclienttoincludefamily memberinteachingactivity.

BASiC NurSiNg SkillS

Hygienic Nursing Measures

TEST ALERT: Assist with activities of daily living.

A. Bedsandcomfortmeasures. 1. Avoidshakinglinens. 2. Holdallsoiledlinensawayfromyouruniform. 3. Mattresses. a. Alternatingpressuremattress. (1)Providesacontinuousshiftofpressureby alternatinginflationanddeflationofairor waterevery2to5minutes. (2) Usedtopreventdevelopmentofortotreat pressure ulcers. b. Eggcratemattress. (1) Foamrubbermattresswithprojectionsthat looklikeaneggcrate. (2) Placedontopofaregularmattress. (3) Usedtopreventpressureareasfromdevel- opinginabedriddenclient.


B. Rangeofmotion(ROM). 1. Active ROM. a. Clientperformsexercisewithoutassistance. b. Usedforclientwhoindependentlyperforms activitiesofdailyliving(ADLs),butforsome reasonisimmobilizedorlimitedregarding activity. c. Goalismusclestrengthening,aswellasmainte- nanceandpreventionofmuscleatrophy. 2. Passive ROM. a. Clientcannotactivelymove. b. Cannotcontractmuscles;thereforemuscle strengtheningcannotbeaccomplished. c. Goalistomaintainjointflexibilityandprevent contractures.C. PrinciplesofROMexercises. 1. Stretchmusclesbymovingthebodypart;avoid movementtothepointofdiscomfort. 2. PerformROMatleasttwicedailyonimmobile clients,withaminimumoffourtofiverepetitionsof eachexercise. 3. Alwayssupportextremityaboveandbelowthejoint whendoingpassiveROMonextremities. 4. Involvetheclientinplanningtheexerciseprogram.

TEST ALERT: Provide for mobility needs – ambulation, range of motion, repositioning.

AsepsisA. Medicalasepsis. 1. Designedtoreducethenumberofpathogensinan areaanddecreasethelikelihoodoftheirtransfer (e.g.,handhygiene).

NURSING PRIORITY: ✔ Proper hand hygiene is one of the most important procedures for the prevention of infection.

2. Oftenreferredtoascleantechnique. 3. Administeringoralmedications,givingenemas, providingtubefeedings,andpracticingdaily hygieneareallcarriedoutwiththecleantechnique.B. Surgical asepsis. 1. Designedtonotjustsimplyreducethenumberof pathogensbuttomaketheobjectfreeofallmicro- organisms. 2. Alsoknownassteriletechnique. 3. Surgicalasepsisisimplantedforsterileprocedures, suchaschangingsteriledressings,completing sterilecatheterizations,andperformingsurgical proceduresintheoperatingroom(Box3-1).

TEST ALERT: Set up a sterile field; use appro-priate equipment to maintain asepsis; use asep-

tic/sterile technique.

Postmortem CareA. Determinewhetherthereareanytissuesororganstobe donated.B. Consultwiththenursingsupervisortodetermine whethertheclient’sdeathneedstobereportedandorif theclient’sdeathnecessitatesanautopsy. 1. Deathresultingfromanaccidentor,homicide,or suicide. 2. Unattendeddeath;deathoccurringataworkplace orduringincarceration.C. Performpostmortemcareassoonaspossible. 1. Determinewhetherfamilywantstoparticipatein postmortemcare. 2. Unlessclientistohaveanautopsy,removeall equipmentaccordingtofacilitypolicy. 3. Cleansethebodyandcoverwithacleansheet. Placeapillowundertheheadandleavethearmson theoutsideofthesheet.Deodorizeroomifneces- sary. 4. Offerthefamilyanopportunitytobewiththe client.Provideprivacyinanunrushedatmosphere.

Procedures Requiring Sterile Technique • Surgicalproceduresintheoperatingroom (e.g.,transurethralprostatectomy[TURP], appendectomy). • Biopsiesintheoperatingroom,treatmentroom,or client’sroom. • Catheterizationsoftheheart,bladder,orotherbody cavities. • Injections:intramuscular(IM),subcutaneous(subQ), intradermal. • Infusions:IV,instillationsorinfusionsofmedicationor radioactiveisotopesintobodycavities. • Dressingchanges: • Usually,firstpostoperativedressingchangedoneby usingsteriletechnique. • Dressingsovercathetersinsertedintobodycavities (e.g.,Hickmancatheter,subclavianlines,dialysis access sites). • Dressingsofclientswithburns,immunological disorders,andskingrafts.

Guidelines for Sterile Field • Neverturnyourbackonasterilefield. • Avoidtalking. • Keepallsterileobjectswithinview(e.g.,belowwaistis notwithinsterilefield). • Moisturewillcarrybacteriaacross/throughaclothor paper barrier. • Transferofobjectsfromsteriletocontaminated (notsterile)=contaminated. • Donotreachacrossasterilefield.

BOX 3-1 STERILE TECHNIQUE: PROCEDURES AND GUIDELINES


5. Returnallpersonalbelongingstothefamily.Docu- mentwhatitemsweretakenandbywhom. 6. Attachidentifyingnametagtothebodyandtothe shroud.Shroudthebodyaccordingtofacility policy.

NURSING PRIORITY: ✔ Make sure there is correct identification attached to the body before allowing the body to be removed from the nursing unit.

Wound CareA wound is a disruption in normal tissue caused by ✽

traumatic injury; also may be surgically created.A. Nursing goals. 1. Promotehealing. 2. Preventfurtherdamage. 3. Prevent infection.B. Woundhealingisaffectedby: 1. Nutritional status. a.Adequatecaloriesandproteinarenecessaryfor tissue healing. b.Theobeseclientisatincreasedriskforpoor woundhealing. 2. Excessivewounddrainage:impairstissueregenera- tionandwillharborbacteria. 3. Aging: slowing of tissue regeneration. 4. Infection:prolongsinflammationanddelayswound granulation. 5. Locationandapproximationofwoundedges. 6. Circulationtothewound.C. Characteristicsofwoundhealing. 1.Blackwounds. a.Necroticdevitalizedtissue;highriskforinfec tion. b.Frequentlyrequiresharporsurgicaldebridement of tissue for healing to occur. 2. Yellowwounds. a.Containdevitalizedtissue;requirecleaningfor healing to occur. b.Mechanicaldebridementrequiresirrigationsand dressingchanges.A19Gintravenous(IV)cath- eterona30mLsyringeprovidessafepressure forirrigationandremovalofdevitalizedtissue. c.Wet-to-drydressings,wet-to-moistdressings, woundpacking,andenzymaticdebridement maybeusedtocleanseyellowwounds. d.Hydrocolloidaldressingstoretainmoisture. 3. Redwounds. a.Requireprotectionoffragilegranulationtissue. b.Topicalantibioticointmentandnonadhering dressingsmaybeusedonshallowwounds. c.Woundsshouldbekeptmoist(moisture-reten- tiondressings,hydrogeldressing);drydressings willdamagethenewgranulationtissue.

D. Processofwoundhealing. 1. Primaryintention:woundedgesapproximatedand closed(surgicalincision). 2. Secondaryintention:woundleftopentohealfrom theinsideoutwiththeformationofgranulation tissue.E Nursing interventions.

NURSING PRIORITY: ✔ When cleansing an area, always start at the cleanest area and work away from that area. Never return to an area you have previously cleaned. Discard the cleansing swab after each horizontal or vertical stroke.

1. Cleansingofwound.(Figure3-2) a. Horizontalwound:cleansedfromcenterofinci- sionoutward,thenlaterally. b. Verticalwound:cleansedfromtoptobottom, then laterally. c. Drainorastabwound:cleansedinacircular motion. 2. Woundirrigations:commonlyusedforlargeopen woundsthatarehealingbysecondaryintention. a. Directthesolutionfromthetoptothebottomof thewound,andfromcleantocontaminatedareas. b.Irrigationsolutionshouldbewarmedtopromote comfort. c.Positionclienttopromotegravitydrainagefrom wound. 3.Drainsareinsertedintoanopenwoundtoprevent theaccumulationofsecretionsandexudate.(Figure 3-3). a.Penrosedrain:softflexibledraininsertedinto wound.

figure 3-2 Wound cleansing. (From deWit, S. Fundamental skills and concepts for nursing, ed 3, St Louis, 2009, Saunders Elsevier.)


NURSING PRIORITY: ✔ Avoid pooling of excessive drainage under saturated dressing; this can lead to skin irritation and infection.

(1) Asafetypinorclipmaybeinsertedthrough thePenrosedraintopreventitfromslipping furtherbackintothewound. (2) Frequentdressingchangesarepreferableto reinforcingthesamedressing. b. Jackson-Prattcatheterordrainagesystem:Bulb mustbecompressedtoallowairtoescapeand thenisrecappedtomaintainsuction. c. Hemovac:Evacuatormustbecompressedat leastevery4hourstoprovidesuction;besureto emptydrainagefrompouringspout. 4. Wet-to-drydressings. a. Purposeistotrapnecrotictissueinthedressing asitdries. b. Dressingshouldbemoistwhenappliedand allowedtodryfor4to6hours. c.Whendressingischanged,thepackeddressing shouldbegentlyremovedalongwithabsorbed drainageandnonviabletissue.Donotsoak packingbeforeremoval;thiswilldecreasethe removalofnonviabletissue.

✔ NURSING PRIORITY: When performing wet to dry dressing change, wring out excessive moisture from dressings. The dressings should be thick and wet enough to dry between dressing changes.

5.Montgomerystraps:usedwhenfrequentdressing changesareneeded;helptopreventskinirritation thatcouldoccurwithtaperemoval.

6. Elasticizedabdominalbindersassisttopreventten- siononthesutureline,especiallybeneficialin obese clients. (Figure 3-4) 7. Obtainaspecimenofwounddrainage. a. Gentlyrollasterileswabinthepurulentdrain- age. b. Obtainwoundspecimenbeforeanymedication orantimicrobialagenthasbeenappliedto woundareaoradministeredtoclient.

TEST ALERT: Perform wound care and/or dressing change.

Heat and Cold ApplicationsA. Heat applications. 1. Purposeofheatapplicationistosoftenexudate,and increasebloodsupplytopromotehealing. 2. Unlessaphysicianorderscontinuousheatapplica- tions,treatmenttimeisusually20to30minutes. 3.Cautionclientregardinghotbathsandvasodilating effectthatmaycauseposturalhypotension. 4. Moistheatpenetratesdeeperthandryheat. 5. Donotuseheatonanareathatisbeingtreatedwith radiation,isbleeding,hasbeeninjuredwithinthe last24hours,orhasdecreasedsensation. 6. Types of heat application. a.Moistheatpack. b.Padthatcirculateswarmedwatertodistribute dryheattobodyparts.Coverthesourceto protecttheskin. c.Heatlamporheatcradle. d.Sitzbath,usecleanwater,notwatertheclient hasusedforbathing.B. Nursing intervention – heat application. 1. Takevitalsignsbefore,during,andafterheatappli- cation,ifheatisappliedtoalargearea. 2. Unlessanorderisforcontinuousheatapplications, treatmenttimeisusually20minutes.

figure 3-3 Medical – Wound drain and suction devices. (From deWit, S, Surgical Nursing: Concepts and Practice, St Louis, 2009, Saunders Elsevier.)

WOUND DRAIN AND SUCTION DEvICES

A, penrose drain.

B, Jackson-pratt drain and reservoir.

C, t-tube drain.

D, hemovac drainage system.

figure 3-4 Abdominal binding. (From deWit, S. Fundamental skills and concepts for nursing, ed 3, St Louis, 2009, Saunders Elsevier.)


3. Closelyobserveskinunderareaofheatapplication. 4. Donotallowclienttoadjusttemperaturesettings.C. Coldapplications. 1. Ice bag, ice collar, or ice glove. 2. Coldcompressorcoldpack. 3. Hypothermiablanket. 4. Reducesedema,swellingandpainifappliedimme- diatelyafteraninjury. 5. Maybeusedtodecreasetemperature.D. Nursingintervention–coldapplication 1. Frequentlycheckthetemperatureofaclientwitha hypothermiablanketfortreatmentofafever.

TEST ALERT: Provide cooling measure for elevated temperature.

2. Removethecoldpackif: a.Thereismottling,orrednessofskin. b.Clientcomplainsofburningpainornumbness.

3. Prevent chilling, 4. Donotusecoldapplicationsonareasofdecreased circulation,openwounds,orareatreatedwith radiationtherapy.

NURSING PRIORITY: ✔ Do not use hot or cold applications with conditions of impaired circulation (e.g., peripheral vascular disease or diabetes).

Specimen Collection

TEST ALERT: Collect specimens for diagnostic testing.

A. General principles. 1. Usesterileequipmenttoobtainspecimenandpre- ventcontaminationfromoutsidesources. 2. Usethecorrectcontainerforeachspecimen:Preser- vatives,anticoagulants,orchemicalsmaybere- quired. 3. Alwaysobservestandardprecautionswhenobtain ingspecimens,keepoutsideofcontainercleanto preventcontaminationintransfertothelaboratory. 4. Properlylabelthespecimen.Collectthecorrect amountatthecorrecttime.B. Typesofspecimen. 1. Urine(seeAppendix18-3). 2. Stool(seeAppendix13-13). 3. Sputum:throatornasopharyngeal(seeAppendix 10-8). 4. Blood.

5. Woundspecimen.

vital Signs

TEST ALERT: Take client vital signs; compare changes in vital signs to client’s baseline; notify supervisor or health care provider for change in

client status.

A. Normalvalues(Table3-1).B. Assessment. 1. Respirations. a. Evaluateaninfant’srespiratorypatternbefore stimulation. b. Checkthoraciccavityforsymmetricalexcur- sion. c. Breathsoundsarebestevaluatedwithclientin sitting position. 2. Pulse rate. a. Irregularradialpulse(weakvolumeorlowrate) shouldbeassessedbytakinganapicalpulserate readingfor1fullminute. b. Apicalpulseisauscultatedatthefifthintercostal spaceatthemidclavicularline(pointofmaximal intensity, PMI). c. Apical-radialpulseisdeterminedbytwopeople countingboththeapicalandtheradialpulse ratesatthesametime.Thisprovidesinformation aboutpulsedeficit,whichisthedifferencein the two values. d. Aweakperipheralpulsemaybeevaluatedbya Dopplerultrasound. e.Checkapicalpulseinneonates,infants,small childrenandinadultclientswithirregularpulse.

TABLE 3-1 NORMAL vITAL SIGNS

NEONATE Respiration 30-60breaths/min Pulse 120-140beats/min

CHILD 2 TO 4 yEARS Respiration 24-32breaths/min Pulse 90-130beats/min

CHILD 6 TO 10 yEARS Respiration 15-26breaths/min Pulse 70-110beats/min Bloodpressure 90/40-110/60mmHg

ADULT Respiration 12-18breaths/min Pulse 60-100beats/min Bloodpressure 100/60-120/80mmHg

NURSING PRIORITY: ✔ Know the range of normal values for vital signs at different age levels. This is critical for identifying changes in a client’s status as well as for determining specific criteria for medication administration.


3. Temperature. a. Temperatureisaffectedbymouthbreathingand temperatureoforalintake. b. Oraltemperatureistakenunlessotherwiseindi- cated. 4. Bloodpressure(BP)assessment(Box3-2).

NURSING PRIORITY: ✔ Know the range of normal values for vitas signs at different levels. This is critical for identifying changes in a client’s status as well as for determining criteria for medication administration.

iMMoBilityImmobility is the therapeutic or unavoidable restric- ✽

tion of a client’s physical activity.A. Causesofrestrictedmovement. 1. Spinalcordorneurologicalinjury. 2. Presence of severe pain: arthritis, surgery, or injury.B. Therapeuticreasonsforrestrictedmovement. 1. Todecreasepain. 2. Toimmobilizeawound. 3. Tolimitexerciseandactivity(e.g.,clientswithcar- diacproblems). 4. Toreduceeffectsofgravityonedema,varicosities.

Adverse Physical Effects of ImmobilityTheprimarynursinggoalinthecareoftheimmobilizedcli-entisthepreventionofcomplications.Thisisachievedbyinitiatingnursingactivitiestopreventcomplicationsandbycarefulassessmentofmajororgansystemsforspecificdataindicatingtheeffectsofimmobility.A. Cardiovascularsystem. 1. Physical effects. a. Orthostatichypotension(dropinbloodpressure [BP]uponstanding). b. Decreaseinabilityofthehearttomaintainout- put. c. Venousstasis. d. Increaseincardiacworkload. 2. Nursingimplications. a. Positionbodytoenhancecirculation. b. Changepositionfrequently. c. Usepassiveandactiverangeofmotion. d. Beginactivitygradually;allowclienttositbe- forestanding.B. Respiratorysystem. 1. Physical effects. a. Decreaseinthoracicexcursion. b. Decrease in O

2/CO

2exchange.

c. Increaseinpulmonaryinfections. d. Increaseincollectionoffluidsinthelung. 2. Nursingimplications. a. Elevateheadofbed. b. Maintainadequatehydration. c. Haveclientturn,cough,anddeepbreatheevery 2 hours.

d. Promoteincreaseinactivityassoonaspossible; haveclientsitupinchairatbedside. e. Assesspulmonarysecretionsforinfection.

NURSING PRIORITY: ✔ Encourage mobility to facilitate improvement in respiratory status, to assist in removal of secretions, to prevent pressure areas on the skin, prevent constipation, and prevent contractures.

C. Urinarysystem. 1. Physical effects. a. Urinary stasis. b. Increasedcalciuminurinemayprecipitatestone formation. c. Urinary tract infections. 2. Nursingimplications. a. Haveclientsituptovoid,ifpossible. b. Increasefluidintake. c. Decreasecalciumintake. d. Assessforurinaryretentionandurinarytract infection.D. Musculoskeletalsystem. 1. Physical effects. a. Demineralizationofbones:decreaseinbone strength.

ProcedureClientshouldbeinasittingpositionwithoutlegscrossed.Theinflatablecuffiswrappedsnugglyaroundtheupperhalfofthearm.Thecuffisinflated20to30mmHgabovethepointatwhichradialpulsationdisappears.Asthecuffisdeflated,asoundisproducedwithinthebrachialarteryjustbelowthecuffandisaudiblewiththestethoscope.Thesounds(Korotkoffsounds)coincidewitheachpulsebeat.Usually,whenthecuffpressureisbelowdiastolic,thesoundswillceaseorbecomemuffled.

Nursing ImplicationsSizeofcuffshouldbe20%widerthanthediameterofthelimb.Ifthecuffistoolarge(e.g.,onachild’sarm),theBPobtainedwillbesubstantiallylowerthanthetrueBP.Ifthecuffistoosmall(e.g.,onanobeseperson’sarm),theBPobtainedwillbehigherthanthetrueBP.ThedifferenceinBPbetweentherightandleftarmsisnormally5to10mmHg.

BOX 3-2 BLOOD PRESSURE ASSESSMENT

NURSING PRIORITY: ✔ It is important to ascertain and record when the sounds become muffled. If there is any doubt, the blood pressure (BP) may be recorded as a tripartite pressure (120/70/50 mm Hg), implying that the sound be-came muffled at 70 mm Hg and disappeared at 50 mm Hg.


b. Muscleweaknessandatrophy,paralyticileus. c. Lossofmotioninjointsleadstofibrosisand contractures. 2. Nursingimplications. a. Performrangeofmotionexercises. b. Encourageactivecontractionandrelaxationof largemusclegroups. c. Positionbodytomaintainproperalignment. d. Encouragedailyweightbearing(standingat bedside)whenpossible.E. Gastrointestinalsystem. 1. Physical effects. a. Anorexia. b. Ineffectivemovementoffecesthroughcolonthat leadstoconstipation. c. Diarrheasecondarytoimpaction. 2. Nursingimplications. a. Establishbowelprogram;forexample,defecate everyotherdayorthreetimesaweek. b. Encouragedietwithadequateprotein,bulk,and liquids. c. Checkforimpaction.F. Integumentarysystem. 1. Physical effects. a. Decreaseintissueperfusionleadingtopressure ulcer. b. Decreaseinsensationinanareaofincreased pressure. 2. Nursingimplications. a. Maintain cleanliness.

b. Promotecirculationthroughfrequentposition- ing changes. c. Protectbonyprominenceswhenturning. d. Preventpressureareasfromtightclothing,cast, or braces. e. Performfrequentvisualinspectionofpressure areas.

TEST ALERT: Provide for mobility needs; maintain skin integrity; identify signs and symptoms

of venous insufficiency.

pAiNPain is a complex, universal experience. ✽

Painisasensoryperceptualexperience Painisatotallysubjectivepersonalexperience Pain is an early warning sign; its presence triggers awarenessthatsomethingiswronginthebody (Figure 3-5).A. Types of Pain 1. Acutepain:hasanidentifiablecause;isprotective; short,predictableduration(lastinglessthan3 months);itfrequentlyhasanimmediateonsetandis reversibleorcontrollablewithtreatment.Most oftenhasanidentifiablesourcesuchaspostopera- tivepainthatdisappearsasthewoundheals. 2. Chronicpain:lastsmorethan6months;continual orpersistentandrecurrent.Painmaynotgoaway; periodsofdecreasedandincreasedpain.Originof painmaynotbeknown.

figure 3-5 Considerations of the pain experience. (From: Black J, Hawks, J: Medical Surgical Nursing: Clinical management for positive outcome, ed 7, 2005, Philadelphia, Saunders.)


3. Referredpain:painthatdoesnotoccuratthepoint ofinjury.Forexample,painrelatedtomyocardial ischemiamaybefeltintheleftarmorshoulder; cholecystitismaybefeltasshoulderpain. 4. Phantompain:painthatfollowstheamputationofa bodypart;maybedescribedasthrobbing,cramping,orburninginthebodypartamputated. 5. Pretendedpain(malingering):clientexpressesthat there is pain when actually has no pain. 6. Psychogenicpain:painduetoemotionalfactors ratherthanphysiologicaldysfunction.B. PainAssessment(Box3-3). 1. Pattern of pain. a.Painonsetandduration:whenitstarted,precipi- tatingcauses,andhowlongitlasts. b.Breakthroughpain:transient;maybemoderate tosevereandoccursbeyondcurrentanalgesic treatment;usuallyrapidonsetandveryintense. 2. Area of pain. a.Asktheclienttoidentifythepainsite. b.Painmaybereferredfromtheprecipitatingsite toanotherlocation—shoulderpainwith cholecystitis,leftarmpainwithMI. c. Sciatica pain follows a nerve pathway of the sciaticnerve,generallydownthebackofthe thighandinsidetheleg. d.Intensityofpain:useapainorratingscaleto helptheclientcommunicatethepainintensity.

TEST ALERT: Validate pain utilizing a rating scale.

3. Typeofpain-sharp,burning,throbbing,cramping. 4. Determineanyactivitiesandsituationsthatprecipi- tateorincreasethelevelofthepain—movement, ambulation,coughing. 5. Client responses to pain. a. Increasedbloodpressure,pulse,andrespira- tions. b.Diaphoresis,increasedmuscletension,nausea andvomiting. 6. Client’sinterpretationandmeaningofthepain experience. 7. Harmfuleffectsofpain.(Box3-4)

Cultural Implications of PainA. Culturalbeliefsandvaluesaffecthowaclientresponds to pain.B. Nursesfrequentlyassumethattheirownculturalimpli- cationsofpainandthewaystheydealwithpainare thesameasthoseoftheclient.C. Assessattitudesandbeliefsthatmayaffecteffective treatmentofthepain.Someclientsmaybelievethat takingpainmedicationswillcause“addiction”; otherclientsmaybelievethatcomplainingofpainis asignofweakness.D. Avoidstereotypingclientsbyassumingaspecificcul- turewillorwillnotexhibitmoreorlesspain.E. Nursingconsiderationsofpaincontrolassociatedwitha client’sculture: 1. Identifywhatthepainmeanstotheclient;for example,awomaninlaborwillperceivepaindif- ferentlythanaclientwhoexperiencespainasan indicationofadvanceddisease. 2. Identifyculturalimplicationsregardinghowaclient respondstoorexpressespain;someclientsmoan andcomplainloudlywhileothersmaybeveryquiet andstoic. 3. Individualizepaincontrolbasedontheclient’sresponse to pain. 4. Establishcommunicationmethodsfortheclientto expresslevelofpainandadequacyofpaincontrol (e.g.,painscales,FACESscale,pictures,images). 5. Expressionofpainissubjective;acceptclient’sper- ceptionandexpressionofpain,andfacilitate nursingcaretomeetclient’sculturalneedsin providingpaincontrol.

TEST ALERT: Recognize cultural diversity in client’s perception of and response to pain.

P:Provokingorpalliativefactors

Q:Quality

R: Region

S: Severity

T:Timing

BOX 3-3 MNEMONIC TO EvALUATE PAIN

Acute PainDisturbs sleepAppetitedecreasesFluidintakedecreasesNauseaandvomiting

Chronic PainFatigueWeight gainPoor concentrationJob lossDivorceDepression

BOX 3-4 ASSESSING THE HARMFUL EFFECTS OF PAIN

NURSING PRIORITY: ✔ The nurse should administer pain medication to clients experiencing acute pain without fear of addicting the client to the medication.


Noninvasive Pain Relief MeasuresA. Nursinginterventionforpainrelief(nonpharmacological). 1. Changepositionsfrequentlyandsupportbodyparts. 2. Encourageearlyambulationaftersurgery. 3. Elevateswollenbodyparts. 4. Checkdrainagetubestoensurethattheyarenot stretched,kinked,orpulled. 5. Providecutaneousstimulationthroughpressure, massage,bathing,andheatorcoldtherapyto promoterelaxation.

NURSING PRIORITY: ✔ Low levels of anxiety or pain are easier to reduce or control than are higher levels; pain relief measures should be used before pain becomes severe.

B. Relaxationtechniques. 1. Relaxedmusclesresultindecreasedpainlevel. 2. Typicalrelaxationexercisesfocusondeepbreathing andalternatetensingandrelaxingofvariousbody partsinasystematicmanner. 3. Meditation:focusesattentionawayfrompain. 4. Rhythmicbreathing:methodofrelaxationanddis- traction by focusing on the breath. 5. Musicmayassistinrelaxation.C. Guidedimagery. 1. Creativevisualizationisthetherapeuticuseofim- agesfromone’simaginationtofocusawayfrom painsensationbyemphasizingpleasantmemories andexperiences. 2. Oftencombinedwithrelaxationandbiofeedback.D. Hypnosisisalsousedtoproduceastateofalteredcon- sciousnessthatischaracterizedbyextremeresponsive- ness to suggestion.E. Biofeedback:providesclientwithinformationabout changesinbodyfunctionsofwhichclientisusually unaware(e.g.,bloodpressure,pulserate).F. Transcutaneouselectricnervestimulation(TENS). 1. Deliversanelectricalcurrentthroughelectrodes appliedtotheskinsurfaceofthepainfulregion or to a peripheral nerve. 2. Identifytriggerpoints(areasthatareextremelysen- sitivewhenstimulated)andplaceelectrodes. 3. InstructclienttoadjustTENSunitintensityuntilit createsapleasantsensationandrelievesthepain.G. Acupuncture:mostcommoncomplementarytherapyto decreasepain. 1. Requiresinsertionofthinmetalneedlesintothe bodyatdesignatedpointstorelievepain. 2. Iseffectiveinpainmanagement,aswellasnausea andvomitingassociatedwithpostoperativeand chemotherapy. 3. Encourageclienttoreviewthecredentialsofthe practitioner,whoshouldhaveamaster’sdegreein orientalmedicineandberegisteredtopracticein the state.

TEST ALERT: Identify client need for PRN medications; provide nonpharmacological mea-

sures for pain relief; use an alternative/complimentary nursing actions in providing pain control (e.g., imagery, massage, repositioning).

Medications for Pain ReliefA. Administeras-needed(PRN)analgesicmedications (seeAppendix3-2:Analgesics). 1. StepsinadministeringPRNmedications. a. Assessclienttodeterminesourceandquality andcharacteristicsofpain. b. Checkclient’schart. (1) Lastmedicationreceivedandrouteofad- ministration. (2) Thetimeadministered. (3) Client’sresponsetomedication c. Checkcurrentorderforpainmedication. d.Selectappropriatemedication. (1) Usenonopioidanalgesicsformildtomod- erate pain. (2) Avoidcombinationsofopioidsforolder adults. (3) IVmedicationsactmorerapidlyforacute pain relief. (4) AvoidIMinjectionsinolderadults. (5) Sustained-releaseandextended-releaseoral medicationsworkwellforchronicpain managementandwillprovidepainman- agementoveralongerperiodoftime.

NURSING PRIORITY: ✔ Use a preventive approach in alleviating pain by administering narcotics before the pain occurs (if it can be predicted), or at least before it reaches severe intensity. This is particularly important in regard to care of the new postoperative client.

e. Documentpainintervention. f. Decreasestimuliinroomanddetermineother factorsinfluencingdiscomfort. g. At15-and30-minuteintervals,assessclient’s responsetopaininterventionanddocument nursing actions.B. Typesofmedications. 1. Narcoticanalgesicsareusedforrelievingsevere pain. Example: Morphine, codeine, hydromorphone (Dilaudid), meperidine (Demerol), oxycodone (Percodan). 2. Nonnarcotic analgesics act at peripheral sites to re- ducepain. Example: Propoxyphene (Darvon), 3. Potentiatingdrugsareusedtointensifytheactionof the narcotic agent. Example: Promethazine (Phenergan), hydroxyzine (Vistaril, Atarax), diazepam (Valium).


4. Nonsteroidalanti-inflammatorydrugshaveanalge- sic,anti-inflammatory,andantipyreticproperties. Example: Acetylsalicylic acid (ASA) or aspirin, acetaminophen (Tylenol), ibuprofen (Motrin, Advil), naproxen (Naprosyn).C. Patient-controlledanalgesia(PCA). 1. Clientcontrolsdeliveryofpainmedicationviaa PCApump. 2. Acommonorderisfor1to4mgofmorphineevery 10minutesuntilpainisrelievedwithalockoutdose of10mgperhour. 3. Checkforparametersforbolusdoseofmedication. a.Shouldbeavailableforepisodesofincreased pain(dressingchanges,chesttubeinsertion,etc). b.Fortheclientwhogoestosleepandawakens withseverepainunrelievedbyPCA. c. Forcancerclientswhoexperiencebreakthrough pain. 4. AdvantagesofPCA. a. More effective pain control. b. Decreasedclientanxiety,clientcontrolspain moreeffectively. c. Increasedclientindependence. d. Decreasedlevelofsedation. e. Clienttendstouselessnarcotic. 5. Instructanyfamilymemberorsignificantothersnot toadministermedication(documentthatyouhave donethis).ExplainthatPCAworksontheprinciple thatwhentheclientisuncomfortable,heorshewill use the PCA.

NURSING PRIORITY: ✔ Fear of addiction is often major concerns of clients (and their families) who are receiving pain medications. The nurse should administer PRN pain medication to clients experiencing acute pain without the fear of addicting the client to the medication.

D. Palliative Pain Relief 1. The prevention or relief of pain when a cure for the client’sillnessisnotfeasible.

TEST ALERT: Palliative/comfort care: assess client for nonverbal signs of pain/discomfort.

Assess, intervene, and educate client/family about pain management.

2. Administeranalgesicsbasedonclient’slevelof pain;medicationisincreasedasclient’spainin- creases. 3. Painmedicationisfrequentlyadministeredonan around-the-clockscheduleratherthanaPRN scheduletomaintaintherapeuticlevelsofmedica- tion.Painmedicationisadministeredintheabsence of pain.

4. Anurse’sorclient’sfearthattheclientwillbecome dependenton,addictedto,ortoleranttomedication is inappropriate in the provision of pain control in palliative care. 5. Breakthroughpainfrequentlyoccursinclientswith cancer;painmayoccurspontaneously,maybepre- cipitatedbycoughing,mayoccuratanytimeduring thedosinginterval,ormayoccurtowardtheendof thedose. 6. Fearthatopioidswillhastendeathisunsubstanti- ated,eveninclientsattheveryendoflife.Itisim- portantthatnursesprovideadequatepainrelieffor theterminallyillclient.

OLDER ADULT PRIORITY: ✔ Analgesics tend to last longer and there is an increased risk for side effects and toxic effects in the older client.

E. Evaluation of Pain Control 1. Identifyclientbehaviorresponsebeforetheinter- ventionandcomparewithresponsefollowingthe intervention. 2. Basedonassessmentofpainpriortomedication, determineifpainhasbeenresolved. 3. Chartclientresponsetopainmedication.

eND-of-life CAreA. Providepsychosocialsupporttoclientandfamily

TEST ALERT: Provide care and support to clients and families at end-of-life; identify

client’s end-of-life needs and ability to cope with end of life interventions.

1. Assistfamilytoidentifyresourcesfordecisions abouttreatmentandtoprepareadvancedirectives. 2. Assistclienttoidentifyandtocontactspiritualad- visors. 3. Respondquicklytocalllights,checkonclient often,thishelpstokeeptheclientfromfeeling abandonedorisolated. 4. Encouragefamilytoparticipateincareassisting withfood,hygienemeasures,physicalcontact.B. Assistclienttounderstandimplicationsofresuscitation andassociatedterms.

NURSING PRIORITY: ✔ It is important that clients understand that full comfort and physical assistance will continue to be provided regardless of their choice to be resuscitated or not. Respect client choices for palliative care.

1. Allownaturaldeath(AND),andordonotresusci- tate(DNR):maintaincomfortmeasures,hygiene andpaincontrol;ordermustbewrittenonchart.


2. Fullcode:fullCPRandresuscitationactions. 3. Hospice care or palliative care a. Does not refer to a place, but rather to a concept ofcarethatprovidessupportfortheclientwhois dying. b.Caremaybeprovidedinlong-termcarefacility, hospital,orathome. c. Criteriaforhospicecareincludestheclient’s desirefortheserviceandaphysician’sstate- mentthattheclientwillprobablynotsurvive beyondthenext6months(theallowedtime frameissomewhatflexiblesinceactualamount oftimecannotbepredicted).

Physical Management of SymptomsA. Physicalsymptomsofimpendingdeath. 1. Sensory. a.Hearingisusuallythelastsensetodisappear –alwaysconsidertheunconsciousclientcan hear. b.Taste,smellarediminished. c.Visionisoftenblurred,blinkreflexmaybeab- sent. 2. Integumentary:skinisoftencoolandclammy; mottlingoccursonextremities;cyanosisoccurs aroundmouthandnoseandonnailbeds. 3. Respiratory a.Respirationsbecomeshallowandirregular; CheyneStokes—periodsofapneaalternating withdeeprapidbreathing. b. Increasedmucusinupperairwaycausing gurgling, noisy respirations. c. Inability to cough or clear airway. 4. Cardiovascular. a.Heartratemayvaryfromaregular,increased ratetoaslowingandirregularheartbeatbefore death. b.Decreasedbloodpressureandtissueperfusion. 5. Elimination. a.Urinary:outputdecreases,incontinenceoccurs. b.Bowel:monitorforconstipation;bowelinconti- nencemayoccur. 6. Musculoskeletal. a.Graduallossofabilitytomove,lossoffacial muscletone. b.Difficultyspeaking,unawareofbodyposition. 7. Neurological. a.Decreasedlevelofconsciousness. b.Decreasedreflexes:gag,cough,swallow.B. Nursing interventions. 1. Providepalliativepainmanagement—thepreven- tionorreliefofpainwhenacurefortheclient’s illness is not feasible. a.Painmedicationisfrequentlyadministeredon anaround-the-clockscheduletomaintainthera- peuticlevelsofmedication;donotdelayordeny painreliefmeasurestoadyingclient.

b.Moderatetolargeamountsofopioidsmaybe requiredtomaintainclient’scomfort. c.Administeranalgesicsbasedonclient’slevelof pain;medicationisincreasedasclient’spain increases. d.Adjuvantmedicationstoincreaseeffectiveness ofanalgesics—antiemetics,antidepressants, corticosteroids. e.Anurse’sorfamily’sfearthattheclientwill becomedependenton,addictedto,ortolerantto painthemedicationisinappropriateinprovision of pain control in palliative care. 2. Dehydration:maintainoralhygiene;donotforcethe clienttoeatordrink.Theoptiontowithhold artificialnutritionorhydrationshouldbemade bytheclientintheadvancedirective,orbythe persondesignatedinadvancedirective. 3. Respiratorydistress:elevatetheheadofthebed, offeroxygen,providemedicationstodecrease apprehension. 4. Elimination. a.Utilizeincontinencepads,preventskinirrita- tion,followfacilityprotocolforindwelling catheters. b.Monitorbowelfunction,assessforimpaction, promotenormalfunctionwithinclient limitations. 5. Anorexia,nauseaandvomiting. a.Assessforprecipitatingcauseandadminister medicationstodecreasenausea. b.Offersmall,frequentmeals,butdonotfocuson client’sneedtoeat. 6. Determineclient’spersonalpreferencesandcultural implicationsregardingdeath.Providefamilycare regardingculturalneeds.

perioperAtive CAreSurgicalprocedures,whetherplannedoranemergencyinter-vention,representacrisisinaclient’slife.Howeverminor,surgicalproceduresalwayscarrysomedegreeofrisk,physi-caldiscomfort,andfinancialstress.A. Perioperativereferstotheentireoperativeexperience (preoperative,intraoperative,andpostoperativecare).B. Preoperativephase:theperiodoftimebeforethesurgi- calprocedure. 1. Assessmentandcorrectionofphysiologicaland psychologicalproblemsthatmayincreasethe client’sriskfactors. 2. Clientteachingregardingthesurgery. 3. Clientteachingregardingpostoperativecareand activities.C. Intraoperativephase:theperiodoftimetheclientisin theoperatingroom.D. Postoperativephase:thisperiodbeginswiththeadmis- sion of the client to the postanesthesia care unit (PACU) andincludestheremainderoftheclient’shospitaliza- tionandrecoveryperiod.


Preoperative Care

TEST ALERT: Perform care for client before and after surgical procedure.

A. Clientprofile. 1. Age:Theolderadultandtheinfanthavemoredif- ficultymaintaininghomeostasisthandothe adultandchild.Theolderadultismorelikelyto havechronichealthproblemscomplicatingsurgery (Box3-5). 2. Weight:Obesitypredisposestheclienttopostopera- tivecomplicationsofinfectionandwounddehis- cence.Fattytissueismoresusceptibletothe infectious process. 3. Preoperative interview. a. Chronichealthproblemsandprevioussurgical procedures. b. Pastandcurrentdrugtherapy,includingover- the-counter(OTC)medications.

NURSING PRIORITY: ✔ Evaluate client’s current medications, be sure to include OTC medications as well as any alternative medications (herbal remedies).

c. Historyofdrugallergiesanddietaryrestrictions. d. Client’sperceptionofhisorherillnessandim- pendingsurgery. e. Client’sleveloforientationandanyvisualor auditoryproblemsthatwouldhinder communication. f. Discomfortorsymptomsclientiscurrentlyex- periencing. g. Religiousaffiliation. h. Familyorsignificantothers. 4. Psychosocialneeds:Fearoftheunknownisthe primarycauseofpreoperativeanxietyinthemen- tallystableclient.Thesurgicalexperienceisunique toeachclientandrepresentsatimeofcrisis. 5. Checkroutinelaboratorystudies–mayvary accordingtoclient’sdiagnosis,valuesshouldbe availabletosurgicalteam. a. Completebloodcount(CBC),bloodtype. b.Clottingstudies(PT,PTT,INR,seeAppendix 11-1). c. Urinalysis. d. Chestx-ray–especiallyforolderadults e. Serumelectrolytes,serumcreatinineandblood ureanitrogen(seeAppendix18-1). f. Electrocardiogram(ECG)-generallyforclients over40yearsorunlessotherwiseindicated.

TEST ALERT: Anticipate questions regarding basic pre and postoperative nursing care as well

as questions that apply to a specific surgical condition or procedure. Nursing implications for specific surgical procedures may be found under the major systems in the care of the medical-surgical client.

B. Preoperativeteaching:Thegoalistodecreasethe client’sanxietyandtopreventpostoperativecomplica- tions. 1. Evaluatetheclient’scurrentunderstandingofhis/ herillnessandoftheanticipatedsurgicalinterven- tion. 2. Useterminologytheclientwillunderstand. 3. Donotoverwhelmtheclientwithtoomuchinfor- mationatonetime;allowadequatetimeforclient questions. 4. Involvetheclient’ssignificantothersinthepreop- erative teaching. 5. Preoperative teaching content. a. Deepbreathingandcoughingexercises. b. Turningandextremityexercises. c. Painmedicationpolicy,forexample,PRN,PCA.

Olderadultclientsareatincreasedriskfordeveloping postoperativecomplicationsbecauseofthedecreased responseoftheimmunesystem(whichdelayshealing) aswellastheincreasedincidenceofchronicdisease. • Cardiovascular:decreasedcardiacoutputandperipheral circulation,arrhythmiasaremorefrequentandcanlead toadecreasedcardiacoutput.Thereisanincreased incidenceofarteriosclerosisandatherosclerosiswhich canleadtohypertension. • Respiratory:decreasedvitalcapacity,reducedoxygen exchange,anddecreasedcoughreflexcanleadtoan increasedriskforatelectasis,pneumonia,andaspiration. • Renal:decreasedrenalfunctioncanleadtofluid overload,dehydration,andelectrolyteimbalance. • Musculoskeletal:increasedincidenceofarthritisand osteoporosisleadtoanincreasedriskoffallsand decreasedmobility. • Sensory:decreasedvisualacuityandhearingaffectthe client’sreactiontimeandcanleadtosafetyproblems associatedwithfallsandinjuries. Poor nutritional status which can affect healing as well as postoperative recovery. Theolderclientmayrequirerepeatedexplanation, clarification,andpositivereassurance.

TEST ALERT: Provide care that meets the special needs of the older adult client.

BOX 3-5 OLDER ADULT CARE FOCUS Preoperative and Postoperative Considerations


d. Adjunctequipmentusedforbreathing:incentive spirometry,nebulizer,O

2mask.

e. ExplanationofNPOpolicyifindicated.C. Physical preparation. 1. Skinpreparation. a.Theoperativesiteandthesurroundingarea shouldbecleanedeitherbytheclientorby specificcleansingofthesitebyamemberof thesurgicalteam. b.Shavingtheoperativeareaisnolongerrecom- mendedtobedonebynursingstaff;ifareaisto beshaveditshouldbedoneinthepreoperative holdingareaorintheoperatingroom. 2. Foodandfluidsarerestrictedforapproximately6 hours preoperatively. 3. Enemasorsometypeofgastrointestinalcleansing isusuallyadministeredtheeveningbeforesurgery involving the GI tract, pelvic area, or retroperitoneal area.Thisassiststopreventfecalcontaminationin theperitonealcavity.Takesafetyprecautionswith olderadultclient,bowelpreparationcanbeexhaust- ing. 4. Promotesleepandrest:Afterthepreoperativepro- ceduresarecompleted,theclientgenerallyreceives asleepingmedicationtopromoterest.Common medicationsusedarebarbiturates.D. InformedConsent 1. The physician is responsible for having the con- sentformsigned.Itmustbesignedbeforesedation isgiven.Thesurgeonshouldgivetheclientafull explanationoftheprocedure,includingcompli- cations,alternatives,andrisksinvolved. 2. Theclient’sinformedconsentrecord(permit)must besignedbythephysician,theclient,andawitness; thewitnessisfrequentlythestaffnurse.

NURSING PRIORITY: ✔ The informed consent record (permit) must be signed before the client receives the preoperative medication.

3. Thesignedconsentrecord(permit)ispartofthe permanentchartrecordandmustaccompanythe clienttotheoperatingroom.

Day of SurgeryA. Nursing responsibilities. 1. Have client follow routine hygiene care or shower withanantisepticsolutionorbactericidalsoap. 2. Reviewclient’sregularlyscheduledmedications anddetermineifanymedicationsaretobeheldon thedayofsurgery,orifallmedicationsshould be given. 3. Recordvitalsignswithin1hourofclientbeing transportedtosurgery. 4. Secureand/orremovevaluablesaccordingtohospi- talpolicy;weddingbandsmaybetapedonfinger.

5. Facilitymayrequiretheclienttoremovefingernail polishorartificialnailfromatleastonefinger. 6. Mostoftendenturesandremovablebridgeworkare removedtopreventbreakage,aspirationorairway obstruction.Checkyoungchildrenforthepresence of loose teeth. 7. Removecontactlens,prostheticdevices,glasses, hairpiecesandgivethemtotheclient’sfamily. Removeanymetalhairpinsorclips. 8. Checkclient’sidentificationforfirstandlastname, dateofbirth,physician,andhospitalnumber. 9. Identifyfamilyandsignificantotherswhowillbe waitingforinformationregardingclient’sprogress. 10. Checkthechartforcompletenessregardinglabora- toryreports,signedconsentform,significantclient observations,historyandphysicalrecords. 11. Makesurethesurgicalteamisawareofadvanced directives,oranyreligiousbeliefsthatcouldimpact surgery(bloodtransfusions).B. Preoperativemedications(seeAppendix3-3). 1. Purpose. a. Decreaseanxietyandprovidesedation. 2. Nursing responsibilities. a. Askclienttovoidbeforeadministrationofmedi- cation. b. Obtain baseline vital signs. c. Medicationisusuallyadministeredaboutan hour before surgery. Many institutions are administeringthemedicationintheoperative suitesotheclientcanparticipateinthe“time out”processforidentificationofoperativesite. d. Raisethesiderailsandinstructtheclientnotto getoutofbed. e. Removedenturesandpartialplates. f. Observefordesiredresponseaswellasundesir- ablesideeffectsofmedication. g. Maintainquietenvironmentbeforebeingtrans- portedtotheoperatingroom. h. Allowparenttoaccompanychildasfaraspos- sible.C. The“timeout”istheprotocolforpreventingwrong site,wrongprocedure,wrongpersonsurgery;itmust occurinthelocationwheretheprocedureisperformed. Allmembersofthesurgicalteamareinvolvedinthe positiveidentificationoftheclient,thenameofthe intendedprocedure,andthesiteoftheprocedure.D. Nursingconsiderationsforspinalanesthesia. 1. Client will not be able to feel any sensation below level of anesthesia. 2. Vasodilationbelowlevelofanesthesiamayprecipi- tate hypotension. 3. Clientmayexperiencepostanesthesiaheadache (“spinal”headache). 4. Clientmayremainawakethroughoutprocedure. 5. Maybeusedinmajorsurgicalproceduresbelowthe levelofthediaphragm.


OLDER ADULT PRIORITY: ✔ Spinal anesthesia may be used for clients undergoing transurethral resec-tion of the prostate (TURP), inguinal herniorrhaphy, or orthopedic procedures, as well as for poor-risk clients who would not tolerate inhalation anesthesia very well.

E. Conscioussedation:theadministrationofanIVmedi- cationtoproducesedation,analgesia,andamnesia. 1. Characteristics. a. Clientcanrespondtocommands,maintains protectivereflexes,anddoesnotneedassistance tomaintainairway. b. Amnesiamostoftenoccursaftertheprocedure. c.Slurredspeechandnystagmusindicatetheend ofconscioussedation 2. Nursingimplications. a. Clientisassessedcontinuously;vitalsignsare recordedevery5to15minutes. b. Monitorlevelofconsciousness;clientshouldnot beunconscious,butrelaxedandcomfortable. c. Clientshouldrespondtophysicalandverbal stimul;protectiveairwayreflexesremainintact. d. Potentialcomplicationsincludelossofgagre- flex,aspiration,hypoxia,hypercapnia,andcar- diopulmonarydepression. e. Doesnotrequireextensiverecoverytimefollow- ing surgery.

Immediate Postoperative RecoveryA. Admissionofclienttorecoveryarea. 1. Obtainbaselineassessment. a. Vitalsigns. b. Status of respirations. c. General color. d. Typeandamountoffluidinfusing. e. Specialequipment. f. Dressings. 2. Notifysupervisororsurgeonregardinganydeterio- rationofclient’sconditionduringthepostoperative recoveryperiod.

Nursing Interventionsv Goal: Tomaintainandsupportrespiratoryfunction.A. Leaveairwayinplaceuntilpharyngealreflex(gagref- lex)hasreturned.B. Positionclienttomaintainventilationandpreventaspi- ration.C. Encouragecoughinganddeepbreathing.D. Administerhumidifiedoxygenasnecessary.E. Reportsignificantchangesinrespiratorystatus.F. Listentothechestforadecreaseinbreathsounds. NotifysupervisororPCPiftherearesignificant changes in respiratory status.G. Monitorstatusandchangesinpulseoximetry.

NURSING PRIORITY: ✔ The client’s respiratory status is a priority concern throughout the client’s entire stay in the postoperative recovery area.

v Goal: Tomaintaincardiovascularstability.A. Checkvitalsignsevery15minutesuntilstable;compare with preoperative vital signs.B. Reportbloodpressuremeasurementthatiscontinually dropping5to10mmHgwitheachreading.C. Reportconsistentlyincreasingbradycardiaortachycar- dia.D. Evaluatequalityofpulseandpresenceofirregular pulse.v Goal: Tomaintainadequatefluidstatus.A. MonitorrateofIVinfusion.B. Measureurineoutputifbladdercatheterispresent (minimumof30mLperhourforanadult).C. Evaluateforbladderdistentionifthereisnocatheter.D. Observeamountandcharacterofdrainageondressings ordrainageincollectingcontainers.E. Assessamountandcharacterofgastricdrainageif nasogastric tube is in place.F. Nauseaandvomitingmayoccurasclientisrecovering fromanesthesia.v Goal: Tomaintainincisionalareas.A. Evaluateamountandcharacterofdrainagefrominci- sionanddrains.B. CheckandrecordstatusofHemovac,Jackson-Pratt,or anyotherwounddrains.v Goal: Tomaintainpsychologicalequilibrium.A. Speaktoclientfrequentlyincalm,unhurriedmanner.B. Continually orient client.C. Maintainquiet,restfulatmosphere.D. Promotecomfortbymaintainingproperbodyalign- ment.E. Explainallprocedures,evenifclientisnotfullyawake.F. Rememberthatintheanesthetizedclient,thesenseof hearingisthelasttobelostandthefirsttoreturn.v Goal: Clientmeetscriteriatoreturntoroom.A. Vitalsignsarestableandwithinnormallimits.B. Clientisawakeandreflexeshavereturned.C. Dressingsareintactwithnoevidenceofexcessive drainage.D. Clientcanmaintainapatentairwaywithoutassistance.

General Postoperative Carev Goal: Tomaintaincardiovascularfunctionandtissueperfusion.A. Monitor vital signs, usually every 4 hours, after full recovery.B. Evaluateskincolorandnailbedsforpalenessand cyanosis.C. Assessclient’stolerancetoincreasingactivity.D. Encourageearlyactivityandambulation.E. Monitorforcirculatorycomplicationsofimmobility.


TABLE 3-2 COMMON POSTOPERATIvE COMPLICATIONS

COMPLICATION SIGNS AND SyMPTOMS NURSING INTERvENTIONAtelectasis - a collapse of a portion of thelungproducinganairlessstateinthealveoli. (Chapter 10)

Pulmonary emboli(PE)movementofathrombusintothepulmonaryartery.(Chapter 10)

Pneumonia–anacuteinflammatoryprocesswherealveolifillwithfluid.(Chapter 10)

Shock-adecreaseincardiacoutputduetolossofcirculatingbloodvolume.(Chapter 11)

Wound infection - an infection of the surgical incision area.

Wound dehiscence

Wound evisceration

Dyspnea,decreasedorabsentbreathsoundsoveraffectedarea,asymmetricalchestexpansion,hypoxia.

Chestpain,dyspnea,tachycardia,increasedanxiety,decreasedpulseoximetry,decreasedbloodpressure.

Fever, shallow respirations, wet breath sounds,coughproductiveofthickyellowmucus,mayprogresstohypoxia.

Decreasingbloodpressure,weakpulse,restless, confusion, oliguria.

Poorwoundhealing,redness,tenderness,fever,tachycardia,leukocytosis,purulentdrainage.

Unintentional opening of the surgical incision.

Protrusion of a loop of bowel through thesurgicalwound.

Positionclientonunaffectedside.Maintainhumidification,oxygen(see Chapter 15). Administernarcoticscautiouslyifclientisatincreasedrisk.Prevention:assistclienttoturn,cough,anddeepbreath;provideadequatehydration;encourageambulation,preventabdominaldistention.

NotifyRNimmediatelyofanychestpainordifficultybreathinginclientsatincreasedrisk.Placeclientinsemi-Fowlerspositionandbeginoxygen.Maintainbedrest.RemainwithclientinrespiratorydistressPrevention:Encourageambulationassoonaspossible, position client to prevent venous stasis.

Maintainclientinloworsemi-Fowlers,monitorpulseoximetrylevels.Humidifiedoxygenandmaintaingoodhydration. Prevention:coughanddeepbreath,encourageincentivespirometry.Olderadultclientsareatincreasedrisk;encouragepostoperative activity as soon as possible.

AnticipateRNwillinitiateIVaccessifnotpresent,maintainNPOandbedrest.Positionclientsupine.Preventhypoxiaandmonitorvitalsigns.(seeChapter11).Prevention:closelymonitordrainsandincisionsforbleeding,identifyclientsatincreasedrisk.

Cultureincisiontodetermineorganism.Evaluateprogressofwoundhealing.Prevention:identifyhigh-riskclients;maintainsteriletechniquewithdressingchanges;goodhandhygiene.

Evaluateforbleeding;maintainbedrestandorposition client to prevent further pressure at incision site.Prevention:identifyclientsatincreasedriskforstressonincisionandpoorhealing;assistclienttosplintincisionwhencoughing;useabdominalbinders.Notify RN or surgeon.

Coverbowelwithsterilesalinesoakeddressing.Donotattempttoreplaceloopofbowel.Notify RN or surgeon;clientwillmostlikelyreturntosurgeryforfurtherexploration.

TEST ALERT: Monitor wounds for signs and symptoms of infection.

Continued


v Goal: Tomaintainrespiratoryfunction.A. Haveclientturn,cough,anddeepbreatheevery2 hours.B. Encourageuseofincentivespirometrytopromotedeep breathing.C. Maintainadequatehydrationtokeepmucussecretions thinnedandeasilymobilized.D. Encourageearlyambulation.E. Evaluatesputumforpresenceofinfection.v Goal: Tomaintainadequatenutritionandelimination.A. Assessforreturnofbowelsoundsandnormalperistal- sis.B. Assess the client with a nasogastric tube for return of peristalsis.C. Encouragefluidsafterclientdemonstratestoleranceto fluids.D. Assessclient’stoleranceoforal(PO)fluids;usually beginwithclearliquids.E. Dietisusuallyprogressiveasclient’sconditionand appetiteindicate.F. Recordbowelmovements;normalbowelfunction shouldreturnasevidencedbynormalbowelmovement onthesecondorthirdpostoperativeday(provided the client is eating).G. Assess urinary output.

1. Clientshouldvoid8to10hoursaftersurgery. 2. Ifbladdercatheterispresent,clientshouldaverage atleast30mLperhour. 3. Promotevoidingbyallowingclienttostandoruse bedsidecommode,ifnotcontraindicated. 4. Avoidcatheterizationifpossible.v Goal: Tomaintainfluidbalance.A. MonitorIVinfusionsforcorrectfluidandrateof infusion.B. Assessforadequatehydration. 1. Moistmucousmembranes. 2. Adequateurineoutputwithnormalspecificgravity. 3. Goodskinturgor. 4. Stable vital signs. 5. Alertandoriented.C. Assesscharacterandamountofgastricdrainage through the nasogastric tube.v Goal: Topromotecomfort.A. Anticipatepain;assessandadministerappropriate analgesics.B. Administerantiemeticfornauseaandvomiting.C. Maintaingoodhygiene(e.g.,cleandressings,clean gown).D. Changeclient’spositionevery2hours.E. Allowforperiodsofrestafteradministrationof analgesics.

TABLE 3-2 COMMON POSTOPERATIvE COMPLICATIONS—cont’d.

COMPLICATION SIGNS AND SyMPTOMS NURSING INTERvENTIONUrinary retention

Gastric dilation

Paralytic ileus-causedbydecreasedperistalsis, or intestinal obstruction, leadingtogastricdistention.

Inabilitytovoid8hoursaftersurgery;bladdermaybepalpable;voidingsmallamounts,dribbling

Nausea,vomiting,abdominaldistention,decreasedbowelsounds.

Determineamountoffluidintakeandwhentoanticipateclienttovoid—generallywithin8hr.Palpatesuprapubicareatoevaluateforbladderdistention.Assistclientintonormalvoidingpositionifpossible,runtapwater,provideprivacy.Catheterizeonlyifnecessary.Prevention:Determinepreoperativerisks:medications,lengthofsurgery,historyofpros-tateproblems.

Clientswithabdominalorbowelsurgeryareatincreasedrisk.Positionclientinsemi-Fowlerstodecreaseriskofaspiration.MaintainclientNPO.Prevention:Olderadultclientsareatincreasedrisk;andclientswithabdominalorbowelsur-geryareatincreasedrisk;encourageactivityassoonaspossible;carefullymonitoranalgesics.

Prevention:sameasforgastricdistention.MaintainnasogastrictubesuctionandNPOsta-tus.IfNGtubeisnotpresent,maybeginearlyfeedingofclearliquidstoincreaseintestinalmotility.Evaluatefordistention,statusofbowelsoundsandabdominaldiscomfort.Monitorforpossiblecompromisedrespirations.

IV, Intravenous; NPO,nothingbymouth;NG, nasogastric.


✔ NURSING PRIORITY: In addition to the pain and discomfort associated with a surgical procedure, it is important to assess other possible sources of discomfort, such as full bladder, occluded catheter or tube, gas accumulation, IV infiltration, or compromised circulation due to position/pressure.

Postoperative Complications – see Table 3-2

DiSASter plANNiNg

TEST ALERT: Participate in preparation for internal and external disasters – participating

in safety drills, identifying safety manager, locating Material Safety Data Sheet (MSDS).

A. Fire 1. Immediatelyreturntoyourunitifafirecodeis called. 2. Iffireislocalized(inoneroomorarea),removethe clientsfromtheimmediatearea. 3. Ifclientsonyourunitarenotinimmediatedanger, closeallofthedoorstotheclient’sroomsandtothe unit. 4. Ifyouneedtoevacuateyourunitbecauseofanim- mediatedangertostaffandclients,evacuateclients inthisordertoprovideforthemostrapidremoval ofthemostclientsinashortperiodoftime: a. First:Ambulatoryclientsarefirstbecausethey canmovethequickestandyoucanremovemore clientsquickly. b. Second:Clientsinwheelchairsorwalkersor clientsthatneedassistancearenexttobe evacuated. c. Third:Clientsthatrequirethemostassistance, forexample,ventilatorclientsorthosewhoare totallybedridden,arethenexttobeevacuated. 5.Knowthetypesoffireextinguishers: a.ClassA:waterorsolutionforpaperorlinenfires. b. ClassB:foamextinguisherforgrease,chemical, orelectricalfires. c. ClassC:multipurposeforpaper,linen,orelectricalfires. 6. Usingafireextinguisher—rememberPASS: Pull the pin. Aimatthebaseofthefire. Squeezethetrigger. Sweepfromsidetoside.B. Responseacronym:RACE Rescue—removeallclientsinimmediatedanger. Alert—initiatethealarm. Confine—closealldoorsandwindows;turnoff oxygenvalvesandelectricalequipment. Extinguish—usetheappropriateextinguisherfor typeoffire.

legAl iMpliCAtioNS

Responsibility for PracticeA. Individualliability. 1. Everynurseisliableforhisorherownconduct. 2. Liabilitymaybesharedbyanotherpersonorgroup (e.g.,thedoctor,anothernurse,orthehospital),but itcannotberemovedbythestatementsoractionsof another. 3. IfanRNisnotavailable,thepracticalnursemay notcarryoutfunctionsthatarerecognizedtobe outsidethescopeofpracticeofapracticalnurse.

TEST ALERT: Identify your professional prac-tice limitations (refuse to perform tasks outside

your scope of practice); report a health care provider’s unsafe practice.

B. Unethical nursing care. 1. Medicationerrorsthataremadeandnotreported/ corrected. 2. Physicalandverbalclientabuse. 3. Providingcarewhileundertheinfluenceofalcohol ordrugs. 4. Breachofclientconfidentiality. 5. Jeopardizingaclient’swell-beingbywithholding careortreatment. 6. Providingcareoutsidetheprotocolforsafe,ethical nursingpracticeaccordingtotheindividualstate nurse practice act. 7. Thepractical/vocationalnurseshouldfollowthe line of authority within the institution for reporting anincident.C. Standardofcare:Thelegalconceptofafictional,rea- sonable,prudentindividualofthesameeducationand professionagainstwhichanotherprofessional’s performanceisjudged. 1.Statementofnursingstandards. a. Practiceacts,andrulesandregulations. b.JointCommission(JC). c. Policyandprocedures’manuals. d. Priorcourtdecisions. 2. Usedtodeterminewhenabreachofdutyhas occurred.D. GoodSamaritanlaws:enactedbyindividualstateswith thepurposeofprotectinghealthcareproviderswhoas sistataccidentsandemergencies. 1. Careprovidedingoodfaith. 2. Caremustbegratuitous;nocompensationis receivedforthecarerendered. 3. Careprovidedshouldnotbenegligent. 4. Know the status in your state.


Legal Considerations A. Negligence:Unintentionalharmtoanotherthatoccurs throughfailuretoactinareasonableandprudent manner.B. Malpractice: Unprofessional nursing practice that fails tomeettheproperstandardofcare.C. Invasion of privacy: Protection of constitutional right to befreefromundesiredpublicityandexposuretopublic view. 1. Propercoveringofphysicalbody. 2. Medicalrecords. a. Releasewithsignedclientconsentform. b. Releaseformedical“needtoknow”limitedto caregivers only. 3. Belongingsmustbeprotectedandmaynotbe searchedwithoutspecificauthorization.Aclient’s listofbelongingsshouldbeexplainedtoandsigned by the client. 4. Conversationsconfidential;insomestatesprotected byspecificstatute. 5. Photographsandviewingofproceduresrequire consent of client. 6. Controlofvisitoraccesstoclientandclientinfor- mation. 7. Reportinglawsareanexception–someinformation isrequiredbylawtobereported.

TEST ALERT: Follow regulation/policy for reporting specific issues (abuse/neglect, gunshot wound, or communicable disease, etc.)

a. Communicablediseases. b. Injuriesordeathsthatare,orcouldbe,causedby physicalviolence(gunshotandknifewounds). c. Clientabuse-childrenandolderadult. d. Othersdefinedbystatestatute. 8. Rightsmaybewaivedbytheclientbutneverby medicalpersonnel. 9. Nursesareobligatedtomaintainconfidentialityof client’shealthinformationinaccordance withtheHealthInsurancePortabilityandAccount abilityAct(HIPAA)of1996.D. Validconsent(informedconsent).

TEST ALERT: Obtain client’s signature on consent form. The signed informed consent form provides evidence the consent process has oc-

curred. The nurse should verify with the client that the physician has discussed the risks and benefits of the sur-gery and the client understands his/her rights.

1. Timely:Somestatesorinstitutionshavespecific timerestrictionsonwhenconsentsaresigned. 2. Written:Thisisrequiredforallinvasiveprocedures.

3. Witnessedsignature:Donotsignaninformedcon- sentasawitnessunlessyouknowclienthasall informationandunderstandstheinformationneces- sarytoaninformeddecision. 4. Procedurespecifiedintermstheclientcanunder- stand. 5. Clientunderstandingofsignificantrisksofproce- dure. 6. Signedwhileclientisfreefrommind-alteringdrugs orconditions. 7. Withdrawalofconsentcanbewrittenorverbaland mayoccuratanytimebeforetheprocedure.E. Orders:doctors/primaryhealthcareprovider.

TEST ALERT: Evaluate appropriateness of an order.

1. Questionanyorderthatisnotclearlywrittenand understood. 2. Eachmedicationordershouldcontainthecorrect medicationname,therouteofadministration,the dosageamount,andthetimeofadministration. 3. Single-doseordersareforamedicationtobegiven onetime. 4. “Stat”orders:procedureormedicationshouldbe given/carriedoutimmediately;newordersshould bescannedinitiallytodetermineifany“stat” ordersarepresent. 5. Thenurseisresponsibleforquestioninganymedi- cationorderiftheorderisnotclear,orifthenurse

Protective ProceduresA. Documentation:writtenrecordofeventssurrounding client’shospitalstay. 1. Protectsclientbypromotinggoodcommunication amonghealthcareproviders. 2. Providesevidenceincourtofcaregiven. a. Courtswillnotassumecareisgivenunlessitis recorded. b. Demonstratesmeetingofstandardofcare.B. Howtodocument(Box3-6). 1. Usetheagencyformatcorrectly. 2. Completeallportionsofformat. a. Useopinionsonlyinassessmentportionof charting,neverinareasrequiringfactualdata. b. Completeanhonestrecordofevents. (1) Donotalterrecordatanytime. (2) Recordallevents,evenunusualevents, factually. (3) Giveallappropriateinformationabouteach note(e.g.,statusofincision:presenceofand typeofdrainage,inflammationofarea,foul odor,andtypeofdressingifany). (4) Explainomissionsincare. 3. Time,date,andsignallentries.


4. Donotskiplines;donotleaveanyblankspacesfor other people to chart (paper charts). 5. Correct errors properly. a. Drawastraightlinethrougherror;dateand initial. (a) No white-out on error. (b) No obliteration or erasure of error. (c) Norecopyingofpagetoomitnote. b. Addomittedinformationbyan“addendum”or “lateentry”;givedateandtimeoforiginalnote aswellasdateandtimeofaddendum. 6. Usemeaningful,specificlanguage,donotuse wordsyoudonotunderstandorunacceptable abbreviations. C. Incidentreports.

TEST ALERT: Report incidents/events/irregular occurrences according to facility guidelines.

1. Onlythepersondirectlyinvolvedintheincident shoulddocumentthefactsinthereport. 2. Donotcompleteanincidentreportforsomeone else. 3. Documentthefacts. a.Donotdrawconclusionsorspeculateonwho causedorwhowasresponsiblefortheincident. b.Donotstateopinionsormakejudgments. 4. Reportdoesnotreplacethedocumentationofthe incidentinthechart. 5. Donotdocumentanyreferencetotheincidentre- portinthechart;thesamefactualinformationfiled ontheincidentreportshouldbeincludedonthe chart. 6. Failuretocompleteanincidentreportcouldbecon- sideredacover-up. 7. Completeanincidentreportforanyunusualoccur- renceoraneventinwhichclientorfamilysafety wascompromised.Followthelineofauthority withintheinstitutionforreportinganincident.D. Knowyourlimits.

TEST ALERT: Recognize task/assignments you are not prepared to perform and seek assistance.

1. Physical-emotional:beawareoffatigueandexhaus- tionandcompensateforthem. 2. Practicecompetency. a.Donotperformprocedureswithoutadequate preparation,knowledge,andexperience. Requestsupervisionifyouareunsureofyour skills. b. Report unsafe practices to your supervisor. c.Donotallowanyonetotalkyouintodoing somethingyouarenotsureofbylettinghim orheragreetotaketheliabilityortellingyou thatyoushoulddoit.

• Allentriesshouldbeaccurateandasobjectiveas possibe. • Makecorrectionsappropriatelyandaccordingtoagency orhospitalpolicies.Donotobliterateanyinformation that is written on the paper chart. • Ifthereisinformationthatshouldhavebeenchartedand wasnot,makea“lateentry,”indicatingthetimethe chartingactuallyoccurredandthespecifictimethe chartingreflects.Example:10/13/09.10:00a.m.late entry,chartingtoreflect10/12/09. • Allidentifiedclientproblems,nursingactionstaken, andclientresponsesshouldbenoted.Donotdescribea clientproblemandleaveitwithoutincludingnursing actionstakenandtheclient’sresponse. • Beasobjectiveaspossibleincharting.Ratherthen charting“Theclienttoleratedtheprocedurewell,”chart thespecificparameterscheckedtodeterminethat conclusion.Achartentryworded“ambulated,tolerated well”wouldbemoreeffectiveifcharted“ambulated completelengthofhall,noshortnessofbreathnoted, pulserateat98,respirationsat22.” • Eachpageofthepaperchartoreachcomputerentry shouldcontainthecurrentdateandtime.Eachtime informationisenteredonanewpage,makesureit reflectsthecurrenttimeofcharting. • Documentwhosawtheclientandwhatmeasureswere initiated.Particularlynotewhenthedoctorsvisited; ifyouhadtocalladoctorbecauseofaproblem,record thedoctor’sresponse.Iforderswerereceived,besure theyaresignedaccordingtopolicy.Thisisespecially importantifyouhadtomakeseveralcallstothedoctor. • Makesureyournotesonthepaperchartarelegibleand clearlyreflecttheinformationyouintended.Itisagood ideatoreadoveryournurse’snotesfromtheprevious daytoseewhethertheystillmakesenseandaccurately portraythestatusoftheclient.Ifthenotesdonotmake sensetoyouthenextday,imaginehowdifficultitwould betodeciphertheinformationatalaterdate,orincourt. • Chartingbyexceptionmaybeavailableonelectronic charts, as well as paper charts. In this case, the nurse mayberequiredtodocumentonlysignificantfindingsor exceptions.Itisimportantthatexceptionnotesare enteredandprovideaclearpictureoftheclient’scare or status. • DonotgiveyourcomputerpasswordorIDtoanyone, anddonotchartforanyotherhealthcareperson. • Ifchartingbycomputerintheclient’sroom,makesure thenursingormedicalrecordhasbeenclosedbefore leavingtheroom. AdaptedfromIrvin,Judy:Legalissues.InZerwekhJ, ClabornJ,editors:Nursing today: Transitions and trends, ed6,St.Louis,2009,Saunders.

BOX 3-6 GUIDELINES FOR EFFECTIvE DOCUMENTATION


E. Clientidentification—TheJointCommissionrequire- ments: 1. Twoidentifiersarerequired;forexample,the hospitalidentificationnumberandtheclient’sname onthearmband.Physiciansnameandclient’sdate ofbirtharecommonlyonidentificationarmbands. 2. Ifclientdoesnothaveanarmband,thentheindi- vidual’sstatednamewouldbeoneidentifier; theclient’sdateofbirth,socialsecuritynumber, address,orphonenumbercouldserveasthesecond identifier. 3. Client’scurrentphotographorvisualrecognition maybeusedasoneidentifierinlong-termcare facilities,homecaresettings,orbehavioralcare facilities.Forshort-termclients,facilitieswith unstablestaffing,and/orhigh-riskmedications,the two-identifierrequirementisnecessary. 4. Theclientdoesnothavetostatehisorhernameas anidentifier.

NURSING PRIORITY: ✔ Always check client identifi-cation according to the Joint Commission guidelines.

Specific Situations at RiskA. Physical injury to the client. 1. Inappropriatesiderailuse. 2. Inadequatesupervisionduringambulation. 3. Obstacleordangersonfloororinpathofclient. 4. ImpropertransportationB. Improperuseofindexrestraints-maybephysicalor chemicalrestraintsandareusedonlytoprotectthe physicalsafetyoftheclientandothers. 1. Useofarestraintonaclientrequiresaphysician’s orderfor: a.Typeandlocationofrestraint. b.Typeofbehaviorforwhichrestraintistobeused. c.Timeframethattheorderfortherestraintcovers. 2. Inanemergencysituation,physicalrestraintsmay beusedwithoutadoctor’sorderforaverylimited periodoftime. 3. Safe nursing practice for the care of a client in re- straintsincludes: a.Checkrestrainedclientevery30minutesand provideforphysiologicalneeds. b.Removerestraintsandproviderangeofmotion every 2 hours. c.Documentthetimeofeachcheckandtheneuro- vascularstatusofclient’sextremities. d.Removerestraintsassoonaspossible. e.Securerestraintstothebedframe,nottotheside rails. f.Discusswithfamilytherationaleforandpur- pose of restraints. g.Investigateallalternativestorestraints:family involvement,methodstoincreaseclient orientation,scheduledtoiletingactivities.

B. Medicationerrors(seeChapter4). 1. Followthesevenrightsofmedicationadministra- tion to protect the client. 2. Haveabasicknowledgeofmedicationsadminis- tered. a.Reasonclientisreceivingthemedication. b.Majorsideeffectsofmedication. c.Anticipatedclientresponsetomedication. 3. Neveradministeramedicationwithoutacomplete order. 4. Notify the supervisor or RN if there is an obvious contraindication to the administration of a medication. C. Administrationofnarcotics 1. Neversignoutforanarcoticyoudonotpersonally administer. 2. Do not sign as a witness for narcotic wasting unless you actually observe the wasting. 3. Alwayshaveanotherlicensedpersonwitnessand co-sign whenever it is necessary to waste a narcotic. D. Telephoneandotherverbalorders(Box3-7).

TEST ALERT: Take a verbal or phone order; transcribe a physician’s order.

1. Practicalnursesmustbeawareofthepoliciesand proceduresoftheinstitutionregardingtelephone orders.SomeinstitutionsdonotallowthePNto takedoctor’sorders.Thepracticalnurseislegally obligatedtofollowthepolicyoftheemploying institution. 2. Writedownthetelephoneorderandreaditback; receiveconfirmationthattheorderiscorrect. 3. Donottakeverbalorderswiththephysicianpresent when it is not an urgent situation. 4. Ordersleftonvoicemailarenotacceptable;the nursemustcallthehealthcareprovidertoobtain theorderdirectly.

• Saywhoyouarerightaway. • Donotapologizeforphoning. • Stateyourbusinessbrieflybutcompletely. • Ifyouwantthedoctortoassessthepatient,sayso. • Ifthedoctoriscoming,askwhentoexpecthimorher. • Ifyougetdisconnected,callback. • Documentattemptstoreachadoctor. • Ifadoctorisrudeorabusive,tellhimorhersoand reportittothenursingmanager. • Ifyoucannotreachadoctororgetwhatyouneed, alwaystellyournursingmanager. FromRosser,Cathy:Building Nursing Management Skills. InZerwekhJ,ClabornJ,editors:Nursing today: Transitions and trends,ed6,St.Louis,2009,Saunders.

BOX 3-7 TIPS FOR COMMUNICATING WITH PHySICIANS ON THE TELEPHONE


5. Verbalordersleftwithpatientsorfamilymembers arenotacceptable;thenursemustcallthehealth careproviderandobtaintheorderdirectly. 6. Obtainneededsignaturepromptlyfortelephone orders.D. Changesinclient’scondition.

NURSING PRIORITY: ✔ Identify and report signifi-cant changes in client condition.

1. Notify appropriate individuals of changes – RN, unit supervisor, physician, or other health care provider. 2. Followthechainofcommandifthereisfailure toprovideappropriatecareafternotificationofsig- nificantchangeinclientcondition. 3. Documentchangesandeventssurroundingthe changeintheclient’sstatus. 4. The practical nurse is responsible for evaluating clients,andobtainingassistance,ornotifying appropriateindividualsofthechangeinclientcon- dition. 5. Followuponassessmentsofclientproblemsand whatnursingactionwastakentoresolvetheprob- lem.Forexample,thenursemayverycarefully documenttheeventssurroundingaclient’sfall, butitisalsocriticaltofollowuponwhatwasdone toprovidecareandtoprotecttheclientafterthe fall.E. Hand-off(shift)report:purposeistoprovideaccurate informationandsafequalitycarethroughouttheclient’s hospitalization. 1. Useaninteractivecommunicationmethodunder standableforallinterdisciplinaryteams—SBAR: Situation—What is happening at the present time? Background—Whatarethecircumstances leadinguptothissituation? Assessment—WhatdoIthinktheproblemis? Recommendation—Whatshouldwedoto correcttheproblem? 2. Theoncomingnurseisresponsibleforthenursing carerequiredonhisorhershift. a.StatusofIVsandamountoffluidtocount. b.Anyabnormalconditions(vitalsigns,pain, specialtreatments). c. Statusofclientwithregardtodiagnosis.For examples,cardiacclient—presenceorabsence ofchestpainanddysrhythmias;surgical client—voiding,incisionstatus;orthopedic client—circulationdistaltocastortraction. d.Psychosocialstatusoftheclient.

TEST ALERT: Provide and receive report on assigned clients.

Legal DocumentsA. Client’smedicalrecordorchart.B. Advancemedicaldirective(AD):awrittendocument regardingaclient’sdesiresforprovisionofmedicalcare ifthatpersonisunabletomakehisorherownchoices ordecisions. a. Livingwill(naturaldeathact):awrittendocument describingtheclient’swishesandspecialinstruc- tionsregardinglifesupportmeasuresintheevent thattheclientisincapacitated. b. Medicalpowerofattorneyforhealthcare. (1) Identifiesthepersondesignatedbytheclient toensurethatpreviouslyagreedADsare carriedoutaccordingtotheclient’sdirection. (2) Identifiesthepersondesignatedtomake healthcaredecisionsfortheclientiftheclient isincapacitated. c. ADsmaybechangedorrevokedbytheclientatany time.

TEST ALERT: Provide information about advance directives (AD).

C. Donotresuscitate(DNR)orders. 1. Writtenbythephysicianbasedontheclient’swrit- tenmedicaldirectives. 2. Nursesareobligatedtorespectandobservethe DNRorder. 3. Healthcarepersonnelshouldbeadvisedofthe DNRorder.

MANAgeMeNt of heAlth CAre WorkerS

A. Delegationistransferringtoacompetentindividualthe authoritytoperformaselectednursingtaskina selectedsituation,theprocessfordoingthework. Thenurseretainsaccountabilityforthedelegation, mostoftendelegationistheroleoftheRN.B. Assignmentdescribesthedistributionofworkthateach staffmemberistoaccomplishinagiventime.Toas- signistodirectanindividualtodoactivitieswithinan authorizedscopeofpractice.C. Supervisionistheprovisionofguidanceordirection, oversight,evaluationandfollow-upbythelicensed nursefortheaccomplishmentofanursingtask delegatedtonursingassistivepersonnel.(NCSBN, 2004).D. Role of the practical nurse (PN) in supervision 1. ThePNshouldensuretheunlicensedassistive personal(UAP)understandstheassignedtask, andtheUAPshouldacknowledgetothePNthat he/sheunderstandsthedirections. 2. ThePNshouldmakeperiodiccheckstodetermine thattheUAPisperformingthetasksasdirected.


3. IftheUAPdoesnotcarryoutthetaskscorrectly, thePNshouldcorrecttheactioninatimelyprofes- sionalmanner.Iftheproblemisnotresolved,the RNshouldbenotified. 4. ThePNshouldassigntaskstotheUAPthatare clearlydefined,arewithintheexpectedexpertise oftheUAP,andhaveveryspecificguidelines:for example,bathing,ambulating,clienthygiene.

TEST ALERT: Make client care or related task assignment.

Study Questions: Concepts of Nursing Management

4. Thenurseenterstheclient’sroomanddiscoversthe clientonthefloorbesidethebed.Thesiderailsareup, andtheclientisconfusedanddisoriented.What informationwouldbeincludedinthenurse’sdocumen- tationintheincidentreport? 1 Uponenteringtheroom,Idiscoveredtheclienton theflooratthesideofthebed;thesiderailswere up. 2 Theclientfelloutofthebedafterthenursingassis- tanthadexplainedtohimtheimportanceofnot getting up. 3 Theclientwasconfusedandapparentlytriedto climboutoverthesiderailsofthebed. 4 Evidentlythepreviousnursedidnotcheckonthe clienttoseethathewasconfused,andhefelloutof bed.5. Theolderadultclientisbeingdischargedwithapre- scriptionforhydrocodone(Vicodin) for pain control. Whatinformationwillthenurseincludewhendiscuss- ingwiththeclientthepossibleadverseeffectsofthe medication? 1 Increaseintakeofbulkandfibertopreventconsti- pation. 2 Thepaincontrolcanbeincreasedbytakinganad- ditionalacetaminophen500mg. 3 Returntotheclinicforserumlabstudiestodeter- minetoxicitylevels. 4 Increasedbruisingmayoccurbecauseofchangesin theskin.

E. Prioritizingclientcareassignments. 1. Identifythemostillorunstableclientofyouras signedclients–evaluateandcareforthatclient first. 2. Physiologicalneedsarethepriority–educationand communicationneedscanusuallywaituntilthe physiologicalneedsaremet. 3. Initiallyreviewtheassignedclientlist–consider thereportreceivedoneachclient.Determinewhich clientneedsimmediatephysicalassistanceinorder tomaintainsafety.(Reviewprioritysettingin Chapter 1).

TEST ALERT: Organize and prioritize care of assigned group of clients.

1. Bedrestisfrequentlyprescribedforclientswhohave hadabrainaccidentorstrokeuntiltheircondition stabilizes.Howcanthenurseavoidpotentialproblems? 1 Insertanindwellingcatheter 2 Helptheclientbathetwotimesdaily 3 Placetheclientonacirculatingairmattress 4 Developanactivityschedulewiththeclient2. Thenursebeginschartingonaclient’spaperchartand afterenteringdatadiscoversithasbeenwrittenon the wrong chart. What is the best way to correct this error? 1 White-outthewronginformationandwriteoverit. 2 Recopy the page with the error so that the chart will be neat. 3 Drawastraightlinethroughtheerror,initial,and date. 4 Obliterate the error so that it will not be confusing.3. Aclientisnauseatedandhasvomitedalargeamount offoulsmellingdarkgreenbilefluidtwiceinthepast hour.Whatisthebestnursingaction? 1 Positiontheclientinasupinepositionandmaintain bedrest. 2 Placeclientonnothingbymouth(NPO)statusand notify the supervisor. 3 Encourageclearliquidstohelpsettlethestomach. 4 Ambulateclienttostimulatedevelopmentofperi- stalsis.


6. Thenurseisexplainingtotheclienttheimportanceof voidingpriortosurgery.Whatwouldthenurseinclude inthisexplanation? 1 ItisimportanttohaveanaccurateaccountofI&O forthatday. 2 Voidingbeforesurgerywillreducetheriskof bladderpainduringsurgery. 3 Voidingpriortosurgerywillpromotethephysi- ologicalsafetyduringsurgery. 4 Priortosurgeryitisimportanttovoidtodecrease the possibility of infection.7. Thenursehasbeenassignedan86-year-oldclientwho hassufferedastroke.Theclientisnotorientedtoper- son,place,ortimeandispullingathisIVcatheterand tryingtoclimboutofthebed.Thenursehasapplieda vestrestraintandbilateralsoftwristrestraints.Which ofthefollowingnursingactionswouldbeappropriate? Select all that apply:____ 1 Providefornutritionandeliminationneedsevery2

hours.____ 2 Obtainaphysicianordereveryshiftforcontinua-

tion of restraints.____ 3 Securetherestraintstothesiderailsofthebed.____ 4 Tietherestraintsinquickreleaseknots.____ 5 Assessanddocumentbehaviorsthatrequirecontin-

ueduseofrestraints.8. Whatpotentialproblemshouldthepracticalnursean- ticipatewhentoomuchstrainisplacedonthesuture line? 1 Thrombosis. 2 Infection. 3 Evisceration. 4 Dehiscence.9. Postoperativepainandcancerpainmaybeconsidered predictable.Howcanthenurseincreasetheeffective- nessoftheanalgesics? 1 GivethemPRN. 2 Administeronceaday. 3 Planaround-the-clockdosing. 4 Administertwiceaday.10. Awoundisleftopenaftersurgeryandallowedtoheal fromtheinsidetotheoutside.Thisdescribeswhattype ofhealing? 1 First intention. 2 Secondintention. 3 Primaryhealing. 4 Superficialhealing.

11. Aclienthasexperiencedadehiscenceandthenurse placestheclientonbedrest.Whatisthepurposeofbed restforthisclient? 1 Todecreaseoxygenconsumption. 2 To increase the healing of the site. 3 Topreventdevelopmentofpneumonia. 4 To prevent the occurrence of evisceration.12. Thenurseiscaringforanimmobilizedclient.What nursingmeasureisusedtopreventthecomplicationsof atelectasisandpneumonia? 1 Turn,cough,anddeepbreathe. 2 Rangeofmotionexercises. 3 Clearliquiddietwithfrequentsuctioningofsecre- tions. 4 Bedrestwithfrequentvitalsignmeasurements.13. Beforeasurgicalprocedure,thenurseasksaclientto signaninformedconsentform.Whatisimportantfor thenursetovalidatebeforetheclientsignsthisform? 1 Thephysicianhasdiscussedthesurgerywiththe client. 2 Theclientunderstandsthepostoperativenursing care. 3 Thephysicianhasdiscussedthepossiblecomplica- tions. 4 Theclientunderstandsthesurgeryandtherisks involved.14. Olderadultclientsareconsideredhighriskforrespira- toryproblemsbasedonproblemsofimmobilityand agingchanges.Whatarethesechangesrelatedto? 1 Decreasedlungexpansionandreducedbreathing capacity. 2 Increasedbreathingandlungcapacity. 3 Poorpostureanddecreasedsizeofchestcavity. 4 Increasedlungsizeanddecreasedtidalvolume.15. With the client in the prone position, which bony prominenceswouldthenurseidentifyasbeingmost susceptibletoskinbreakdown? 1 Sacrumandelbows. 2 Shoulderareaandtrochanter. 3 Anterioriliacspinesandpatellae. 4 Trochanter.

Answers and rationales to these questions are in the section at the end of the book titled Chapter Study Questions: Answers and Rationales.


Continued

Appendix 3-1 POSITIONING AND BODy MECHANICS

POSITION PLACEMENT USEFowler’s

Semi-Fowler’s

Low Fowler’s

Lateral (side-lying)

Semi-prone (Sims’)

Lithotomy

Prone

Supine

Headofbedat45-to60-degreeangle;hipsflexed

Headofbedat30-to45-degreeangle;hipsflexed

Headofbedat15-to30-degreeangle;hipsmayormaynotbeflexed

Headofbedlowered;pillowsunderarmandlegsandbehindback;flexkneeofanteriorside

Headofbedlowered;clientplacedonsidewithdependentshoulderliftedoutandlyingpartiallyonabdomen;placepillowunderflexedarmandunderupperflexedknees

Onbackwiththighflexedagainstabdomenandlegssupportedbystirrups.

Headofbedflat,clientonabdomen,headturnedtoside

Bedinflatposition,smallpillowunderhead

Theheightmaybedeterminedbyclientprefer-enceortolerance;frequentlyusedforclientwithrespiratorycompromise.

Cardiac,respiratory,neurosurgicalconditions,orclientcomfort.

PostoperativeandclientswithGIproblems;usedforclientcomfort.

Forclientcomfort;increasesuterineandrenalperfusioninpregnancyandpreventssupinevenacavasyndromeduringlabor.

Preventspressureareas,usedforcomfort

Forgynecologicalexaminationandsurgicalproceduresintheperinealarea.

Usedtopromotedrainageafteroralsurgeryortonsillectomy;usedtopreventcontracturesinclientswithabove-the-kneeamputation.Positionwillprotectinfantwithimperforateanus,orspinabifida.

Forclientcomfort.

TEST ALERT: Position client to prevent complications after tests, treatments, or procedures.

BODy MECHANICS—PREvENTION OF INjURyManualliftingofaclientshouldbeavoided.Ifitisnecessarytomanuallyliftmostoralloftheclient’sweight,obtainliftequipmentand askforadequateassistance.

Body mechanics: 1. Avoidtwistingyourbody;keepyourheadandneckalignedwithyourspine.2.Flexyourkneesandplaceyourfeetwideapartforgoodbaseofsupport.3. Positionyourselfclosetothebedorclosetotheclient.4.Usearmsandlegstoassistinliftingclient,notyourback.5.Usepullsheetorslideboardtomoveclienttosideofbedand/ortomoveupinbed.

✔ key points: Assisting the Client to Move up in Bed• Lowertheheadofthebedsothatitisflatoraslowastheclientcantolerate;raisethebedframetoapositionthatdoesnotrequireleaning.• Ifmorethanonepersonisneededforassistance,obtainaliftingdevice.• Determinetheclient’sstrongsideandhavehimorherassistwiththemove.• Instructtheclienttobendlegs,putfeetflatonbed,andpush.• With2people,useadrawsheetoraliftsheet.• Neverpullaclientupinbedbyhisarmsorbyputtingpressureunderhisarms.

✔ key points: logrolling the Client• Spinalimmobilization—useateamapproach.• Maintainproperclientalignmentonheadandbackareaswhileturning.• Beforemovingpatient,placeapillowbetweenclient’sknees.• Moveclientinonecoordinatedmovement,usingaturn/liftsheet.

TEST ALERT: Use transfer assistance device (roller, client lifts).


Appendix 3-1 POSITIONING AND BODy MECHANICS—cont’d.

✔ key points: Moving from Bed to Chair• Moveclienttothesideofthebed(bedwheelslocked),closesttotheedgewheretheclientwillbegettingup,placeachairwith armsatbedside.• Planonassistingclienttogetoutofbedonhisstrongestside.• Raiseheadofbed,assistclienttosideofthebed.• Moveclienttoedgeofbedandplaceyourhandsunderclient’slegsandshifthisweightforward,pivottheclient’sbodysoheis sittingpositionandhisfeetareflatonthefloor.• Haveclientreachacrosschairandgraspthearmofthechair.• Stabilizeclientbypositioningyourfootattheoutsideedgeofclient’sfoot.• Pivotclientintochairusingyourlegmusclesinsteadofyourbackmuscles.• Assistclienttomovebackandupinthechairforbetterposition.

tips for Moving and positioning Clients• Useaturnsheettoprovidemoresupportforclient.• Encourageclienttoassistinmovebyusingthesiderailsandstrongsideofhisorherbody.• No-liftpolicy:useliftequipmentandassistancewheneveraclientrequiresmostofhisweighttobesupportedorliftedbysomeone.• Usetrochanterrollmadefrombathblanketstoaligntheclient’shipstopreventexternalrotationwheninthesupineposition.• Usefoldedtowels,blankets,orsmallpillowstopositionclient’shandsandarmstopreventdependentedema.

TEST ALERT: Maintain correct body alignment.

Continued

NURSING PRIORITY: ✔ Advise cli-ents using fentanyl patches not to expose patch to heat (hot tub, heating pad) since this will accelerate the release of the fen-tanyl.

OLDER ADULT PRIORITY: ✔ Pre-vent problems with constipation, monitor respiratory status.

HIGH

ALERT

Appendix 3-2 ANALGESICS

general Nursing implicationsAssessclientforpainparameters:bloodpressure,pulse,andrespiratorystatusbeforeandperiodicallyafteradministration.•Useascaletodeterminelevelofpain.•Formoreeffectiveanalgesiceffect,administermedicationbeforepainissevere.•Olderordebilitatedclientsmayrequiredecreaseddosage. •

Medications Side Effects Nursing Implications

NARCoTIC ANALGESICS: Bindtoreceptorsinthecentralnervoussystem(CNS),alteringtheperceptionofandemotionalresponsetopain.Controlledsubstances(ScheduleII).

STRoNG oPIoID ANAlGESICS

Morphinesulfate:PO,subQ,IM,IV,epiduralanalgesia

Meperidine(Demerol): PO, subQ,IM

Fentanyl (Fentanyl, Sublimaze, Duragesic): IM, IV,PO,transdermal

RespiratorydepressionOrthostatic hypotensionSedation,dizziness,lightheadedness,IncreasedtendencyforseizuresConstipationTolerance,physicalandpsychologicaldependenceMaydecreaseawarenessofbladderstimuli

1.MorphineismostcommonlyusedforPCA.2.Demerol:Notcommonlyusedforcontrolofchronicpainduetoneurotoxiceffect;usewithcautioninchildrenandolderadultclientsbecauseofincreasedriskfortoxicityandseizures.3.Allopioids:Usewithcautioninclientswhohaverespiratorycompromise.4.Pediatricimplications:Medicationdosageiscalculatedaccordingtobodysurfaceareaandweight.

5.Assessvoidingandencourageclienttovoidevery4 hours.6.RequiresdocumentationasindicatedbyControlled Substance Act.7.Instructclienttochangepositionslowlytominimize orthostatic hypotension.


Appendix 3-2 ANALGESICS—cont’d.

Medications Side Effects Nursing Implications

MoDERATE oPIoIDS

Butorphanol (Stadol): IM, IV,nasalsprayNalbuphine (Nubain):subQ,IV,IM

Dizziness,drowsiness 1. Monitor client for effective pain control.2.Abruptwithdrawalafterprolongedusemayproducesymptomsofwithdrawal.

NURSING PRIORITY: ✔ Pain will return when Narcan is administered.

NARCoTIC ANTAGoNIST - Antagonistscompetitivelyblocktheeffectsofnarcoticswithoutproducinganalgesic.

Naloxone(Narcan):IV,IM,subQ

Hypotension,hypertension,dysrhythmias. 1.Assessrespiratorystatus,bloodpressure,pulse,and level of consciousness until narcotic wears off. Repeat dosesmaybenecessaryifeffectofnarcoticoutlaststhe effect of the narcotic antagonist.2.Rememberthatnarcoticantagonistsreverseanalgesiaalongwithrespiratorydepression.Titratedoseaccordinglyandmonitorpainlevel.3. Uses:UsedtoreverseCNSandrespiratorydepressioninnarcoticoverdose.4. Contraindications and precautions: Use with caution innarcotic-dependentpatients;maycauseseverewithdrawalsymptoms.

CDC,CentersforDiseaseControlandPrevention;CNS,centralnervoussystem;IM,intramuscularly; IV, intravenously; PCA, patient-controlledanalgesia;PO,bymouth(orally);subQ, subcutaneously

MoDERATE To STRoNG oPIoID ANAlGESICSCodeine:PO,subQ

Hydromorphone(Dilaudid): PO,subQ,IM,IV,suppository

Oxycodone(Percodan, combinationwithibuprofen;Percocet, Tylox combinationswithacetaminophen;oxyContin): PO

Hydrocodone(Vicodin, Lorcet combinationswithacetaminophen;Vicoprofen, combinationwithibuprofen): PO

Propoxyphene(Darvon, Darvocet): PO

Sedation,euphoria,respiratorydepression,constipation, urinary retention, cough sup-pression

1.Usuallyadministeredbymouth.2.Codeineisanextremelyeffectivecoughsuppressant.3.Donotconfusehydromorphonewithmorphine.4.Warnpatienttoavoidactivitiesrequiringalertnessuntileffectsofdrugareknown.5.Medicationsareofteninvariousstrengthcombinationswithacetaminophenand/oribuprofen.

NURSING PRIORITY: ✔ Help client to identify OTC medications that contain acetaminophen or ibuprofen – increased risk of overdose if taken in addition to combination opiod analgesics.

HIGH

ALERT

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